Terbinafine Superior to Itra in Toenails
Source: Evans EG, et al. BMJ 1999;318: 1031-1035.
Because therapeutic concentrations of itraconazole persist in the nail bed for several days, some experts advocate that, for the treatment of onychomycosis, the administration of this azole should be cycled. In contrast to itraconazole, which is fungistatic, terbinafine is a newer allylamine antifungal agent that has cidal activity against most dermatophytes. In a double-blind, randomized, controlled trial, 496 patients with onychomycosis were randomized to receive either continuous terbinafine 250 mg daily for either 12 or 16 weeks or itraconazole 400 mg daily for one week of every month for 12 or 16 weeks. Eligible patients had distal subungual or total dystrophic nail disease confirmed by culture as well as KOH.
Continuous terbinafine was substantially better, resulting in clinical cures (defined as 100% toenail clearing) in 54% of patients at 12 weeks and 60% of patients at 16 weeks. In contrast, only 32% of patients receiving itraconazole were clinically cured. Mycological cures were achieved in 76-80% of patients receiving terbinafine and 38-49% receiving itraconazole. Both drugs were well tolerated and the frequency of side effects was similar. While daily terbinafine is superior to intermittent itraconazole in the treatment of onychomycosis, clinicians should keep in mind that 20-40% of patients may fail three to four months of therapy and require a longer course of treatment.
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