How to treat FUNGAL NAIL infections

As a community pharmacist, patients will ask you how to get rid of fungal nail infections. They get frustrated with treatments that often don't work, or when the infection comes back after an initial improvement. Help patients sort through their options.

Oral antifungals are the most effective. Start with oral terbinafine (Lamisil, etc) 250 mg daily for 6 weeks for fingernails or 12 weeks for toenails. It's the most effective and has the fewest drug interactions. Explain that about half of patients will have a cure, but it still takes months for the damaged nails to grow out.

• Itraconazole (Sporanox, etc) is less effective and interacts with many drugs like simvastatin, amlodipine, oxycodone, etc. Consider monitoring liver enzymes with terbinafine or itraconazole.
• Try not to use oral fluconazole, it's the least effective.
• Ciclopirox nail lacquer (Batrafen, Mycoster, etc) cures only about 7% of patients, even after using it for a year. Make sure patients know about the long odds and the long wait.
• OTC nail lacquers (Fungi-Nail, etc) treat fungus around the nail, they don't penetrate the nail plate. Don't recommend them.

Laser therapy (PinPointe, etc) is now approved to improve the appearance of fungal nails. It can require multiple sessions and usually isn't covered by health insurance. Consider it if oral medications aren't effective or tolerated.

• Vicks VapoRub and tea tree oil are popular home remedies, but don't recommend them. There's not enough reliable evidence. Caution patients about possible recurrence.
• For toenails, suggest keeping feet clean and dry, and possibly using an antifungal cream or spray regularly for their feet and shoes.

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References

1. de Berker D. Clinical practice. Fungal nail disease. N Engl J Med. 2009 May 14;360(20):2108-16.
2. Chang CH, Young-Xu Y, Kurth T, Orav JE, Chan AK. The safety of oral antifungal treatments for superficial dermatophytosis and onychomycosis: a meta-analysis. Am J Med. 2007 Sep;120(9):791-8.

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