The treatment of onychomycosis has improved considerably over the past several decades, following the introduction of the oral antifungals terbinafine and itraconazole. However, these drugs may have side effects such as liver damage or drug interactions.
There has been a lot of research on topical versus oral antifungal medications in an effort to determine which is the more effective treatment tool for nail infections. While there is not a full consensus as of yet, this research has helped determine that many of the topical antifungal medications don’t work effectively as desired because the fungal medication has to penetrate the nail bed and then get to the nail matrix which gives rise to the nail cells. The nail is permeable, however, has its limitations. In addition, if the nail is very thick there are more nail cell layers, then the medication must seep through all those layers which can limit how much actually gets to the infected nail matrix cells. Thickened nails, extensive involvement of the entire nail, lateral disease, and yellow spikes contribute to a poor response to topical treatments.
Further complicating the scenario is the fact that certain antifungals will bind to the nail plate and not be able to get to the site of infection, which is the nail bed and nail matrix. For example, terbinafine has been shown to accumulate rapidly in the nail, persisting up to 2 months following the end of treatment. Many different approaches to solving the problem of nail bed penetration have been attempted recently. There have been penetration enhancers developed to facilitate drug delivery through the nail plate, as well as the creation of terbinafine nail lacquer. Another technique to enhance the penetration of nail lacquer was the incorporation of terbinafine into Transfersome Lipid Vesicles, which are highly deformable and thus able to pass through the intercellular spaces plate.
At Weil Foot & Ankle Institute, we work with compounding companies that formulate a specific medication. Once we receive the lab results via polymerase chain reaction testing, the results are submitted to the compounding pharmacy and then a medication is created based on the specific patient’s individual pathology to cover all pathogens detected. The medication is applied over the affected nail once a day for up to 4-5 months.
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