What is the treatment for onychomycosis (fungal infection of the toenail)?

From the Guidelines

Toenail infections should be treated with terbinafine as the first-line treatment, given its higher efficacy and tolerability compared to itraconazole, with a recommended dose of 250 mg per day for 12-16 weeks. This recommendation is based on the British Association of Dermatologists' guidelines for the management of onychomycosis 2014, which suggests that terbinafine should be considered as the first choice unless there are contraindications 1. The guidelines also recommend that patients should be re-evaluated 3-6 months after treatment initiation and further treatment should be given if the disease persists.

Some key points to consider when treating toenail infections include:

• Keeping feet clean and dry
• Trimming nails straight across
• Wearing breathable shoes
• Avoiding walking barefoot in public areas
• Seeking medical attention immediately if the patient has a compromised immune system or is diabetic, as infections can lead to more serious complications

It's also important to note that other treatment options, such as itraconazole and fluconazole, may be considered in certain cases, but terbinafine remains the preferred choice due to its higher efficacy and tolerability 1. Additionally, a study on Candida onychomycosis suggested that itraconazole may be more effective than terbinafine for this specific type of infection, but this is not the case for dermatophyte onychomycosis, which is the most common cause of toenail infections 1.

In terms of treatment duration, terbinafine should be given for 12-16 weeks for toenail infections, and patients should be re-evaluated 3-6 months after treatment initiation to determine if further treatment is needed 1. Itraconazole can be given as an alternative, with a recommended dose of 200 mg per day for 12 weeks continuously, or as pulse therapy at a dose of 400 mg per day for 1 week per month, with three pulses recommended for toenail onychomycosis 1.

Overall, the most effective treatment for toenail infections is terbinafine, due to its higher efficacy and tolerability, and it should be considered as the first-line treatment unless there are contraindications 1.

From the FDA Drug Label

Terbinafine tablets are an allylamine antifungal indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) (1) Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). The efficacy of terbinafine tablets in the treatment of onychomycosis is illustrated by the response of patients with toenail and/or fingernail infections who participated in three US/Canadian placebo-controlled clinical trials

Treatment of Toenail Infection:

• Terbinafine tablets are indicated for the treatment of onychomycosis of the toenail due to dermatophytes (tinea unguium) 2.
• The efficacy of terbinafine tablets in the treatment of onychomycosis of the toenail has been demonstrated in clinical trials, with mycological cure rates of 70% and effective treatment rates of 59% 2.
• Prior to initiating treatment, appropriate nail specimens for laboratory testing should be obtained to confirm the diagnosis of onychomycosis 2.

From the Research

Causes and Effects of Toe Nail Infection

• Onychomycosis is a common fungal infection of the nail apparatus, which can be difficult to treat and may require prolonged systemic antifungal therapy 3.
• The infection can cause discoloration of the nail plate, discomfort, and in severe cases, loss of the nail plate altogether 4.
• Onychomycosis may become a source of more widespread fungal lesions, spreading to other nails, body sites, and even to family members 4.

Treatment Options for Toe Nail Infection

• Oral antifungal agents such as fluconazole, itraconazole, and terbinafine have improved treatment success for onychomycosis 3.
• Terbinafine is effective in the treatment of onychomycosis, particularly for dermatophyte infections, and has a good safety profile 3, 5.
• Topical antifungal agents such as efinaconazole and tavaborole have also been approved for the treatment of onychomycosis, providing an alternative to systemic antifungals 6.
• Treatment should continue for at least one week after clinical clearing of infection, and may require attention to exacerbating factors such as skin moisture 7.

Considerations for Treatment

• The choice of antifungal agent depends on the type of infection, with terbinafine being the preferred treatment for dermatophyte infections and azoles being recommended for Candida and non-dermatophyte infections 3.
• Topical therapy is generally successful for superficial fungal infections, but systemic therapy may be required for more extensive or resistant infections 7.
• The presence of inflammation may necessitate the use of an agent with inherent anti-inflammatory properties or a combination antifungal/steroid agent 7.