Medication Summary

The goals of pharmacotherapy for onychomycosis are to reduce morbidity and to prevent complications.

Class Summary

The goals of pharmacotherapy for onychomycosis are to reduce morbidity and to prevent complications.

Terbinafine (Lamisil)

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Terbinafine inhibits squalene epoxidase, which decreases ergosterol synthesis, causing fungal cell death. Use the medication until symptoms significantly improve. More studies are needed to establish the efficacy of pulse regimens and the optimal duration of treatment.

Itraconazole (Sporanox)

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Itraconazole has fungistatic activity. It is a synthetic triazole antifungal agent that slows fungal cell growth by inhibiting CYP-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.

Fluconazole (Diflucan)

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Fluconazole has fungistatic activity. It is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal CYP-450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol, thereby disrupting cellular membranes. Treatment should continue until the infection resolves.

Class Summary

Treatment of onychomycosis with topical antifungals is typically used as adjunctive therapy in combination with oral agents.

Ciclopirox (Penlac)

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Ciclopirox interferes with the synthesis of DNA, RNA, and protein by inhibiting the transport of essential elements in fungal cells.

Efinaconazole (Jublia)

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Efinaconazole is a topical triazole antifungal agent. It inhibits fungal lanosterol 14α-demethylase involved in the biosynthesis of ergosterol, a constituent of fungal cell membranes. It is indicated for onychomycosis of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes.

Tavaborole (Kerydin)

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Tavaborole, a topical oxaborole antifungal (boron-containing compound), is indicated for onychomycosis of the toenails due to Trichophyton rubrum or Trichophyton mentagrophytes. It is available as 0.5% topical solution.

Questions

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Media Gallery

Distal subungual onychomycosis. Onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.
Distal subungual onychomycosis. Subungual hyperkeratosis onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.
Proximal subungual onychomycosis. Proximal leukonychia. Image courtesy of Dr Antonella Tosti.
White superficial onychomycosis. Image courtesy of Dr Antonella Tosti.
Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. Image courtesy of Dr Antonella Tosti.
Dermoscopy of distal subungual onychomycosis showing irregular margin of the onycholytic area with spikes projecting into the proximal nail plate, reported as the "aurora borealis" pattern. Handyscope at 20X.

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Author

Antonella Tosti, MD Professor of Dermatology, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine

Antonella Tosti, MD is a member of the following medical societies: American Academy of Dermatology, International Society of Dermatology, European Academy of Dermatology and Venereology, Women's Dermatologic Society, Canadian Dermatology Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: PharmaDerm<br/>Received income in an amount equal to or greater than $250 from: Valeant; Pharmaderm.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina at Chapel Hill School of Medicine; Professor Emeritus of Dermatology, Columbia University College of Physicians and Surgeons

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Medical Association, The Society of Federal Health Professionals (AMSUS), International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Mark Blumberg, MD, MS, Gary R. Kantor, MD, and John Ratz, MD, MBA, to the development and writing of this article.

Onychomycosis Medication

Medication Summary

Antifungals, Systemic