From the Guidelines
Terbinafine should be considered as the first choice for onychomycosis treatment due to its higher efficacy and tolerability compared to itraconazole, with a recommended dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection. The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 support this recommendation, citing several large studies that demonstrate higher efficacy rates for terbinafine in comparison with itraconazole 1.
Key Considerations
- Terbinafine has been shown to be more effective than itraconazole, with complete cure rates of 55% compared to 26% for pulsed itraconazole at follow-up at 72 weeks 1.
- The long-term effectiveness of treatment also favors terbinafine, with mycological cure without a second therapeutic intervention found in 46% of terbinafine-treated patients compared to 13% of itraconazole-treated patients at the end of a 5-year blinded prospective follow-up study 1.
- Itraconazole may be considered as an alternative, with a recommended 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.
- Fluconazole may also be considered as an alternative, particularly in patients unable to tolerate terbinafine or itraconazole, with a recommended dose of 450 mg per week for 3 months in fingernail infections and for at least 6 months in toenail infections 1.
Adjunctive Measures
- Keeping nails short, dry, and clean
- Wearing breathable footwear
- Using antifungal powders in shoes
- Preventive measures should continue after treatment to reduce the risk of recurrence, which is common (10-50%) 1.
From the FDA Drug Label
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 Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium)
The treatment for onychomycosis includes:
- Topical treatment: Ciclopirox Topical Solution, 8%, (Nail Lacquer) is indicated for mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 2
- Oral treatment: Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 3
From the Research
Onychomycosis Treatment Options
- Onychomycosis has several clinical presentations and is caused by various infectious organisms, including dermatophytes, non-dermatophyte molds, and yeast 4.
- Several treatment options are available, including:
- Oral antifungals: terbinafine, itraconazole, fluconazole
- Topical antifungals: ciclopirox 8% nail lacquer, efinaconazole 10% nail solution, tavaborole 5% solution
- Laser therapy (although further studies are needed to recommend its use) 4
Combination Therapy
- Combination therapy of oral terbinafine and topical ciclopirox nail lacquer has been shown to be more effective than oral terbinafine alone in treating onychomycosis caused by dermatophytes 5.
- The mycological cure rates were 64.7% for the terbinafine-only group and 88.2% for the combination therapy group (p<0.05) 5.
Topical Antifungal Therapy
- Topical antifungal therapy can be an effective treatment for onychomycosis, especially for mild to moderate cases [<50-65% nail involvement] 6, 7.
- Newer topical agents, such as efinaconazole 10% solution and tavaborole 5% solution, have shown superior efficacy compared to older agents like ciclopirox 8% nail lacquer 6.
- Topical treatment with amorolfine, ciclopirox, tavaborole, or efinaconazole is appropriate for cases of mild to moderate toenail onychomycosis due to dermatophyte or mixed dermatophyte/Candida infection 7.
Current Understanding and Future Directions
- Onychomycosis is a common fungal infectious disease that affects patients physically, socially, and psychologically, and can seriously influence their quality of life 8.
- Oral antifungals are routinely used to treat onychomycosis, but are associated with severe side effects and longer treatment times 8.
- Research is ongoing to develop more effective and targeted therapies, including topical and transungual delivery systems, to improve treatment outcomes and reduce recurrence rates 8.