2013/2014 Medicines Optimisation LES

Intervention 8.1 Topical Antifungal Treatments for Fungal Nail Infections

Title of Intervention

Avoid prescribing topical treatments for fungal nail infections (onychomycosis).

Rationale

There is lack of evidence of efficacy for topical agents in onychomycosis. Where antifungal treatment is indicated, systemic treatments are more effective.1

Nail lacquers and solutions are expensive. Amorolfine nail lacquer is available over-the- counter (OTC) for mild cases and for the treatment of a maximum of two nails.

Evidence

Onychomycosis is an infection of the nail apparatus by fungi that include dermatophytes, non-dermatophyte moulds and yeasts (mainly Candida species).

Onychomycosis is classified clinically as distal and lateral subungual onychomycosis (DLSO), superficial white onychomycosis (SWO), proximal subungual onychomycosis (PSO), candidal onychomycosis and total dystrophic onychomycosis.

There are four topical antifungal preparations available on the UK market (salicylic acid, methyl undecenoate, amorolfine and tioconazole), both as prescription-only medicines and on an OTC basis.

There are no published studies on the efficacy of salicylic acid (Phytex®) and methyl undecenoate (Monphytol®) in fungal nail infection and their use cannot be recommended.1 The cure rates for the other two topical antifungal preparations amorolfine (Loceryl®) and tioconazole (Trosyl®) do not compare favourably with those obtained with systemic drugs.

Because topical treatment is inferior to systemic therapy it can only be recommended for the treatment of SWO and in very early cases of DLSO where the infection is confined to the distal edge of the nail.1

There is insufficient evidence of efficacy to advocate combined topical and systemic therapy.1

Costs

Preparation / Cost 2
Terbinafine 250mg tablets (28) / £2.61
Amorolfine 5% Nail Lacquer (Loceryl) 1 x 5ml / £18.17
Amorolfine 5% Nail Lacquer (Omicur) 2 x 2.5ml / £19.53
Tioconazole 28% 12ml (Trosyl) / £27.38

Procedure for carrying out intervention

1.  Search for patients prescribed topical antifungal agents on repeat prescription.

2.  Review therapy in view of evidence and consider whether systemic therapy is required.

3.  Avoid prescribing topical antifungal agents for new patients presenting with onychomycosis.

References

1Roberts DT, Taylor WD, Boyle J. British Journal of Dermatology 2003; 148: 402–410. Guidelines for treatment of onychomycosis. Accessed on 24th July 2013 at http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Onychomycosis.pdf 2 British National Formulary 65 March – September 2013