Onychomycosis Treatments

Treatment of onychomycosis is challenging because the infection is embedded within the nail and is difficult to reach.

As a result full removal of symptoms is very slow and may take a year or more.

Pharmacological

Most treatments are either systemic antifungal medications such as terbinafine and itraconazole, or topical such as nail paints containing ciclopirox or amorolfine.

There is also evidence for combining systemic and topical treatments.

For superficial white onychomycosis systemic rather than topical antifungal therapy is advised.

Relative effectiveness of treatments

In July 2007 a meta-study reported on clinical trials for topical treatments of fungal nail infections. The study included 6 randomised controlled trials dating up to March 2005.

The main findings are:

There is some evidence that ciclopiroxolamine and butenafine are both effective but both need to be applied daily for prolonged periods (at least 1 year).
There is evidence that topical ciclopiroxolamine has poor cure rates and that amorolfine might be substantially more effective.
Further research into the effectiveness of antifungal agents for nail infections is required.

A 2002 study compared the efficacy and safety of terbinafine in comparison with placebo, itraconazole and griseofulvin in treating fungal infections of the nails.

The main findings were that for reduced fungus terbinafine was found to be significantly better than itraconazole and griseofulvin, and terbinafine was better tolerated than itraconazole.

A small study in 2004 showed that ciclopirox nail paint was more effective when combined with topical urea cream.
A study of 504 patients in 2007 found that aggressive debridement of the nail combined with oral terbinafine significantly reduced symptom frequency over terbinafine alone.
A 2007 randomised clinical trial with 249 patients show that a combination of amorolfine nail lacquer and oral terbinafine enhances clinical efficacy and is more cost-effective than terbinafine alone.

Drug pipeline

Most drug development activities are focused on

the discovery of new antifungals
novel delivery methods to promote access of existing antifungal drugs into the infected nail plate

Active clinical trials investigating Onychomycosis:

Phase III

A medicinal nail lacquer, NM100060 from NexMed, contains terbinafine as the active ingredient and a permeation enhancer which facilitates the delivery of the drug into the nail bed where the fungus resides. Commercial sale of the product is cancelled.
A comparison of delivery methods for Itraconzole.
Safety and tolerability of topical Terbinafine.
Laser-based treatments
Topical IDP-108
Nail ablation with urea paste

Phase II

A topical treatment, AN-2690, is being developed by Schering-Plough Corp and Anacor Pharmaceuticals. It is active against Trichophyton species.
Posaconazole, taken orally.
A topical treatment, NB-002, is being developed by NanoBio Corporation. It has completed Phase II trials.

Drug-free treatments

Newer treatments include use of laser light sources which kill the fungus in the nail bed.

A Noveon-type laser that is already in use by physicians for some types of cataract surgery has proved very effective and painless.

It has even been reported that common laser pointers when aimed close to the nail for several minutes a week can help with the growth and appearance of the infected nail.

A promising new laser treatment for toenail fungus has been cleared by the Food and Drug Administration for the PinPointe FootLaser system, which has been available in the U.S. since September 2008.

Natural remedies

As with many diseases, there are also some scientifically unverified folk or alternative medicine remedies.

Australian tea tree oil. There is insufficient information to make recommendations for or against the use of tea tree oil for onychomycosis.
Grapefruit seed extract as a natural antimicrobial is not demonstrated. Its effectiveness is scientifically unverified. Multiple studies indicate that the universal antimicrobial activity is due to contamination with synthetic preservatives that were unlikely to be made from the seeds of the grapefruit.
Thyme oil has been shown to have a potential to be effective against the fungus that commonly infects toenails.
Snakeroot leaf extract has been shown to cure superficial Onychomycosis without side effects