topical treatment for fungal nail disease

Last edited 08/2020 and last reviewed 10/2020

Topical drugs in fungal nail disease

  • antifungal drugs can be:
    • fungistatic
      • preventing further growth of fungal cells, or
    • fungicidal
      • killing fungal cells entirely

Recommendations when to use topical therapy as monotherapy (1):

  • role of monotherapy with topical antifungals is limited to Superficial White Onychomycosis (SWO) (except in transverse or striate infections),
  • early Distal and Lateral Subungal Onychomycosis (DLSO) (except in the presence of longitudinal streaks) when < 80% of the nail plate is affected with lack of involvement of the lunula,
  • or when systemic antifungals are contraindicated

Topical drugs are usually applied daily for 12 months in order to allow the normal nail to grow and replace the regions damaged by infection:

    • drugs formulated for topical application in onychomycosis include:
      • allylamine (e.g. butenafine, terbinafine),
      • azole (e.g. clotrimazole, efinaconazole, miconazole),
      • hydroxypyridone (e.g. ciclopirox),
      • morpholine-derivative (e.g. amorolfine, Kunzea oil) - 5% amorolfine nail lacquer used once or twice a week 6 months for fingernails and 12 months for toe nails is recommended by PHE (2)
      • benzoxaborole (e.g. tavaborole) classes
    • azoles, allylamines, and morpholine-derivative drugs
      • inhibit ergosterol biosynthesis, an essential component of the cell wall
    • hydroxypyridone-class drug ciclopirox
      • inhibits metalloproteases by binding metal ions (metalloproteases are enzymes that help with fungal cell survival)
    • benzoxaborole-class drugs
      • inhibit protein translation by inhibiting the fungal leucine transfer ribonucleic acid (tRNA) synthetase
  • application of topical treatments is usually daily for 12 months, with amorolfine applied once or twice weekly for 12 months

  • topical treatments come in cream, lacquer, and solutions of varying concentrations (e.g. 5% to 10%) and are applied to the nail plate and skin surrounding the nail
    • in lacquers, alcohol solution is used to remove buildup of lacquer on the nails
    • topical treatments do not generally have drug interactions, which is useful where patients are already taking multiple oral medications
    • adverse events are usually related to skin reactions around the nail, such as rash, itching, or burning
    • a 40% urea ointment is available for the treatment of onychomycosis
      • urea ingredient provides non-surgical nail ablation of onychomycosis

  • a systematic review concluded that (5):
    • there is
      • high-quality evidence that efinaconazole 10% solution is more effective in achieving complete cure
      • low-quality evidence that ciclopirox 8% lacquer may better lead to complete cure
      • moderate-quality evidence in support of tavaborole 5% solution and P-3051 (ciclopirox 8% hydrolacquer) probably being more likely to achieve complete cure
        • although for P-3051 the comparators are ciclopirox 8% lacquer or amorolfine 5%, rather than vehicle
      • not all patients can be expected to achieve complete cure, since reported cure rates in clinical studies, while better than vehicle, are still low

Reference:

Related pages:

fungal nail disease