Onychomycosis Treatment Guidelines

Introduction to Onychomycosis Treatment

The British Association of Dermatologists guidelines state that ketoconazole cannot be prescribed for dermatophyte onychomycosis because of problems with hepatotoxicity 1, 2, 3

The British Association of Dermatologists recommends terbinafine 250 mg daily for 12 weeks as the first-line treatment for toenail onychomycosis caused by dermatophytes, due to its superior efficacy, lower relapse rates, and fungicidal activity against dermatophytes 4, 5
Terbinafine has a strength of recommendation A, level of evidence 1+, and minimal drug interactions compared to azole antifungals 4

Baseline liver function tests and complete blood count should be obtained before starting terbinafine treatment, as recommended by the British Association of Dermatologists 4, 5
Terbinafine is contraindicated in patients with active or chronic liver disease or lupus erythematosus, as stated by the British Association of Dermatologists 4

Itraconazole can be considered as an alternative treatment option, with pulse therapy of 400 mg daily for 1 week per month, and 3 pulses for toenails, as recommended by the British Association of Dermatologists 1, 2
Itraconazole is active against both dermatophytes and Candida species, but requires liver function monitoring for treatment durations longer than 1 month, as stated by the British Association of Dermatologists 1, 2
Fluconazole can be considered as a second-line treatment option, with a dose of 3-6 mg/kg once weekly for 18-26 weeks for toenails, but its dose and duration are not yet clearly established, as recommended by the British Association of Dermatologists 1, 2, 3, 6
Griseofulvin has poor cure rates and high relapse rates for toenail infections, and is only recommended when newer agents are contraindicated, as stated by the British Association of Dermatologists 1, 2, 3