Management of onychomycosis: examining the role of monotherapy and dual, triple, or quadruple therapies.

The high prevalence of onychomycosis warrants effective lasting treatment. Currently available monotherapeutic options in the United States include surgical or chemical nail avulsion/debridement, a topical antifungal nail lacquer, and systemic antifungal agents. Failure to respond to therapy and relapse rates of approximately 25% to 50% both point to the need for a shift in the approach to treating this chronic disease. In vitro data indicate synergistic and additive effects when combining certain antifungal agents, eg, ciclopirox and terbinafine. Clinical reports suggest that combining topical and oral antifungal agents (eg, ciclopirox nail lacquer and oral terbinafine), administered for a shortened duration compared with the standard regimen, may yield cure rates as good as, if not better than, the indicated oral monotherapy regimen. Drug penetration to different parts of the nail unit and complimentary modes of action may contribute to the success of combination therapy.