Recommended Medications
The authors all agreed that treatment should be individualized for each patient based on nail involvement (number, surface area, thickness), infecting organism, patient characteristics (including comorbidities), current medications, biomechanics, cost/availability/accessibility based on insurance, and patient preference.26 A decision tree to provide practical guidance on therapeutic recommendations in onychomycosis treatment has been developed by the authors (Figure 3). Therapeutic recommendations by drug are also detailed in Figure 4.
In general, the consensus was that for oral medications, terbinafine is most commonly used as first-line treatment, followed by fluconazole (can be used in patients for whom terbinafine is contraindicated). Itraconazole is generally avoided (black box warnings and frequent drug-drug interactions) and griseofulvin is rarely used (inferior efficacy). There had previously been little guidance on utility of laboratory monitoring.34-36 It was agreed by the authors that a baseline liver profile may be needed in many patients to rule out preexisting conditions, and that interval monitoring may not be necessary in young or healthy adult patients. For liver function testing, alanine aminotransferase (ALT) alone may be sufficient to capture transaminase changes and is cost-saving.34
Among topical products, authors agreed that efinaconazole is ideal as first-line medication in pediatric patients, patients with less severe disease, and those with dermatophytomas. A topical medication was also recommended for use in combination with terbinafine or fluconazole (particularly in older, immunosuppressed, diabetic, or severe patients) and can be considered as maintenance therapy to prevent relapse. To improve outcomes, concurrent tinea pedis should be treated in all patients receiving topical therapy for onychomycosis.37
Treatment by severity or clinical pattern
For treating patients with mild-to-moderate disease, topical efinaconazole or terbinafine are recommended as first-line therapy (Figure 3). For severe disease, defined in Figure 2, use terbinafine as a first-line oral with or without a topical. DLSO is the most common clinical pattern. As such, clinical trials typically exclude patients with other patterns, leaving a paucity of information regarding treatment efficacy in non- DLSO patterns.1,12 Authors recommend all patterns be treated by severity following recommendations above. In the case of fingernail only infection with confirmed Candida albicans, treat with fluconazole first.
The authors all agreed that treatment should be individualized for each patient based on nail involvement (number, surface area, thickness), infecting organism, patient characteristics (including comorbidities), current medications, biomechanics, cost/availability/accessibility based on insurance, and patient preference.26 A decision tree to provide practical guidance on therapeutic recommendations in onychomycosis treatment has been developed by the authors (Figure 3). Therapeutic recommendations by drug are also detailed in Figure 4.
In general, the consensus was that for oral medications, terbinafine is most commonly used as first-line treatment, followed by fluconazole (can be used in patients for whom terbinafine is contraindicated). Itraconazole is generally avoided (black box warnings and frequent drug-drug interactions) and griseofulvin is rarely used (inferior efficacy). There had previously been little guidance on utility of laboratory monitoring.34-36 It was agreed by the authors that a baseline liver profile may be needed in many patients to rule out preexisting conditions, and that interval monitoring may not be necessary in young or healthy adult patients. For liver function testing, alanine aminotransferase (ALT) alone may be sufficient to capture transaminase changes and is cost-saving.34
Among topical products, authors agreed that efinaconazole is ideal as first-line medication in pediatric patients, patients with less severe disease, and those with dermatophytomas. A topical medication was also recommended for use in combination with terbinafine or fluconazole (particularly in older, immunosuppressed, diabetic, or severe patients) and can be considered as maintenance therapy to prevent relapse. To improve outcomes, concurrent tinea pedis should be treated in all patients receiving topical therapy for onychomycosis.37
Treatment by severity or clinical pattern
For treating patients with mild-to-moderate disease, topical efinaconazole or terbinafine are recommended as first-line therapy (Figure 3). For severe disease, defined in Figure 2, use terbinafine as a first-line oral with or without a topical. DLSO is the most common clinical pattern. As such, clinical trials typically exclude patients with other patterns, leaving a paucity of information regarding treatment efficacy in non- DLSO patterns.1,12 Authors recommend all patterns be treated by severity following recommendations above. In the case of fingernail only infection with confirmed Candida albicans, treat with fluconazole first.
