Almirall
Onychomycosis

Onychomycosis treatments

What are the treatments for onychomycosis?

Onychomycosis is a fungal infection affecting the fingernails or, far more commonly, the toenails. It is often slow to resolve, can persist for years, and may respond unpredictably to treatment.

Management usually involves one or more of the following: oral antifungal medicines, topical preparations, and, in exceptional cases, mechanical removal of part or all of the affected nail. The most appropriate option depends on how severe the infection is, the type of fungus involved, the number of nails affected and the patient’s overall health. 

Oral treatments for onychomycosis

  • Oral antifungal therapy remains the most effective approach for moderate-to-severe onychomycosis, particularly when the infection reaches the nail matrix, affects several nails or is unlikely to respond to topical agents alone. The medicines most commonly prescribed include terbinafine and itraconazole; fluconazole may also be used in some regions.
  • Terbinafine is often preferred because it generally achieves higher clearance rates. For toenail infections, it is typically taken daily for several weeks, although exact dosing may vary depending on local clinical guidelines.
  • Itraconazole can be prescribed continuously or as part of an intermittent schedule, depending on the specific product and national recommendations.

Because these treatments act systemically, they carry risks such as liver toxicity and interactions with other medicines—especially with azole-based drugs. For this reason, baseline assessments and careful patient selection are essential.

Oral therapy is usually recommended when:

  • More than one nail is affected, or over half of the surface of a single nail is involved.
  • The infection reaches the lunula or nail matrix.
  • Laboratory testing confirms dermatophyte infection.
  • Rapid or predictable results are preferred.

In cases where the patients cannot take oral antifungals due to liver disease, interacting medications, or difficulties with adherence, it may be better to resort to topical options. 

Topical treatments for onychomycosis

Topical preparations are generally used in mild to moderate infections: usually one or two nails affected, limited nail involvement, no matrix disease and confirmed dermatophyte infection.

Their main advantage is safety, as they avoid systemic exposure. They also preserve oral options for future episodes. However, the nail plate provides a significant barrier, which limits penetration and contributes to lower cure rates compared with oral medicines.
Common topical options include:

  • antifungal nail lacquers (such as ciclopirox-based formulations, including newer preparations designed to enhance nail penetration)
  • newer azole-based topical treatments are available in certain regions
  • supportive measures such as regular debridement, thinning or chemical softening of the nail to improve absorption
     

Although they are often slower and less reliable than oral treatments, topical agents remain appropriate for early or uncomplicated infections, or where oral therapy is unsuitable. 

Is ciclopirox nail lacquer effective?

Ciclopirox 8% lacquer is one of the most established topical treatments for onychomycosis. Evidence shows that it can clear infection in a proportion of patients, although results tend to be modest when compared with systemic therapy. More recent formulations that improve the lacquer’s ability to penetrate the nail appear to perform better than older water-insoluble products.

Clinical guidelines generally recognize ciclopirox lacquer as a suitable option for mild-to-moderate cases.

It is important, however, to set realistic expectations:

  • Complete clearance rates are relatively low in everyday practice
  • Results rely heavily on consistent, long-term use, often over the course of a year or more.
  • Regular debridement or thinning of the nail enhances success

Ciclopirox can therefore be effective in appropriately selected patients, but those with more advanced infection may ultimately require oral therapy or a combination approach. 

Surgical or chemical nail avulsion

In very thick, distorted or extensively damaged nails, the penetration of topical or oral agents may be severely reduced. In such cases, mechanical or chemical removal of the affected nail can be considered to complement antifungal treatment. 

These methods may include:

  • partial or complete surgical removal of the nail plate
  • chemical avulsion using keratolytic agents (such as high-strength urea)
  • debridement to thin the nail and remove subungual debris 

By reducing fungal load and allowing better access for medicines, these approaches can accelerate clinical improvement. They are usually viewed as supportive measures rather than standalone treatments. Device-based techniques, including lasers and photodynamic therapy, are being studied, but current evidence remains limited. 

What are the key factors in choosing a treatment?

Selecting the most appropriate treatment strategy for onychomycosis involves a careful evaluation of multiple factors:

 

Extent and severity of infection

Number of nails involved, percentage of nail plate affected, involvement of lunula/matrix; more extensive disease favours oral therapy.

Type of fungus

Dermatophytes respond more reliably than non-dermatophyte moulds or yeasts.

Patient characteristics

Underlying conditions, liver or kidney health, immunosuppression, potential drug interactions and the ability to follow long treatment courses.

Nail features

Markedly thick or dystrophic nails may require debridement or avulsion.

Balance of risks and benefits

Oral drugs carry higher systemic risks but also higher cure rates; topical therapy is safer but slower.

Cost, access, and convenience

Preventive measures and long-term care should be considered, especially in patients with a history of repeated infections.

Risk of recurrence

Preventive measures and long-term care should be considered, especially in patients with a history of repeated infections.

 

A tailored plan combining medical factors and patient priorities usually leads to the best outcomes. 

What happens if the onychomycosis treatment does not work?

Treatment failure or relapse is relatively common. When an initial approach is unsuccessful, several steps can help refine the management plan:

 

Confirm the diagnosis

Nail disorders such as psoriasis, trauma or eczema can mimic fungal infection. Laboratory testing may be needed before changing treatment.

Adjust or escalate therapy

Switching from topical to oral medication, or using both together, can be beneficial. Combination therapy, however, is generally recommended only when single-therapy options have been exhausted.

Add mechanical or chemical measures

Removing thickened nail material often improves penetration and outcomes.

Consider emerging treatments

Device-based therapies may be explored in resistant cases, though evidence is still developing.

Strengthen prevention

Good foot hygiene, avoiding shared nail tools, wearing protective footwear in communal areas, and managing underlying conditions such as diabetes all reduce the risk of reinfection.

Manage expectations

Nails grow slowly, so visible improvement may take nine to twelve months or longer. Regular follow-up is often required.

 

If left untreated or insufficiently managed, onychomycosis may progress, causing greater nail thickening, discomfort, and, in vulnerable individuals, secondary infections such as cellulitis. 

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