Cochrane for Clinicians

Putting Evidence into Practice

Topical and Device-Based Treatment of Toenail Onychomycosis


Am Fam Physician. 2021 Feb 1;103(3):145-146.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are topical and device-based therapies safe and effective in the treatment of toenail onychomycosis?

Evidence-Based Answer

Topical antifungal drugs, including efinaconazole 10% solution (Jublia), tavaborole 5% solution (Kerydin), and ciclopirox 8% lacquer and hydrolacquer, are beneficial in treating mild to moderate toenail onychomycosis.1,2 Potential adverse effects are mild and include dermatitis and vesicles.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Onychomycosis, a fungal infection of the nail caused by dermatophytes, nondermatophyte molds, and yeasts, is the most common nail disorder encountered in primary care.1,3 Aside from its cosmetic impact, toenail onychomycosis may cause pain and discomfort.1 Oral antifungal medications are considered the most effective treatment; however, they are associated with drug interactions and systemic adverse effects.1 The authors of this review sought to determine the safety and effectiveness of topical and device-based therapies to treat toenail onychomycosis.

This Cochrane review included 56 randomized controlled trials (published between 1993 and 2019) involving 12,501 participants.1 The primary outcomes were complete cure rate (defined as mycologic cure and resolution of all clinical symptoms) and treatment-related adverse effects. Secondary outcomes at follow-up included mycologic cure rate (negative mycologic testing) and clinical cure rate (0% nail plate involvement). Ultimately, 12 studies involving 4,269 participants were included in the quantitative meta-analysis.1 Most studies addressed mild to moderate onychomycosis without matrix involvement and with more than one toenail affected. Participants were 27 to 68 years of age, on average, with a treatment duration of 36 or 48 weeks, and clinical outcomes were measured up to four weeks after treatment completion.

High-quality evidence demonstrated that efinaconazole 10% solution was superior to

Author disclosure: No relevant financial affiliations.


show all references

1. Foley K, Gupta AK, Versteeg S, et al. Topical and device-based treatments for fungal infections of the toenails. Cochrane Database Syst Rev. 2020;(1):CD012093....

2. Ghannoum M, Isham N, Catalano V. A second look at efficacy criteria for onychomycosis: clinical and mycological cure. Br J Dermatol. 2014;170(1):182–187.

3. Lipner SR, Scher RK. Onychomycosis: clinical overview and diagnosis. J Am Acad Dermatol. 2019;80(4):835–851.

4. Kimberlin DW, Brady MT, Jackson MA, et al., eds. Red Book: 2018–2021. Report of the Committee on Infectious Diseases. 31st ed. American Academy of Pediatrics; 2018. Accessed June 17, 2020.

5. Ameen M, Lear JT, Madan V, et al. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014;171(5):937–958.

6. Nail fungus medications. GoodRx. Accessed August 11, 2020.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at



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