From the Guidelines
The best treatment for onychomycosis is terbinafine, which is generally preferred over itraconazole due to its higher efficacy and safety profile, as recommended by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1.
Treatment Options
The treatment of onychomycosis typically involves oral antifungal medications, with terbinafine being the first line of treatment for dermatophyte onychomycosis, due to its high efficacy and relatively low risk of adverse effects 1. The recommended dosage is 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection.
Key Considerations
- Monitoring: Baseline liver function tests and a complete full blood count are recommended in adult patients with a history of hepatotoxicity or haematological abnormalities 1.
- Adverse Effects: Common adverse effects of terbinafine include headache, taste disturbance, and gastrointestinal upset, and it can also aggravate psoriasis and cause a subacute lupus-like syndrome 1.
- Prevention of Reinfection: Preventing reinfection requires keeping feet dry, wearing breathable footwear, using antifungal powders, and avoiding walking barefoot in public areas, as well as treating all infected family members simultaneously 1.
Alternative Treatments
- Itraconazole: May be used as an alternative to terbinafine, with a recommended dosage 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.
- Topical Treatments: Such as ciclopirox 8% nail lacquer or efinaconazole 10% solution, may be used for milder cases or when oral medications are contraindicated 1.
- Nail Removal: May be necessary before medication treatment in severe cases, and laser therapy is also available but has variable results 1.
From the Research
Treatment Options for Oncomychosis
- Topical antifungal therapy, such as efinaconazole 10% solution and tavaborole 5% solution, have shown promising results in treating onychomycosis, with mycologic cure rates superior to those achieved with ciclopirox 8% nail lacquer 2.
- Oral antifungals, such as itraconazole, are also effective in treating onychomycosis, but may have higher recurrence rates 2, 3.
- Nail debridement is a common treatment option for onychomycosis, often used in combination with topical or oral antifungals 3, 4.
- Combination therapy, including the use of device-based treatments, may enhance cure rates and reduce recurrence rates 5.
Diagnosis and Assessment of Onychomycosis
- Diagnosis of onychomycosis is predominantly based on clinical aspects, including subungual hyperkeratosis, white-yellow-orange subungual scales, and absence of salmon-pink coloration 3, 6.
- Microscopy and fungal culture are commonly employed to establish the diagnosis, with culture being the gold standard 3, 5.
- Assessment of clinical features is the main method for follow-up, with the main criterion to define cure being a combination of mycologic cure and clinical cure 3.
Recommendations for Treatment and Referral
- Treatment options should be patient-tailored, taking into account factors such as concurrent tinea pedis diagnosis, immunocompromised status, and diabetes 3.
- Referral to a specialist should be considered in cases of severe onychomycosis, treatment failure, concomitant diseases/comorbidities, presence of a dermatophytoma or involvement of the nail matrix, or involvement of several/all nails 3.