Terbinafine, Fluconazole, and Itraconazole for Dermatophyte Toenail Onychomycosis

A novel study used network meta-analysis to compare pulse and continuous systemic therapies for toenail onychomycosis.

The following article is part of coverage from the American Academy of Dermatology’s Annual Meeting (AAD 2020). Because of concerns regarding the coronavirus disease 2019 (COVID-19) pandemic, all AAD 2020 sessions and presentations were transitioned to a virtual format. While live events will not proceed as planned, readers can click here to view more news related to research presented during the AAD VMX 2020 virtual experience.

Terbinafine may be more effective than fluconazole and itraconazole in the treatment of dermatophyte toenail onychomycosis, but all regimens appear to be safe and effective when administered for up to 3 to 12 months, according to study results presented at the American Academy of Dermatology’s Virtual Meeting Experience (AAD VMX) 2020, held online from June 12 to 14, 2020.

This study was a meta-analysis based on a systematic review conducted by researchers from Canada and the United Kingdom. A total of 22 studies with 4205 randomly assigned patients were included in the final analysis. Researchers focused on comparing the mycological cure (MC) and adverse event rates of 250 mg terbinafine administered continuously for 12, 16, and 24 weeks and 500 mg terbinafine pulsed for 3 or 4 months vs 200 mg itraconazole administered daily for 12 weeks, 400 mg itraconazole pulsed for 3 or 4 months vs 150, 300, or 450 mg fluconazole administered once weekly for 9 to 12 months.

In terms of MC, no significant differences were observed between the continuous 12-week terbinafine and continuous 12-week itraconazole groups. Also, there was no difference in 3-pulse itraconazole vs 3-pulse terbinafine in regard to MC. The researchers also found no difference in  continuous 12-week terbinafine and 500 mg pulsed terbinafine for 3 months for MC. Patients randomly assigned to continuous 12-week itraconazole, however, experienced less efficacy with treatment compared with patients randomly assigned to continuous 24-week terbinafine (RR, 0.613; P <.05).

Continuous 12-week itraconazole was less effective than continuous 24-week terbinafine (risk ratio [RR], 0.613; P <.05). The fluconazole regimens were less effective than continuous 24-week terbinafine (RR, 0.582; P <.05). No treatments were significantly different from placebo in likelihood of causing AEs.

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Gupta A, Stec N, Bamimore MA, et al. The efficacy and safety of pulse vs. continuous therapy for dermatophyte toenail onychomycosis. Presented at: AAD VMX 2020; June 12-14, 2020. Abstract/Poster 16014.