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Topical Therapy for Toenail Onychomycosis: An Evidence-Based Review

  • Evidence-Based Review
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Abstract

Background

Managing toenail onychomycosis with topical treatments is challenging. It is difficult for topical medication to penetrate the nail plate, and this is reflected in lower cure rates with topical treatment than with oral treatment. However, oral medications may not be suitable for some patients, because of drug interactions; therefore, topical treatments are critical in managing the disease in certain patient populations.

Objective

This paper reviews the quality and content of the scientific literature on topical treatments for toenail onychomycosis.

Methods

PubMed, Ovid (Medline and Embase), Scopus, Cochrane library, and clinicaltrials.gov databases were searched for original clinical reports of topical monotherapy for microscopy and/or culture-confirmed toenail onychomycosis in adults. Studies were evaluated using an onychomycosis study quality scale, which was based on the CONSORT guidelines.

Results

Twenty-five publications (28 studies) were identified and met the inclusion criteria. Thirteen studies scored high ratings on the quality scale. These were randomized controlled trials or randomized comparative trials. Low-quality studies were nonrandomized, open studies that prevented statistical analysis. Most studies reported clinical and mycological cure. The most variation was observed with reporting outcomes of clinical improvement. Amorolfine, ciclopirox, tavaborole, and efinaconazole produced clinical and mycological cure in patients with mild to moderate toenail onychomycosis (<50–65 % nail involvement), with efinaconazole showing the highest rates. Treatments were generally applied daily for 24–48 weeks, with longer treatment and follow-up showing better outcomes.

Conclusion

Topical treatment with amorolfine, ciclopirox, tavaborole, or efinaconazole is appropriate for cases of mild to moderate toenail onychomycosis due to dermatophyte or mixed dermatophyte/Candida infection.

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Conflict of interest

AKG has been a clinical trials investigator for Valeant Canada, Bristol Myers Squibb, Eli Lilly, Merck, Novartis, Janssen, Nuvolase, and Allergan. AKG has served as a speaker for Valeant Canada and Bayer, as well as consulting for Anacor Pharmaceuticals. DD and KAF are employees of Mediprobe Research Inc., which conducts clinical trials under the supervision of AKG.

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Authors and Affiliations

  1. University of Toronto, Toronto, Canada

    Aditya K. Gupta

  2. Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada

    Aditya K. Gupta, Deanne Daigle & Kelly A. Foley

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  1. Aditya K. Gupta
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Correspondence to Aditya K. Gupta.

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Gupta, A.K., Daigle, D. & Foley, K.A. Topical Therapy for Toenail Onychomycosis: An Evidence-Based Review. Am J Clin Dermatol 15, 489–502 (2014). https://doi.org/10.1007/s40257-014-0096-2

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