Terbinafine and itraconazole are most effective for toenail onychomycosis

Reference

Gupta AK, Foley KA, Mays RR, Shear NH, Piguet V. Monotherapy for toenail onychomycosis: a systematic review and network meta-analysis. Br J Dermatol 2019;182(2):287-299.

Synopsis

Network meta-analyses can include both direct comparisons (drug A vs drug B in individual trials), as well as indirect comparisons (comparing drug A with drug C by linking studies of A vs B and B vs C). These researchers performed an appropriate search, and of the 10,845 studies initially identified, 75 met the inclusion criteria but only 26 reports of 31 clinical trials provided outcome data regarding cure rates or adverse events that could be used in the analysis. The included studies had a total of 8136 patients and reported 8 different treatment regimens, including some with the same drug given continuously or in a pulsed fashion (ie, daily for one week of a month). Most studies treated patients for 12 weeks to 24 weeks, and the study drugs included ciclopirox 8% solution, efinaconazole 10% solution, fluconazole, itraconazole, terbinafine, and tavaborole 5% solution. The researchers used conventional methods for data abstraction, quality assessment, and analysis. Of the 31 trials, only 5 were judged to be at overall low risk of bias. Most studies failed to describe randomization procedures or allocation concealment, 52% failed to mask participants, and 64% failed to mask outcome assessors. Based on placebo-controlled trials itraconazole 200 mg and terbinafine 250 mg were most effective. Continuous regimens were more effective than pulsed regimens. This is consistent wth the results based on both direct and indirect comparisons. Regarding mycologic cure, continuous terbinafine and continuous itraconazole were again most likely to be effective. Adverse events did not differ much among the drugs; itraconazole was the safest among the effective drugs.