What's the best treatment for onychomycosis?

1.

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.

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.

Elsevier ClinicalKey Clinical Overview

Treatment First line agents are terbinafine and griseofulvin In the United States, terbinafine is the first choice because it is superior for treating Trichophyton species, which is responsible for most tinea capitis in this country Griseofulvin is superior for treating infection with Microsporum species For patients with tinea capitis or tinea barbae complicated by presence of a kerion, choose first line treatment with griseofulvin, unless Trichophyton species has been confirmed as the infectious agent Second line agent is itraconazole Use fluconazole for disease refractory to first or second line agents For all patients, treat the scalp with topical antifungal therapy (medicated shampoo) early in the course of systemic therapy to reduce transmission of spores Combined topical and oral antifungal therapy may increase the cure rate Treatment is based on patient needs and expectations For patients who are not in pain or bothered by the appearance, treatment may not be necessary, although some experts recommend that all cases be treated Systemic antifungal therapy offers greater success rates for eradicating infection, particularly distal subungual onychomycosis Systemic therapy is not used unless diagnosis has been confirmed using potassium hydroxide preparation, fungal culture, or nail biopsy Oral terbinafine appears to be the most effective agent recommended as first line therapy Itraconazole is nearly as effective and tolerable as terbinafine; griseofulvin is another option Terbinafine resistance is an emerging problem in some countries Topical antifungal therapy is generally less effective but appropriate in some circumstances Recommended when infection involves less than 80% of the nail plate (excluding the lunula and in the absence of longitudinal streaks), for patients with contraindications to systemic treatment, and as post-treatment prophylaxis May also be effective in superficial white onychomycosis

4.

Werth, Victoria P., Armstrong, April W. (2024). In Goldman-Cecil Medicine (pp. 2697). DOI: 10.1016/B978-0-323-93038-3.00404-4

Griseofulvin is best taken with a fatty meal to improve absorption and is the only antifungal drug not requiring regular monitoring of liver enzymes. Griseofulvin shows weak affinity for keratin, and thus it must be used for 18 months for onychomycosis of the toenails and 6 months for the fingernails to achieve even relatively poor cure rates. Terbinafine is the only fungicidal drug; the rest are fungistatic. The number of interactions with medications is lower with terbinafine than with the triazole antifungals and ketoconazole because terbinafine does not inhibit or induce hepatic isoenzyme cytochrome P (CYP3A4) (Chapter 25). However, terbinafine affects CYP2D6, another hepatic isoenzyme, so it is relatively contraindicated in patients who are taking cyclosporine or rifampin. Itraconazole and fluconazole have been used in pulse-dosing regimens for the treatment of onychomycosis. Fluconazole and terbinafine are not dependent on gastric acidity for optimal gastrointestinal absorption. Overall, the side effects of the systemic antifungal agents are similar and include headache and gastrointestinal symptoms (griseofulvin, terbinafine), nausea and vomiting (itraconazole, fluconazole, ketoconazole), hepatitis, and lupus-like syndromes (terbinafine).

5.

Food and Drug Administration (DailyMed).

Publish date: November 5, 2019.

Dosage And Administration 2. DOSAGE AND ADMINISTRATION Fingernail onychomycosis: One 250 mg tablet once daily for 6 weeks. Toenail onychomycosis: One 250 mg tablet once daily for 12 weeks. The optimal clinical effect is seen some months after mycological cure and cessation of treatment. This is related to the period required for outgrowth of healthy nail. • Fingernail onychomycosis: One 250 mg tablet, once daily for 6 weeks ( 2 ) • Toenail onychomycosis: One 250 mg tablet, once daily for 12 weeks ( 2 )

Clinical Studies 14. CLINICAL STUDIES The efficacy of terbinafine tablets in the treatment of onychomycosis is illustrated by the response of subjects with toenail and/or fingernail infections who participated in 3 US/Canadian placebo-controlled clinical trials. Results of the first toenail trial, as assessed at week 48 (12 weeks of treatment with 36 weeks follow-up after completion of therapy), demonstrated mycological cure, defined as simultaneous occurrence of negative KOH plus negative culture, in 70% of subjects. Fifty-nine percent (59%) of subjects experienced effective treatment (mycological cure plus 0% nail involvement or >5mm of new unaffected nail growth); 38% of subjects demonstrated mycological cure plus clinical cure (0% nail involvement). In a second toenail trial of dermatophytic onychomycosis, in which nondermatophytes were also cultured, similar efficacy against the dermatophytes was demonstrated. The pathogenic role of the nondermatophytes cultured in the presence of dermatophytic onychomycosis has not been established. The clinical significance of this association is unknown. Results of the fingernail trial, as assessed at week 24 (6 weeks of treatment with 18 weeks follow-up after completion of therapy), demonstrated mycological cure in 79% of subjects, effective treatment in 75% of the subjects, and mycological cure plus clinical cure in 59% of the subjects. The mean time to overall success was approximately 10 months for the first toenail trial and 4 months for the fingernail trial. In the first toenail trial, for subjects evaluated at least 6 months after achieving clinical cure and at least 1 year after completing therapy with terbinafine tablets, the clinical relapse rate was approximately 15%.

6.

Frazier WT, Santiago-Delgado ZM, Stupka KC. American Family Physician. 2021;104(4):359-367.

Publish date: October 5, 2021.

Onychomycosis is a chronic fungal infection of the fingernail or toenail bed leading to brittle, discolored, and thickened nails. Onychomycosis is not just a cosmetic problem. Untreated onychomycosis can cause pain, discomfort, and physical impairment, negatively impacting quality of life. Onychomycosis should be suspected in patients with discolored nails, nail plate thickening, nail separation, and foul-smelling nails. Accurate diagnosis is important before initiating treatment because therapy is lengthy and can cause adverse effects. A potassium hydroxide preparation with confirmatory fungal culture, periodic acid-Schiff stain, or polymerase chain reaction is the preferred diagnostic approach if confirmative testing is cost prohibitive or not available. Treatment decisions should be based on severity, comorbidities, and patient preference. Oral terbinafine is preferred over topical therapy because of better effectiveness and shorter treatment duration. Patients taking terbinafine in combination with tricyclic antidepressants, selective serotonin reuptake inhibitors, atypical antipsychotics, beta blockers, or tamoxifen should be monitored for drug-drug interactions. Topical therapy, including ciclopirox 8%, efinaconazole 10%, and tavaborole 5%, is less effective than oral agents but can be used to treat mild to moderate onychomycosis, with fewer adverse effects and drug-drug interactions. Nail trimming and debridement used concurrently with pharmacologic therapy improve treatment response. Although photodynamic and plasma therapies are newer treatment options that have been explored for the treatment of onychomycosis, larger randomized trials are needed. Preventive measures such as avoiding walking barefoot in public places and disinfecting shoes and socks are thought to reduce the 25% relapse rate.

7.

Martin, Kari L. (2025). In Nelson Textbook of Pediatrics (pp. 4142). DOI: 10.1016/B978-0-323-88305-4.00704-5

Fungal infection(onychomycosis)of the nails has been classified into four types. White superficial onychomycosis manifests as diffuse or speckled white discoloration of the surface of the toenails. It is caused primarily byTrichophyton mentagrophytes,which invades the nail plate. The organismmay be scraped off the nail plate with a blade, but treatment is best accomplished by the addition of a topical azole antifungal agent. Distal subungual onychomycosis, the most common type, involves foci of onycholysis under the distal nail plate or along the lateral nail groove, followed by development of hyperkeratosis and yellow-brown discoloration. The process extends proximally, resulting in nail plate thickening, crumbling (Fig. 704.10), and separation from the nail bed.Trichophyton rubrumand, occasionally,T. mentagrophytesinfect the toenails; fingernail disease is almost exclusively caused byT. rubrum,which may be associated with superficial scaling of the plantar surface of the feet and often of one hand. The dermatophytes are found most readily at the most proximal area of the nail bed or adjacent ventral portion of the involved nail plates. Topical therapies such as ciclopirox 8% lacquer, amorolfine 5% lacquer, or bifonazole-urea 1%/40% ointment may be effective for solitary nail infection. Topical efinaconazole 10% and topical tavaborole 5% solution may also be effective; laser treatment is an expensive but safe alternative to oral therapy. Because of its long half-life in the nail, oral itraconazole may be effective when given as pulse therapy (1 week of each month for 3-4 months). Dosage is weight-dependent. Oral daily terbinafine is also quite effective. Either agent is superior to griseofulvin, fluconazole, or ketoconazole. The risks, the most concerning of which is hepatic toxicity, and costs of oral therapy are minimized with the use of pulsed dosing.

8.

Food and Drug Administration (DailyMed).

Publish date: February 3, 2024.

Indications And Usage Onychomycosis of the toenail Analyses were conducted on data from three double-blind, placebo-controlled studies (N=214 total; 110 given SPORANOX (itraconazole) ® Capsules) in which patients with onychomycosis of the toenails received 200 mg of SPORANOX (itraconazole) ® Capsules once daily for 12 consecutive weeks. Results of these studies demonstrated mycologic cure, defined as simultaneous occurrence of negative KOH plus negative culture, in 54% of patients. Thirty-five percent (35%) of patients were considered an overall success (mycologic cure plus clear or minimal nail involvement with significantly decreased signs) and 14% of patients demonstrated mycologic cure plus clinical cure (clearance of all signs, with or without residual nail deformity). The mean time to overall success was approximately 10 months. Twenty-one percent (21%) of the overall success group had a relapse (worsening of the global score or conversion of KOH or culture from negative to positive). Onychomycosis of the fingernail Analyses were conducted on data from a double-blind, placebo-controlled study (N=73 total; 37 given SPORANOX (itraconazole) ® Capsules) in which patients with onychomycosis of the fingernails received a 1-week course (pulse) of 200 mg of SPORANOX (itraconazole) ® Capsules b.i.d., followed by a 3-week period without SPORANOX (itraconazole) ®, which was followed by a second 1-week pulse of 200 mg of SPORANOX (itraconazole) ® Capsules b.i.d. Results demonstrated mycologic cure in 61% of patients. Fifty-six percent (56%) of patients were considered an overall success and 47% of patients demonstrated mycologic cure plus clinical cure. The mean time to overall success was approximately 5 months. None of the patients who achieved overall success relapsed.

9.

Elsevier ClinicalKey Drug Monograph

Content last updated: March 4, 2024.

Description Lamisil At is an oral and topical antifungal agent that is pharmacologically similar to naftifine. Oral lamisil at is highly effective for treating onychomycosis due to its fungicidal activity and ability to concentrate within the nail. In clinical studies, the efficacy of oral lamisil at in the treatment of onychomycosis was found to be superior to both griseofulvin and itraconazole. Further, the rate of relapse with lamisil at were lower than those observed with griseofulvin. Onychomycosis clinical cure rates for lamisil at are approximately 50% to 70%. Oral lamisil at has also been utilized in small open-label studies as an alternative treatment for bronchopulmonary aspergillosis refractory to other treatments; in some cases lamisil at has suppressed or eradicated the disease. Topical lamisil at was approved by the FDA in 1993. Lamisil At oral tablets were approved May 1996. Lamisil At cream received approval as an over-the-counter treatment of tinea pedis in March 1999. Lamisil At oral granules were approved for use in pediatric patients, ages 4 years and older, for the treatment of tinea capitis in September 2007.