What are the treatment options for fungal toenail infection?

Treatment Options for Fungal Toenail Infection

Oral terbinafine is the first-line treatment for dermatophyte onychomycosis due to its superior efficacy compared to other antifungals, with cure rates of 70-80% for toenail infections. 1, 2

Systemic (Oral) Antifungal Treatments

First-Line Options:

• Terbinafine: 250 mg daily for 12-16 weeks for toenail infections; fungicidal action with high-quality evidence showing superior efficacy compared to placebo and azoles 1, 3, 2
• Itraconazole: Can be given as 200 mg daily for 12 weeks continuously, or as "pulse therapy" with 400 mg daily for 1 week per month for 3 months (toenails); first-line alternative if terbinafine is contraindicated 1

Alternative Oral Options:

• Fluconazole: Weekly pulse therapy (200-300 mg once weekly for 6 months) for toenail infections; particularly useful in immunocompromised patients on antiretrovirals due to fewer drug interactions 1, 4
• Griseofulvin: Less effective (30-40% cure rates) with longer treatment duration (12-18 months for toenails); only oral antifungal licensed for children but no longer considered first-line due to limited efficacy 1, 2

Topical Antifungal Treatments

Topical treatments are generally less effective than oral therapy but may be appropriate for:

• Very early or superficial infections
• Cases where systemic therapy is contraindicated
• As adjunctive therapy with oral medications 1

Available options include:

• Amorolfine 5% nail lacquer: Applied 1-2 times weekly for up to 6 months (fingernails) or 9-12 months (toenails) 1
• Ciclopirox 8% nail lacquer: Applied daily for up to 48 weeks; requires monthly removal of unattached infected nail by healthcare professional; mycological cure rates of 29-36% 1, 5
• Tioconazole 28% solution: Limited efficacy with mycological and clinical cure achieved in only 22% of patients 1
• Efinaconazole 10% solution: Once-daily application for 48 weeks; mycological cure rates approaching 50% 1

Treatment Selection Algorithm

1. Confirm diagnosis with mycological testing (direct microscopy and culture) before starting treatment 1

2. Assess extent of infection:

   • If <50% of nail plate affected or <3 nails involved: Consider topical therapy 6
   • If >50% of nail plate affected or >3 nails involved: Oral therapy recommended 6

3. Evaluate patient factors:

   • Immunocompetent patients: Terbinafine preferred for dermatophyte infections 1, 2
   • Immunosuppressed patients: Terbinafine or fluconazole preferred (fewer drug interactions with antiretrovirals) 1
   • Candidal nail infections: Azoles (itraconazole or fluconazole) preferred 1, 6
   • Patients with liver disease: Monitor liver function or consider topical therapy 1

Addressing Treatment Failures

Treatment failure occurs in 20-30% of cases even with terbinafine 1. Common reasons include:

• Presence of dermatophytoma (dense white lesion beneath nail) requiring mechanical removal 1
• Thick nails (>2mm), severe onycholysis, or slow outgrowth 1
• Poor compliance or inadequate treatment duration 1

For treatment failures:

• Consider switching to alternative antifungal agent 1
• Partial nail removal may be necessary for dermatophytomas 1
• Combined approaches (mechanical debridement plus oral therapy) may improve outcomes 1

Prevention of Recurrence

Onychomycosis has high recurrence rates (40-70%) 1. Prevention strategies include:

• Always wear protective footwear in public bathing facilities, gyms, and hotel rooms 1
• Apply antifungal powders (miconazole, clotrimazole, tolnaftate) to shoes and feet 1
• Wear cotton, absorbent socks 1
• Keep nails short and avoid sharing nail clippers 1
• Consider discarding contaminated footwear or treating with naphthalene mothballs in sealed plastic bag for 3 days 1
• Treat all infected family members simultaneously 1

Special Considerations

• Surgical approaches: Surgical avulsion followed by topical therapy has shown disappointing results and is not recommended based on current evidence 1
• Debridement alone: Not recommended as standalone treatment but may be necessary to remove dermatophytomas 1
• Emerging therapies: Photodynamic therapy and laser treatments show promising results but cannot be recommended at this stage due to limited evidence 1