From the Guidelines
Terbinafine should be considered as the first choice for treating onychomycosis due to its higher efficacy and tolerability compared to other options. When considering treatment options for onychomycosis, several factors such as the severity of the infection, patient compliance, and potential side effects must be taken into account.
Treatment Options
- Oral medications:
- Terbinafine 250mg daily for 6 weeks (fingernails) or 12 weeks (toenails) is recommended as the first line of treatment 1.
- Itraconazole 200mg twice daily for 1 week per month for 2 months (fingernails) or 3 months (toenails) is an alternative option 1.
- Fluconazole 150-300mg weekly for 3-6 months may be considered for patients who cannot tolerate terbinafine or itraconazole 1.
- Topical antifungals:
- Ciclopirox 8% nail lacquer applied daily for up to 48 weeks.
- Efinaconazole 10% solution applied daily for 48 weeks.
Important Considerations
- Combination therapy using both oral and topical treatments may improve outcomes.
- Mechanical approaches like nail debridement or removal can be helpful adjuncts, especially for thick nails.
- Treatment success requires patience as complete cure takes time while the infected nail grows out.
- Oral medications work by inhibiting fungal cell wall synthesis but require liver function monitoring, while topical treatments have fewer systemic effects but need consistent application.
- Preventing recurrence involves keeping feet dry, wearing breathable footwear, and using antifungal powders. It is essential to note that the choice of treatment should be individualized based on the patient's specific needs and medical history. Regular follow-up appointments are necessary to monitor the treatment's effectiveness and adjust the treatment plan as needed.
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
Onychomycosis treatment options 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 3
From the Research
Onychomycosis Treatment Options
- Onychomycosis is a common nail disease that can be treated with various options, including oral antifungal agents, topical therapies, and devices 4, 5.
- The goals of antifungal therapy are mycological cure and a normal-looking nail, and treatment depends on the clinical type of onychomycosis, the number of affected nails, and the severity of nail involvement 4.
- Oral antifungal agents, such as terbinafine and azoles, offer greater efficacy for onychomycosis treatment but are limited by risks of systemic toxicity and drug-drug interactions 5, 6.
- Topical antifungals, such as amorolfine, ciclopirox, tavaborole, and efinaconazole, are well-tolerated and generally safe, with only potential local side effects, and are suitable for cases of mild to moderate toenail onychomycosis 7, 8.
Treatment Efficacy
- High-quality evidence shows that terbinafine is more effective than placebo for achieving clinical cure and mycological cure, with moderate-quality evidence of excess harm 6.
- Azoles are also effective treatments for onychomycosis, with high-quality evidence showing that they are more effective than placebo for achieving clinical cure and mycological cure 6.
- Terbinafine probably leads to better cure rates than azoles with the same risk of adverse events, and may improve cure and be associated with fewer adverse effects when compared to griseofulvin 6.
Treatment Safety
- Systemic antifungals, especially azole antifungals, are associated with numerous drug-drug interactions, some of which are life-threatening and fatal, and a detailed medication history is critical before prescribing these medications 5.
- Topical antifungals are generally safe, with only potential local side effects, and are suitable for cases of mild to moderate toenail onychomycosis 7, 8.
- Laser therapy is likely less effective than systemic and topical therapies but may be safely used during pregnancy and breastfeeding 5.