574 Oral antifungals effective for toenail onychomycosis

April 21, 2018

written by Brian McAvoy

Clinical question

How effective are oral antifungal treatments for toenail onychomycosis?

Bottom line

There was high-quality evidence that oral azole and terbinafine treatments were more effective for achieving mycological cure and clinical cure for onychomycosis, when compared with placebo.

When compared directly, terbinafine was probably more effective than azole and likely not to be associated with excess adverse events (both moderate-quality evidence).

Low-certainty evidence showed griseofulvin to be less effective than terbinafine in terms of both mycological and clinical cure, while griseofulvin and azole probably had similar efficacy (moderate-quality evidence).

Griseofulvin was associated with more adverse reactions than azoles (moderate-quality evidence) and terbinafine (low-quality evidence).

No study addressed quality of life.

The evidence in this review applied for treatments of at least 12 weeks in duration.


Only a limited number of studies reported adverse events, and the severity of the events was not taken into account, which limited the direct application to clinical practice. Not all comparisons measured recurrence rate, and the available evidence was based on low to very low-quality evidence.


Toenail onychomycosis is common, and treatment is taken orally or applied topically. Oral treatments appear to have shorter treatment times and better cure rates.

Cochrane Systematic Review

Kreijkamp-Kaspers S et al. Oral antifungal medication for toenail onychomycosis. Cochrane Reviews, 2017, Issue 7. Art. No.: CD010031.DOI: 10.1002/14651858. CD010031. pub2. This review contains 48 studies involving 10,200 participants.

Pearls are an independent product of the Cochrane primary care group and are meant for educational use and not to guide clinical care.