Management of onychomycosis: combination therapy is not a new concept

Abstract

Onychomycosis has been treated successfully with oral and topical antimycotics. Oral therapies, such as terbinafine and itraconazole, as well as the topical nail lacquers, ciclopirox and amorolfine have greatly improved efficacy rates. Although the development of new therapies have improved efficacy, onychomycosis remains a difficult to treat disease in a substantial portion of patients due to its recurring or chronic nature. In an effort to try and improve cure rates in moderate to severe onychomycosis, and the more complex presentations of onychomycosis, possible options include the combination of two or more of topical, oral, and mechanical forms of therapy. The use of combination therapies is not a new concept to dermatologists who routinely use two or more agents to manage other more difficult to treat diseases such as psoriasis, acne vulgaris, rosacea, and actinic damage. When the nail is thickened, many dermatologists will consider reducing the mass of keratinized material by debridement or curettage. This approach may augment treatment with a nail lacquer or an oral antimycotic. In the case of a dermatophytoma, it may be advisable to combine a topical or oral antifungal therapy with surgical excision of the overlying nail plate and curettage of the underlying mass of keratin/fungal material. In vitro studies suggest that in some instances, ciclopirox may have a synergistic effect with terbinafine or itraconazole. The combined use of a topical with an oral antifungal may enable complementary drug penetration into the diseased nail bed and plate. The management of onychomycosis needs to be individualized to suit each patient’s needs. In many instances, monotherapy may not be sufficient to elicit a cure. In such instances a combined approach may result in a more favorable outcome. Onychomycosis has been treated successfully with oral and topical antimycotics. Oral therapies, such as terbinafine and itraconazole, as well as the topical nail lacquers, ciclopirox and amorolfine have greatly improved efficacy rates. Although the development of new therapies have improved efficacy, onychomycosis remains a difficult to treat disease in a substantial portion of patients due to its recurring or chronic nature. In an effort to try and improve cure rates in moderate to severe onychomycosis, and the more complex presentations of onychomycosis, possible options include the combination of two or more of topical, oral, and mechanical forms of therapy. The use of combination therapies is not a new concept to dermatologists who routinely use two or more agents to manage other more difficult to treat diseases such as psoriasis, acne vulgaris, rosacea, and actinic damage. When the nail is thickened, many dermatologists will consider reducing the mass of keratinized material by debridement or curettage. This approach may augment treatment with a nail lacquer or an oral antimycotic. In the case of a dermatophytoma, it may be advisable to combine a topical or oral antifungal therapy with surgical excision of the overlying nail plate and curettage of the underlying mass of keratin/fungal material. In vitro studies suggest that in some instances, ciclopirox may have a synergistic effect with terbinafine or itraconazole. The combined use of a topical with an oral antifungal may enable complementary drug penetration into the diseased nail bed and plate. The management of onychomycosis needs to be individualized to suit each patient’s needs. In many instances, monotherapy may not be sufficient to elicit a cure. In such instances a combined approach may result in a more favorable outcome.