Toenail Fungus: Treatment Options Table

When it is used

Topical Treatments

Jublia® (efinaconazole)
Available since 2014

Used to treat mild-to-moderate fungal toenail infections that are caused by certain fungi and do not involve the white, crescent-shaped area of the nailbed.

Penlac® (ciclopirox and generics)
Available since 2004

Used to treat mild-to-moderate fungal nail infections that are caused by a number of fungi and do not involve the white, crescent-shaped area of the nailbed.

Oral Treatments

Lamisil® (terbinafine and generics)
Available since 1993

Used for treatment of fungal nail infections.

Must not be used if there is pre-existing chronic or active liver disease.

Sporonox® (itraconazole)
Available since 1993

Used for treatment of fungal nail infections.

How it works

Topical Treatments

Jublia® (efinaconazole)
Available since 2014

Blocks the production of ergosterol, an important part of the fungal membrane. Without ergosterol, the fungi cannot function and eventually they die off, reducing the infection.

Penlac® (ciclopirox and generics)
Available since 2004

Prevents certain types of fungus from growing and reproducing.

Oral Treatments

Lamisil® (terbinafine and generics)
Available since 1993

Kills fungi and prevents certain types of fungi from growing and reproducing.

Sporonox® (itraconazole)
Available since 1993

Inhibits the production of a compound known as ergosterol, which is found in the cell membrane of fungi. Without ergosterol, the fungi cannot function and eventually they die off, reducing the infection.

Dosage

Topical Treatments

Jublia® (efinaconazole)
Available since 2014

Applied once daily (preferably at bedtime) to clean, dry toenails using the built-in brush applicator. One drop should be applied onto the affected toenails and a second drop to any affected big toenail(s).

Clip your toenails every 4 weeks. Clip the unaffected toenails first before the affected ones.

No removal of dead, damaged, or infected tissue is needed.

Penlac® (ciclopirox and generics)
Available since 2004

Applied to the affected nail once daily (preferably at bedtime or 8 hours before washing) using the provided brush applicator.

Accumulated lacquer should be removed with alcohol weekly.

The nail should be filed, trimmed, and cleaned with alcohol weekly.

Should be used as a component of a comprehensive management program that includes removal of unattached infected nail by a health care professional, weekly trimming by the patient, and daily application of the medication.

Oral Treatments

Lamisil® (terbinafine and generics)
Available since 1993

Taken orally (by mouth) once per day.

No removal of dead, damaged, or infected tissue is needed.

Sporonox® (itraconazole)
Available since 1993

Taken orally (by mouth) twice per day for 1 week, followed by a 3-week drug-free interval. Usually 3 courses of treatment are given for toenail infections.

No removal of dead, damaged, or infected tissue is needed.

Side Effects*

Topical Treatments

Jublia® (efinaconazole)
Available since 2014

Side effects:

Can include redness, itching, burning, and stinging sensation where the drug is applied.

Uncommon side effects can include serious skin reactions (skin becomes very red, itchy, swollen, blistered, or crusted), in which case you should stop using the medication and seek medical attention.

Penlac® (ciclopirox and generics)
Available since 2004

Side effects:

Rash, redness, burning sensation of skin where the drug is applied.

The drug can also affect the nail by changing its shape or colour, causing irritation, and causing an ingrown toenail where the drug is applied.

Oral Treatments

Lamisil® (terbinafine and generics)
Available since 1993

Side effects:

Very common:
headache, nausea, mild abdominal pain, stomach discomfort after a meal, diarrhea, bloating of abdomen, loss of appetite, skin rashes, joint and muscle pain.

Common:
mood disorder (depression), disturbance or loss of sense of taste, dizziness, eye disorder, and tiredness.

Uncommon:
low red blood cells (symptoms include pale skin or nail beds, unusual tiredness/weakness, breathlessness on exertion), anxiety, tingling or numbness, decreased skin sensitivity, increased sensitivity to sun, ringing/hissing in ears, fever, and weight loss.

Rare:
liver problems (symptoms include yellowing of eyes and skin), abnormal liver function tests.

Stop taking the medication and seek immediate medical attention if the following occur:
liver problems (symptoms include persistent nausea and vomiting, abdominal pain, fatigue, loss of appetite, dark urine, pale stool, and yellowing of eyes/skin), blood problems (symptoms include sore throat, fever, unusual bleeding or bruising), inflammation of blood vessels or pancreas (symptoms include severe upper stomach and back pain), serious allergic reactions, serious skin reactions (symptoms include blistering and peeling skin), severe muscle damage (symptoms include muscle pain, weakness, and dark urine).

Special notes:

Your doctor may routinely monitor your liver function and blood for potential effects caused by this medication.

Sporonox® (itraconazole)
Available since 1993

Side effects:

Common:
skin rash, high triglyceride test results, high liver test results, and digestive system problems (e.g., nausea, bloating, diarrhea).

Other:
upset stomach, vomiting, abdominal pain, constipation or excess gas in stomach, cough, fluid in the lungs, altered voice, inflammation of the sinuses, inflammation of the nose, upper respiratory tract infection, headache, dizziness, menstrual disorders, erectile dysfunction, confusion, tremor, sleepiness, fatigue, chills, muscle weakness or pain, painful joints, pain, chest pain, swelling, generalized swelling, unpleasant taste, hair loss, inflammation of the pancreas, fever or excessive sweating.

Talk with your doctor or pharmacist immediately if the following occur:
heart problems (symptoms include shortness of breath, unusual swelling of feet/ankles/legs, sudden weight gain, feeling unusually tired, coughing up white/pink phlegm, unusually fast heartbeat, waking up at night), blurry or double vision, ringing in ears, decreased ability to control urine, or urinating more than usual.

Stop taking the medication and seek immediate medical attention if the following occur:
liver problems (symptoms include feeling unusually tired, loss of appetite, nausea, vomiting, abdominal pain, yellowing of eyes/skin, dark-coloured urine, pale stools), nerve problems (symptoms include tingling, numbness, reduced sense of touch, weakness in limbs, pain, pins and needles, prickling, or burning), serious allergic reaction (symptoms include skin rash, itching, hives, difficulty breathing, shortness of breath, swelling of the face), severe skin reaction (symptoms include widespread rash with peeling skin and blisters in the mouth, eyes, and genitals, rash with small pustules or blisters), oversensitivity to sunlight, hearing loss.

Special notes:

Your doctor may routinely monitor your liver function for potential liver toxicity caused by this medication.

Interactions

Topical Treatments

Jublia® (efinaconazole)
Available since 2014

Studies have not been done.

Penlac® (ciclopirox and generics)
Available since 2004

Studies have not been done.

Oral Treatments

Lamisil® (terbinafine and generics)
Available since 1993

The following are some but not all of the medications that may interact with LAMISIL**:

Some antibiotics

Some antidepressants (such as tricyclic antidepressants, selective serotonin reuptake inhibitors including class, monoamine oxidase inhibitors Type B, and desipramine)

Some medicines used to treat irregular heart rhythm called antiarrhythmics (such as propafenone and amiodarone)

Some medications used to treat high blood pressure (such as beta-blockers such as metoprolol)

Theophylline, used to relieve bronchospasm in asthma

Some medicines used to treat cough (such as dextromethorphan)

Cyclosporine, used to control the immune system, used to prevent transplant rejection

St. John's wort (Hypericum perforatum), a herbal medicine used to treat depression

Sporonox® (itraconazole)
Available since 1993

A wide variety of drugs may interact with this medication. Never take this medication if you are taking any of the following medications**:

felodipine, eplerenone, ticagrelor, lovastatin, simvastatin, triazolam, lurasidone, pimozide, methadone, ergotamine, ergometrine, eletriptan, irinotecan, dronedarone, quinidine, domperidone.

There are other medications that are not recommended unless your doctor feels it is necessary. For a complete list, please view the product monograph.

* Please note that this is not a complete exhaustive list of all possible side effects. For complete listing please view the product monograph.

** Please note that this is not a complete list of possible medications that may interact with the product. Please tell your doctor and pharmacist all the medications (including over-the-counter products, supplements, and natural products) that you're taking before starting on this medication.

Please note that the following contains information on lifestyle and non-prescription treatment options for nail and other foot fungus infections.

You can lower your chances of getting a fungal infection in your toenails by making some lifestyle changes, such as wearing breathable footwear, thoroughly drying your feet after washing, and avoiding walking barefoot in public areas (i.e., swimming pools, gyms).

However, it is important to contact your doctor if you suspect that you are developing a toenail fungus infection. Allowing it to spread can permanently damage the nail and change the nail’s shape or colour in ways that can limit your daily activities and affect your quality of life.

Other than prescription medications, some non-drug treatment strategies for nail fungus infections that are performed at the doctor’s office include nail removal procedures and laser therapy. There are also over-the-counter products for foot and nail fungus infections that you can get without a doctor’s prescription. These are listed below.

When it is used

Topical Agents

Emtrix® (Carbamide (urea), -lactic acid)
Available since 2012

Used to treat fungal nail infections.

Excilor® (acetic acid 1%)
Available since 2016

Used to treat fungal nail bed infections.

Fungi-Nail® (undecylenic acid 25%)
Available since 2013

Used to treat athlete’s foot and ringworm, and to relieve the itching, burning, and cracking associated with these conditions.

Not effective on the scalp or nails.

Do not use on children under 2 years of age unless directed by a doctor.

Fungicure® Liquid (undecylenic acid 25%)
Available since 2012

Used to treat athlete’s foot affecting finger and toe areas and ringworm, and to relieve the itching, scaling, cracking, burning, redness, soreness, irritation, and discomfort associated with these conditions.

Not effective on the scalp or nails.

Intended for use by healthy adults only.

Persons under 18 years of age or those with highly sensitive or allergic skin should use only as directed by a doctor.

Ask a doctor before using on children under 2 years of age.

Flexitol® Anti-fungal Liquid (undecylenic acid 25%)
Available since 2009

Used to treat most athlete’s foot and to relieve the itching, scaling, cracking, burning, redness, soreness, and irritation.

Not effective on the nails.

Do not use on children under 2 years of age unless directed by a doctor.

How it works

Topical Agents

Emtrix® (Carbamide (urea), -lactic acid)
Available since 2012

Reduces growth of the fungi causing the infection.

Excilor® (acetic acid 1%)
Available since 2016

Changes the pH of the nail to create a hostile environment for fungal growth.

Fungi-Nail® (undecylenic acid 25%)
Available since 2013

Inhibits the growth and reproduction of fungal cells.

Fungicure® Liquid (undecylenic acid 25%)
Available since 2012

Inhibits the growth and reproduction of fungal cells.

Flexitol® Anti-fungal Liquid (undecylenic acid 25%)
Available since 2009

Kills the fungus.

Dosage

Topical Agents

Emtrix® (Carbamide (urea), -lactic acid)
Available since 2012

Applied once daily to affected nails.

Excilor® (acetic acid 1%)
Available since 2016

Applied to affected nails twice a day (once in the morning and once in the evening).

Fungi-Nail® (undecylenic acid 25%)
Available since 2013

Available in ointment and liquid solution form.

Applied to cleaned and dried affected areas daily or as directed by a doctor.

Fungicure® Liquid (undecylenic acid 25%)
Available since 2012

Applied to cleaned and dried affected areas twice a day (morning and night), or as directed by a doctor.

Flexitol® Anti-fungal Liquid (undecylenic acid 25%)
Available since 2009

Applied to cleaned and dried affected areas as directed by a doctor.

Side Effects*

Topical Agents

Emtrix® (Carbamide (urea), -lactic acid)
Available since 2012

Side effects:

It can be expected for some individuals to experience temporary mild irritation of the skin next to the nail and nail discolouration (whitening).

It is possible for the affected nail to loosen or detach from the underlying nail bed. Do not apply Emtrix® to the nail bed if this occurs.

Excilor® (acetic acid 1%)
Available since 2016

Side effects:

Stop using the medication and consult a health care provider if symptoms persist or worsen.

Fungi-Nail® (undecylenic acid 25%)
Available since 2013

Side effects:

Stop using the medication and consult your health care provider if irritation occurs or if there is no improvement within 4 weeks of use.

Fungicure® Liquid (undecylenic acid 25%)
Available since 2012

Side effects:

Stop using the medication and consult a health care provider if irritation occurs or if there is no improvement within 4 weeks of use.

Flexitol® Anti-fungal Liquid (undecylenic acid 25%)
Available since 2009

Side effects:

Stop using the medication and consult a health care provider if irritation occurs or if there is no improvement within 4 weeks of use.

* Please note that this is not a complete exhaustive list of all possible side effects. For complete listing please view the product monograph.

*** Please note that some of the options listed are not specifically indicated for the treatment of nail fungus infections, but only for other types of foot fungus infections.