Onychomycosis treatment
Posted by dkwinter

Oral therapy

  • Terbinafine [Lamisil; Terbinex] (duration--same for adults & peds: 6 weeks for fingernails, 12 weeks for toenails)
    • Monitoring: less liver complications than azoles but reasonable to check LFTs at baseline and up to q6weeks; also check CBC
    • Interactions: inhibits CYP2D6--less interactions than with azoles
    • Adult dose:
      • 250 mg PO daily
    • Pediatric doses:
      • 10-20 kg: 62.5 mg PO daily
      • 20-40 kg: 125 mg PO daily
      • Above 40 kg: 250 mg PO daily
  • Itraconazole [Sporanox; Onmel] (6 weeks for fingernails, 12 weeks for toenails)
    • Monitoring: check LFTs at baseline and approx. q6weeks. Also follow renal function.
    • Interactions: inhibits CYP3A4--interactions common
    • Adult dose:
      • 200 mg PO daily
    • Pediatric dose (pulse dosing: daily for one week per month x 2 months for fingernails, or 3 months for toenails):
      • Less than 20 kg: 5mg/kg PO daily
      • 20-40 kg: 100 mg PO daily
      • 40-50 kg: 200 mg PO daily
      • More than 50 kg: 200 mg PO BID
  • Fluconazole
    • Monitoring: periodic monitoring of LFTs, renal function and potassium
      • Monitoring is generally NOT required for pulse therapy
    • Interactions: inhibits CYP3A4--interactions common
    • Pediatric dose (12-16 weeks for fingernails, 18-26 weeks for toenails)
      • 3-6 mg/kg PO given as just one dose per week

 

Topical therapy

  • Efinaconazole 10% solution [Jublia]
    • Indication: distal lateral subungual onychomycosis
    • ​Efficacy ~15% cure rate at one year
    • Dose:
      • ​Apply to affected toenail(s) once daily for 48 weeks
  • A couple other topical options have success rate in the 5-7% range. For more info see: http://www.uptodate.com/contents/onychomycosis