What is the preferred treatment for tinea unguium?

1.

Elsevier ClinicalKey Clinical Overview

Treatment Terbinafine Hydrochloride Oral granules; Adolescents and Children 4 years of age and older weighing greater than 35 kg: 250 mg PO daily for 3-4 weeks. Terbinafine Hydrochloride Oral granules; Adults: 250 mg PO daily for 3 to 4 weeks. Indicated as therapy for distal subungual onychomycosis (tinea unguium) Terbinafine Hydrochloride Oral tablet; Children >= 2 years† and Adolescents†: Use not established. Although experience is limited, a published review suggested a dose of 62.5 mg/day PO for weight < 20 kg, and 125 mg/day PO for weight 20—40 kg. Terbinafine Hydrochloride Oral tablet; Adults: 250 mg PO daily for 6 weeks for fingernails and 12 weeks for toenails. Alternatively, an intermittent dosage† of 500 mg PO daily for 7 days during the first week of each month for 3 months was equivalent to the standard continuous dosage. Because toenails grow slowly, treatment of tinea unguium of the toenails may take 9 to 12 months Griseofulvin Indicated as first line therapy for patients with tinea capitis with confirmed Microsporum infection or for patients with disease complicated by a kerion Griseofulvin, Microcrystalline Oral suspension; Adolescents and Children greater than 2 years: Dosage varies with formulation. FOR ULTAMICROSIZE: 7.3 mg/kg/dose PO once daily (range, 5 to 15 mg/kg/day); Max: 750 mg. FOR MICROSIZE: 10 to 20 mg/kg/day PO divided twice daily; Max: 1 g/day. Treat until organism completely eradicated. Suggested durations: tinea corporis, 2 to 4 weeks; tinea capitis, 4 to 6 weeks; although, some experts recommend 6 to 8 weeks (or longer) for tinea capitis.

Treatment Indicated as first line therapy for tinea manuum Butenafine Hydrochloride 1% Topical cream; Adults, Adolescents, and Children 12 years and older: Apply to affected area(s) and to immediately surrounding skin once daily for 4 weeks OR apply twice daily for 7 days. The 4 week regimen is preferred. Naftifine (2% cream) Indicated for tinea corporis, tinea cruris, and tinea pedis Naftifine Hydrochloride Topical cream; Adults, Adolescents, and Children 2 years and older: Apply topically once daily for 2 weeks. Stop treatment if irritation develops. Clotrimazole Indicated for tinea corporis, tinea cruris, and tinea pedis Clotrimazole Topical cream; Children and Adolescents 2 to 17 years: Apply to affected skin and surrounding areas twice daily. Clotrimazole Topical cream; Adults: Apply to affected skin and surrounding areas twice daily. Ciclopirox 8% nail lacquer Indicated as first line treatment for tinea unguium Ciclopirox Topical solution; Adults: Apply once daily to affected nails for up to 48 weeks. Cure rates range from 29% to 47% Amorolfine 5% nail lacquer Currently not available in the United States Indicated as first line treatment for tinea unguium Amorolfine Topical Solution, 5% (Nail Lacquer); Adults: Apply once or twice a week for up to 12 months. Tavaborole Tavaborole Topical solution; Adults: Apply topically to affected toenail(s) daily for 48 weeks. Ensure entire toenail is completely covered. Efinaconazole Efinaconazole Topical solution; Adults: Apply topically to affected toenail(s) once daily for 48 weeks. Ensure the entire toenail is completely covered. Urea

Treatment May also be effective in superficial white onychomycosis Available agents include amorolfine, ciclopirox, efinaconazole, and tavaborole A systematic review of studies that used these medications to treat mild to moderate onychomycosis reported the highest cure rates with efinaconazole Surgical curettage or scraping of affected nail plate may be effective for superficial onychomycosis Combine with topical antifungal therapy Surgical debridement of the nail plate or nail bed to remove dermatophytomas may improve outcomes in some cases of deeper infection Chemical avulsion (eg, with urea ointment) may enhance penetration of topical agents subsequently applied to the nailbed Surgical avulsion is generally not recommended and actually is contraindicated in patients with peripheral vascular disease, diabetes, and autoimmune disorders Novel treatments include photodynamic therapy and laser treatments; these are generally not curative but result in cosmetic improvement These treatments are an option for patients who cannot tolerate systemic therapy or as an adjunct to topical or systemic treatment Combination therapy using both oral and topical agents has been shown to improve outcomes, although data are sparse for newer agents. Therapy may be concurrent or sequential Similarly, limited data suggest that combined oral and laser therapies may be more efficacious than either alone Treatment of coexisting tinea pedis may improve success rates Follow-up with patients for the duration of therapy to assess treatment response and occurrence of side effects and to provide ongoing nail hygiene (eg, clipping, trimming): Once a month for fingernail infections Once every 6 to 8 weeks for toenail infections Degree of response to treatment may not be fully evident until nail is completely grown out (ie, 6 months for fingernails, 12-18 months for toenails)

2.

Humphrey, Stephen R. (2025). In Nelson Textbook of Pediatrics (pp. 4159). DOI: 10.1016/B978-0-323-88305-4.00707-0

Systemic antifungals are more effective at treating onychomycosis than topical antifungals. The long half-life of itraconazole in the nail has led to promising trials of intermittent short courses of therapy (double the normal dose for 1 week of each month for 3-4 months). Oral terbinafine is also used for the treatment of onychomycosis. Terbinafine once daily for 12 weeks is more effective than itraconazole pulse therapy. Pulse terbinafine treatment has also been used in adults and has been effective. Topical antifungals may be an acceptable treatment for mild disease without matrix involvement, and typically children have a better response to topical therapy than adults, likely because of faster growth of the nails. Several topical agents have been FDA approved for the treatment of onychomycosis in adults, including ciclopirox, efinaconazole, and tavaborole. Small clinical trials have demonstrated efficacy of ciclopirox in children. Efinaconazole and tavaborole can be used in children 6 and older as well.

3.

Tosti, Antonella (2024). In Goldman-Cecil Medicine (pp. 2747). DOI: 10.1016/B978-0-323-93038-3.00409-3

Treatment depends on clinical type, number of affected nails, and severity of nail involvement.A systemic treatment is preferred for proximal subungual onychomycosis and for distal subungual onychomycosis involving the proximal nail. Terbinafine (250mg/day) for 2 months (fingernails) or 3 months (toenails) is the most effective treatment for dermatophyte infections.Topical efinaconazole,and tavaborole,usually used daily for 6 months, are FDA approved for mild/moderate onychomycosis of the toenails, but these antifungal medications are not as effective as oral terbinafine.

4.

Noguchi H, Kubo M, Kashiwada-Nakamura K, et al. The Journal of Dermatology. 2021;48(9):1401-1404. doi:10.1111/1346-8138.15973. Copyright License: CC BY

Publish date: September 3, 2021.

Efinaconazole is a topical antifungal drug approved in Japan for tinea unguium. Although topical treatments generally have low cure rates with a prolonged therapy period, a Cochrane review confirmed that high-quality evidence supports the effectiveness of efinaconazole for the complete cure of tinea unguium. Combination therapy is a way to improve the cure rate of onychomycosis. In this study, topical efinaconazole was administrated to 12 patients who had been treated with oral terbinafine (125 mg daily) for more than 20 weeks with little expected effect. Because terbinafine accumulates for a long time in the nail, treatment immediately followed by other drugs can be considered sequential combination therapy. During terbinafine monotherapy, the percentage involvement decreased from 53.5% to 44.0% after 37.4 weeks and the effective and cure rates were 16.7% and 0%, respectively. During sequential topical efinaconazole therapy combined with lasting terbinafine in the nail, the percentage involvement decreased from 44.0% to 18.7% after 28.4 weeks, and the effective and cure rates were 66.7% and 16.7%, respectively. The improvement rate per month of combination therapy (12.6%) was higher than that with monotherapy (2.1%) (p = 0.002). There were no serious side-effects. This sequential combination therapy with efinaconazole was effective in poor terbinafine responders, making it a promising regimen for improving the cure rate of tinea unguium.