Treatment of Onychomycosis

Medications

In the past, medicines used to treat onychomycosis (OM) were not very effective. OM is difficult to treat because nails grow slowly and receive very little blood supply. However, recent advances in treatment options, including oral (taken by mouth) and topical (applied on the skin or nail surface) medications, have been made. Newer oral medicines have revolutionized treatment of onychomycosis. However, the rate of recurrence is high, even with newer medicines. Treatment is expensive, has certain risks, and recurrence is possible.

• Topical antifungals are medicines applied to the skin and nail area that kill fungus.
  
  
  • These topical agents should only be used if less than half the nail is involved or if the person with onychomycosis cannot take the oral medicines. Medicines include amorolfine (approved for use outside the United States), ciclopirox olamine (Penlac, which is applied like nail polish), sodium pyrithione, bifonazole/urea (available outside the United States), propylene glycol-urea-lactic acid, imidazoles, such as ketoconazole (Nizoral Cream), and allylamines, such as terbinafine (Lamisil Cream).
  
  
  
  • Topical treatments are limited because they cannot penetrate the nail deeply enough, so they are generally unable to cure onychomycosis. Topical medicines may be useful as additional therapy in combination with oral medicines.
     
• Newer oral medicines are available. These antifungal medicines are more effective because they go through the body to penetrate the nail plate within days of starting therapy.
  
  
  • Newer oral antifungal drugs terbinafine (Lamisil Tablets) and itraconazole (Sporanox Capsules) have replaced older therapies, such as griseofulvin, in the treatment of onychomycosis. They offer shorter treatment periods (oral antifungal medications usually are administered over a 3-month period), higher cure rates, and fewer side effects. These medications are fairly safe, with few contraindications (conditions that make taking the medicine inadvisable), but they should not be taken by patients with liver disease or heart failure. Before prescribing one of these medications, doctors often order a blood test to make sure the liver is functioning properly. Common side effects include nausea and stomach pain.
  
  
  
  • Fluconazole (Diflucan) is not approved by the Food and Drug Administration (FDA) for treatment of onychomycosis, but it may be an alternative to itraconazole and terbinafine.
     
• To decrease the side effects and duration of oral therapy, topical and surgical treatments may be combined with oral antifungal management.

Surgery

Surgical approaches to onychomycosis treatment include surgically or chemically removing the nail (nail avulsion or matrixectomy).

• Removing the nail plate (fingernail or toenail) is not effective treatment on its own. This procedure should be considered an adjunctive (additional) treatment combined with oral therapy.



• A combination of oral, topical, and surgical therapy can increase the effectiveness of treatment and reduce the cost of ongoing treatments.