Key points

• The main oral antifungal agents used to treat onychomycosis are terbinafine, itraconazole and fluconazole. Griseofulvin and ketoconazole are the traditional antifungal agents, but their use has decreased substantially since the introduction of the newer oral antifungal agents. In addition, the use of ketoconazole for onychomycosis, where long duration therapy is required, has diminished markedly given the potential for hepatotoxicity.

• The preferred regimens with the new oral antifungal agents are continuous terbinafine, pulse itraconazole and once-weekly fluconazole. The duration of therapy with these agents for fingernail onychomycosis is typically 6 weeks with continuous terbinafine, two pulses of itraconazole and 6-9 months of once-weekly fluconazole. The corresponding durations of therapy with these antifungal agents for toenail onychomycosis are 12 or 16 weeks, three or four pulses, and 9-15 months, respectively.

• RCTs have demonstrated that griseofulvin, continuous terbinafine, itraconazole (pulse and continuous) and fluconazole are effective and safe for treatment of dermatophyte fingernail onychomycosis.

• RCTs have demonstrated that continuous terbinafine, itraconazole (pulse and continuous) and fluconazole are effective and safe for treatment of dermatophyte toenail onychomycosis.

• Several factors need to be considered when deciding which agent to prescribe for onychomycosis. These include, efficacy, causative organism, regimen preference (for example continuous versus pulse versus once weekly, and expected duration of therapy), safety of antifungal agent, medical status of patient, potential for drug interactions, relapse rates and cost of therapy.

• None of the newer oral antifungal agents have been approved for the treatment of onychomycosis in children, where the disease occurs much less frequently than in adults.

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