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  • Presentation

Topical and Device Treatments for Onychomycosis: Current, Emerging, and Practical Uses

Description

The speaker reviewed current, emerging, and practical topical and device-based treatments for onychomycosis. He noted the three FDA-approved topicals: ciclopirox 8%, efinaconazole 10%, and tavaborole 5%, and emphasized that mycological cure is often a more realistic goal than complete cure, which can be limited by preexisting nail dystrophy. Topicals are generally best for superficial disease, distal lateral subungual involvement affecting less than 50% of the nail without lunula involvement, nails less than 2 mm thick, limited numbers of nails, or when systemic therapy is contraindicated; he also recommended treating concomitant tinea pedis at the same time. He highlighted topical usefulness in children, dermatophytomas, and some older adults, and discussed evidence suggesting efinaconazole performs well across racial groups and ages. For dermatophytoma, he noted limited trial data but described topical therapy, especially tavaborole or efinaconazole, as effective and more acceptable than surgical excision. A review of urea found improved nail appearance but no clear benefit in cure rates. Emerging therapies mentioned included trichostatin A and nitric oxide, with the latter notable for biofilm penetration. Home remedies such as tea tree oil and Vicks VapoRub have weak evidence. In contrast, lasers are only approved for temporary cosmetic improvement, not cure, and he does not use them routinely. He closed by mentioning microwave energy as a promising device approach with antimicrobial effects and early clinical results.

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Conclusions

  • Topical antifungals remain the mainstay for mild or limited onychomycosis, especially when disease is superficial, affects few nails, or systemic therapy is unsuitable.
  • Among FDA-approved topicals, efinaconazole appears to have the strongest overall efficacy, with better mycological and complete cure rates than ciclopirox and tavaborole.
  • Treating concomitant tinea pedis at the same time as nail disease can improve topical treatment outcomes for onychomycosis.
  • Children generally respond better than adults to topical therapy because their nails are thinner and grow faster, making topicals a common first-line option in pediatric onychomycosis.
  • Dermatophytomas are difficult but can respond to topical therapy, and efinaconazole or tavaborole may be effective enough to avoid more invasive measures in some cases.
  • Topical efinaconazole seems effective across racial groups and in older adults, with low discontinuation rates and quality-of-life benefits.
  • Urea may improve the nail’s appearance when used with antifungals, but the best available data do not show clear improvement in mycological or complete cure rates.
  • Homeopathic or over-the-counter remedies such as tea tree oil or Vicks VapoRub have weak and unconvincing evidence overall and should not be relied on as definitive therapy.
  • Lasers should not be viewed as curative for onychomycosis because they are only approved for temporary cosmetic improvement and lack the same efficacy standards as antifungal drugs.
  • Microwave-based devices show early promise as a potential future treatment, but the evidence is still emerging and not yet strong enough to replace established therapies.
  • Several investigational agents, including nitric oxide- and trichostatin-based approaches, may expand future topical or device-based options if ongoing trials prove successful.
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