Terbinafine (Lamisil®) and itraconazole (Sporanox® ) are both popular oral medications for the treatment of fungal toenail. These medications are expensive and the treatment regimen typically involves 3 months of therapy. Itraconazole has been shown to be effective with a pulse dosing regimen, which means the medication is taken daily for one week and not taken for 3 weeks, repeating the pulsing three times. This regimen reduces the cost of the medication when compared to a daily dose for 12 weeks. Terbinifine has classically been prescribed as a continuous dose, the treatment regimen is 250 mg per day for 12 weeks. In a recent study, the authors compared results from trials of continuous and intermittent terbinafine and intermittent itraconazole. The three treatments regimens were as follows. Intermittent terbinafine: 250 mg/day for 4 weeks followed by 4 weeks of no terbinafine and then 4 weeks of terbinafine 250 mg/day. Pulse Itraconazole: pulse of 200 mg twice daily for 7 days on, 21 days off, 7 days on, 21 days off, 7 days on (total of 3 pulses). Continuous terbinafine: 250 mg/day for 12 weeks.
The participants were followed for 72 weeks and mycological cure rates were found to be 83% for the pulse terbinafine group, 78% cure rate for the continuous terbinafine group and 56% for the pulse itraconazole group. Minimal adverse events were recorded and did not require interruption of the drug regimen. Adverse events did not differ significantly from one group to another. The authors concluded that the intermittent terbinafine regimen was as safe and effective as the continuous terbinafine regiment and both were more effective than the itraconazole therapy. (J Eur Acad Dermatol Venereol. 2009 Mar;23(3):256-62).
Sporanox is contraindicated in patients with congestive heart failure. Sporanox® should not be administered for the treatment of onychomycosis to pregnant patients or to women contemplating pregnancy. Side effects may include nausea, vomiting, diarrhea, abdominal pain, fatigue, rash, headache, liver abnormalities. Rare cases of serious hepatotoxicity, including liver failure and death have occurred.
Lamisil is contraindicated in patients with active liver disease. Side effects associated with Lamisil include headache, diarrhea, abdominal pain, naursea, flatulence, rash, taste and visual disturbances and liver enzyme abnormalities. Some people taking Lamisil have developed severe liver damage leading to liver transplant or death.
Tips for Treatment and Prevention of Fungal Toenails
1. Place an anti-fungal powder or spray in your shoes daily or after use.
2. Rotate your shoes often. Don’t wear the same shoes each day.
3. Keep shoes in a cool, dry place. Fungus grows in moist warm environments and will continue to grow in shoes if the shoes are not dried out and stored in a cool place.
4. Change your insoles frequently. In between use, pull the insoles partially out of the shoe to allow them to completely dry.
5. Use an antiperspirant spray if your feet sweat excessively. Antiperspirant sprays will decrease the amount of moisture and help prevent growth of the fungus.
6. Wash your shower mat regularly in hot water. The shower mat that you step onto after a shower tends to retain moisture because of the moist, warm environment of the bathroom. Washing the mat in hot water and drying completely on a weekly basis will decrease fungus growth.
7. Bleach out the shower on a weekly basis. Anti-microbial cleaners will not be as helpful as a diluted bleach concentration once a week.
8. Avoid ill-fitting shoes as they can lead to jamming at the toes. When the toes are jammed in the toebox, micro-trauma occurs at the nails, causing small breaks in the skin under and surrounding the nail. This increases the chance for fungal infection.
9. Wear sandals in the locker room, if you belong to a gym or health club. One of the most common places to pick up a foot fungus infection is in the shower or locker room of a gym. Even if the gyms are cleaned regularly, the moist, warm area is a perfect environment for fungus to grow.
10. Wash feet with an anti-fungal soap to prevent re-infection & spreading.
