From the Guidelines
For topical treatment of Aspergillus terreus onychomycosis, efinaconazole 10% solution applied daily for 48 weeks is the most effective option, with mycological cure rates approaching 50% and complete cure in 15% of patients. The treatment regimen involves applying the solution to the affected nail and surrounding skin once daily without removal. This is based on the most recent and highest quality study available, which found efinaconazole to be more effective than vehicle in the treatment of onychomycosis 1.
Key Considerations
- Topical treatments work by disrupting fungal cell membranes and inhibiting ergosterol synthesis, though they have limited efficacy against Aspergillus terreus due to poor nail plate penetration.
- For best results, combine topical therapy with mechanical nail debridement or chemical nail avulsion using 40% urea ointment to improve drug penetration 1.
- Be aware that topical treatments alone may be insufficient for severe infections or when the nail matrix is involved, in which case oral antifungals like itraconazole or terbinafine may be necessary, as suggested by earlier guidelines 1.
- Treatment success should be monitored by clinical improvement and mycological testing.
Alternative Options
- Ciclopirox 8% nail lacquer applied daily for 6-12 months is another option, although it may not be as effective as efinaconazole 10% solution.
- Amorolfine 5% nail lacquer, applied once or twice weekly for 6-12 months, may also be used where available, but its efficacy against Aspergillus terreus is not well established.
Important Notes
- The choice of topical treatment should be based on the severity of the infection, the extent of nail involvement, and the patient's overall health status.
- It is essential to follow the treatment regimen carefully and to monitor treatment success regularly to ensure the best possible outcome.
From the Research
Topical Treatment Options
- Topical treatment with 1% Pimafucin in a mixture of 60% dimethylsulfoxide (DMSO) and 40% water as well as 9% aqueous solution of sodium benzoate were both effective in treating onychomycosis caused by Aspergillus terreus 2
- Amorolfine is a topically active antifungal agent that has been shown to be effective in treating onychomycosis, with a mycological and clinical cure rate of approximately 40 to 55% in patients with mild onychomycosis 3
- Amorolfine has been shown to have a sporicidal effect, with the ability to kill microconidia of Trichophyton rubrum, chlamydospores of Epidermophyton floccosum, and blastospores of Candida albicans 4
Newer Topical Agents
- Efinaconazole 10% solution and tavaborole 5% solution are new topical antifungals that have been developed for the treatment of dermatophyte onychomycosis, with mycologic cure rates superior to those achieved with ciclopirox 8% nail lacquer 5
- These newer agents may provide viable monotherapy alternatives to oral therapy for onychomycosis, and may also find a role in combination therapy and/or as continued therapy after initial clearance to reduce recurrence or re-infection 5
Combination Therapy
- Combining oral and topical antifungal drugs has been associated with higher success rates in treating onychomycosis 6
- The combination of terbinafine with amorolfine has been shown to be more effective than terbinafine in conjunction with ciclopirox, with additive or synergistic effects observed in most combinations 6
- The use of combined therapy with topical amorolfine and oral terbinafine may be beneficial to patients with onychomycosis, particularly if the pathogen is a non-dermatophyte fungus such as Scopulariopsis brevicaulis 6