What are the best treatments for onychomycosis (fungal infection of the toenail)?

From the Guidelines

Terbinafine should be considered as the first choice of treatment for onychomycosis due to its higher efficacy and tolerability compared to itraconazole. The treatment of onychomycosis, a fungal infection of the toenail, requires a comprehensive approach to ensure optimal outcomes in terms of morbidity, mortality, and quality of life.

Treatment Options

When considering treatment options, the following points are crucial:

• Terbinafine is licensed at a dose of 250 mg per day for 12–16 weeks in toenail infection 1.
• Itraconazole is licensed at a dose of 200 mg per day for 12 weeks continuously, or alternatively as pulse therapy at a dose of 400 mg per day for 1 week per month 1.
• Several large studies demonstrate higher efficacy rates for terbinafine in comparison with itraconazole, with complete cure rates of 55% for terbinafine compared to 26% for pulsed itraconazole at 72 weeks follow-up 1.

Considerations for Treatment Success

To achieve treatment success, the following factors are essential:

• Consistent treatment for the full duration, as toenail fungus is notoriously difficult to eradicate due to the slow growth of toenails and the protective barrier they provide for the fungus.
• Monitoring for potential liver side effects when using oral antifungal medications.
• Preventing reinfection by keeping feet clean and dry, wearing breathable footwear, and using antifungal powders in shoes is also essential for long-term success.

Comparison of Treatment Options

A comparison of terbinafine and itraconazole reveals that:

• Terbinafine has a higher efficacy rate and is more tolerable than itraconazole 1.
• Terbinafine has a lower relapse rate, with mycological and clinical relapse significantly higher in the itraconazole group (53% and 48%, respectively) than in the terbinafine group (23% and 21%) 1.

From the FDA Drug Label

Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). Ciclopirox Topical Solution, 8%, (Nail Lacquer), as a component of a comprehensive management program, is indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum

The best treatments for onychomycosis (fungal infection of the toenail) include:

• Terbinafine (PO): indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
• Ciclopirox (TOP): indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum, as part of a comprehensive management program 3

From the Research

Treatment Options for Onychomycosis

The following are some of the best treatments for onychomycosis (fungal infection of the toenail):

• Oral terbinafine: has demonstrated excellent fungicidal activity against dermatophytes and variable activity against yeasts and non-dermatophyte molds in vitro 4
• Oral itraconazole: can be used to treat onychomycosis, but has been shown to be less effective than terbinafine in some studies 4, 5
• Topical antifungal agents: such as efinaconazole and tavaborole, can be used to treat onychomycosis, especially in patients who cannot use systemic antifungals 6

Efficacy of Terbinafine

Studies have shown that terbinafine is an effective treatment for onychomycosis:

• A multicenter trial found that terbinafine had a mycologic cure rate of 72.1-77.0% at 72 weeks, depending on the duration of treatment 7
• A study comparing continuous and pulse dose terbinafine regimens found that the continuous dose regimen had a significantly higher clinical cure rate (76.67% vs 26.67%) 8
• A North American multicenter trial found that 74% of patients treated with terbinafine achieved a successful clinical outcome, with approximately 11% showing evidence of relapse 18-21 months after cessation of treatment 5

Safety and Tolerability

Terbinafine has been shown to be well tolerated and safe:

• Adverse events were experienced by 10.5% of terbinafine recipients, with gastrointestinal complaints being the most common 4
• Terbinafine has a low potential for drug-drug interactions, unlike some other antifungal medications 4