Treating Toenail Fungus Expectations

You’ll get questions about treating stubborn toenail fungus…now that sandal season is upon us.

Onychomycosis can be a cosmetic concern when nails are discoloured, thick, and brittle…but treatment isn’t always needed.

Set expectations. It can take over a year to see improvement with meds…until the toenail grows out. And recurrence is common.

Suggest treatment based on cure rate, interactions, and cost.

Rx orals. Stick with terbinafine first for most patients…especially if the nail bed or several nails are affected. About half of patients “clear” the fungus after 12 weeks of daily use.

Explain that terbinafine is usually more effective than itraconazole or fluconazole…has fewer interactions..

Plus monitoring is simpler now. Advise checking liver function before starting…and if normal, follow-up labs usually aren’t needed.

Consider pulse dosing…such as terbinafine 250 mg/day for 4 weeks, then 4 weeks off, and then 4 more weeks. Point out this seems to work as well as daily use…and may limit side effects.

Rx topicals. Advise limiting topicals (Jublia, etc). Fewer than 20% of patients “clear” the fungus after a YEAR of daily use.

Plus topicals are cumbersome to apply…and costly.

Don’t recommend combining Rx topical and oral meds. It’s not likely to improve cure rates…and adds cost.

OTCs or home remedies. Patients will ask about many options…topical clotrimazole, tea tree oil, Vicks VapoRub, etc. Explain these aren’t likely to be harmful…but evidence they help is scant.

Advise treating athlete’s foot…it’s often the culprit for recurrence. And share prevention tips…such as keeping feet cool and dry, trimming nails, and wearing flip-flops at the pool.