From the Guidelines
Terbinafine is the preferred treatment option for onychomycosis due to its higher efficacy and tolerability compared to other oral antifungal medications. The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 recommend terbinafine as the first-line treatment, unless there are contraindications 1.
Treatment Options
The following treatment options are available for onychomycosis:
- Terbinafine 250mg daily for 6 weeks (fingernails) or 12 weeks (toenails)
- Itraconazole 200mg twice daily for 1 week per month for 2 months (fingernails) or 3 months (toenails)
- Fluconazole 150-300mg weekly for 3-6 months, which may be a useful alternative in patients unable to tolerate terbinafine or itraconazole 1
Key Considerations
When treating onychomycosis, it is essential to consider the following:
- Liver function tests should be monitored with oral therapy, especially for terbinafine and itraconazole
- Mechanical or chemical nail debridement before starting treatment can improve medication penetration and outcomes
- Patients should continue treatment until clinical improvement is seen, as premature discontinuation often leads to recurrence
- The choice of treatment depends on the severity and type of infection, as well as patient tolerance and potential drug interactions
Efficacy and Safety
Studies have shown that terbinafine has higher efficacy rates compared to itraconazole, with complete cure rates of 55% and 26%, respectively, at 72 weeks follow-up 1. Fluconazole has also been shown to be effective, but with lower cure rates compared to terbinafine and itraconazole 1.
Adverse Effects
The common adverse effects of fluconazole include headache, skin rash, gastrointestinal complaints, and insomnia, with adverse effects leading to treatment discontinuation occurring in 20% of patients receiving fluconazole 150mg per week 1.
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, as part of a comprehensive management program 3
From the Research
Onychomycosis Treatment Options
Onychomycosis, a common nail disease, can be treated with various options, including oral and topical antifungal agents. The choice of treatment depends on the clinical type of onychomycosis, the number of affected nails, and the severity of nail involvement 4.
Oral Antifungal Agents
Oral antifungal agents, such as terbinafine and azoles, are effective treatments for onychomycosis, with high-quality evidence showing that they are more effective than placebo for achieving clinical and mycological cure 5. Terbinafine is probably more effective than azoles for achieving clinical and mycological cure, with moderate-quality evidence showing that it has a similar risk of adverse events 5.
Topical Antifungal Agents
Topical antifungal agents, such as amorolfine, ciclopirox, tavaborole, and efinaconazole, are also effective treatments for onychomycosis, particularly for mild to moderate cases (<50-65% nail involvement) 6. These treatments are generally applied daily for 24-48 weeks, with longer treatment and follow-up showing better outcomes 6.
Combination Therapy
Combination therapy, such as the use of oral terbinafine and topical ciclopirox, may be more effective than oral terbinafine alone, especially in younger patients and in shorter-duration onychomycosis 7.
Safety Considerations
The safety of onychomycosis treatments is an important consideration, with oral antifungal agents carrying a risk of systemic toxicity and drug-drug interactions 8. Topical antifungal agents are generally well-tolerated and safe, with only potential local side effects 8.
- Key points to consider when choosing an onychomycosis treatment: