Options for Nail Fungus Treatment

JANUARY 01, 2006
Shannon W. Fields, BA, CPhT

Onychomycosis, or nail fungus, is a common dermatologic condition, occurring when fungi infect one or more of the nails. It is estimated that, by the age of 70, up to 50% of individuals will have been infected. Onychomycosis is most often seen in adults, becoming increasingly common with advancing age. While onychomycosis is among the most common fungal infections found in the body, it can be difficult to treat and is prone to recurrence.

Fungal nail infections are unsightly, can be painful, and may cause permanent nail damage. Far more serious complications can occur, however, particularly in people with diabetes, peripheral vascular disease, or weakened immune systems. In such cases, a minor injury or infection can lead to serious complications such as foot ulcers. For these reasons, treatment of the infected nail is important. Symptoms include brittleness, discoloration, thickening of the nail, distortion of the nail's shape, crumbling or ragged nails, dullness, loss of luster or shine, or loosening or detachment of the nail.

Types of Onychomycosis

Onychomycosis is generally classified into 4 subtypes. They are:

  • Distal subungual: The most common subtype, usually presenting as a yellow or white patch of discoloration at the distal end of the nail.
  • White superficial: Fungi invade the superficial layer of the nail plate and cause white spots to appear.
  • Candidal: Often occurs in nails previously damaged by infection or trauma; particularly common in patients with chronic mucotaneous candidiasis.
  • Proximal subungual: The least common form; usually seen in immunocompromised patients.

Treatment of Nail Fungus

Several approaches are accepted for treating onychomycosis, although some are safer and more cost-effective than others. Systemic treatments are frequently used today but pose a risk of liver toxicity and other significant side effects. Serious drug interactions may occur with the use of systemic antifungal treatments, and full disclosure of all current medications is vital. Most systemic medications can also be made into topical compounds. Commonly used systemic treatments include:

  • Griseofulvin: Inhibits fungal cell wall synthesis and DNA production. Possible side effects include rash, gastrointestinal (GI) symptoms, joint pain, peripheral neuropathy, and, occasionally, memory loss.
  • Itraconazole: May be used continuously or as part of a pulse dose therapy. Potential side effects include rash, headache, GI symptoms, dry skin, weakness, hypertension, or dizziness. Liver function should be monitored carefully.
  • Terbinafine: Inhibits ergosterol production. Side effects may include headache, rash, GI symptoms, and changes in taste.
  • Fluconazole: Considered an off-label use but has proven effective in some cases with pulse-dose therapy. Liver enzymes should be monitored. Immunocompromised patients have a greater risk of developing side effects, such as GI symptoms, headaches, and pruritis. Significant drug interactions may occur with drugs such as terbinafine, theophylline, coumadin, cyclosporine, and oral hypoglycemics.

Nonsystemic Treatments and Compounded Medications

For many patients, systemic therapy is contraindicated, and a topical preparation may be more appropriate. Currently, one preparation is commercially available, but other options are available through a compounding pharmacy.

Ciclopirox is available under the trade name Penlac. It is used topically once daily for up to a year, and its side effects are usually minimal.

Compounded preparations provide a valuable resource for the treatment of onychomycosis. A host of options may be considered, as any of the commercially available systemic products mentioned above may be prepared as a topical agent by an experienced compounding pharmacist. Other agents may also be added to enhance the effectiveness of the drug. Some physicians combine topical treatment with oral pulse therapy for maximum effectiveness.

Compounded medications may be less costly than systemic treatments. For this reason, as well as the lower chance of potentially harmful side effects and the ability to individualize treatment, compounded medications for onychomycosis should be considered as a first-line treatment for nail fungus.

Ms. Fields is with the International Journal of Pharmaceutical Compounding and is a pharmacy technician at Innovative Pharmacy Services in Edmond, Okla.

For More Information The International Journal of Pharmaceutical Compounding (IJPC) is a bimonthly scientific and professional journal emphasizing high-quality pharmaceutical compounding. The journal covers topics relevant and necessary to empower pharmacists to meet the needs of today's patients. For more information, or to subscribe to IJPC, visit www.ijpc.com, or call 888-588-4572.