An open, randomized, comparative study of oral fluconazole, itraconazole and terbinafine therapy in onychomycosis

In this open, randomized and comparative study, the safety and efficacy of systemic fluconazole, itraconazole and terbinafine was investigated in 50 patients with distal subungual toenail onychomycosis diagnosed clinically and mycologically. The patients with positive mycology and also the patients with positive microscopy and negative culture were investigated.

The treatment duration was 3 months, and the follow-up period was 6 months. Patients were randomly assigned: 16 patients received 150 mg fluconazole once weekly, 18 patients received 200 mg itraconazole twice daily with meals during the first week of each month, and 16 patients received 250 mg/day terbinafine during the treatment period.

In a clinical evaluation, at the endpoint of the follow-up period, the clinical cure rates were 81.3% (13/16) in the terbinafine group, 77.8% (14/18) in the itraconazole group, and 37.5% (6/16) in the fluconazole group. The mycological cure rates were 75% (12/16), 61.1% (11/18) and 31.2% (5/16), respectively. The overall assessment rates were 62.5% (10/16), 61.1% (11/18) and 31.2% (5/16), respectively. Statistically significant intra-group reductions from baseline symptom severity values were seen at the endpoint of treatment and at the endpoint of the follow-up period for all three treatment groups in onycholysis, subungual hyperkeratosis, affected-area percentage score and total score parameters (p < 0.001). At the endpoint of the follow-up period, statistically significant differences between the treatment groups were seen in clinical, mycological and overall assessment (p < 0.05). However, while no statistically significant difference between the terbinafine and itraconazole groups was seen, there was a clinical and statistical difference between the other groups and the fluconazole group. Treatment was not stopped for side effects such as mild gastrointestinal and central nervous system symptoms. These effects were noted in four patients in the fluconazole group (25%), five patients in the itraconazole group (27.8%), and three patients in the terbinafine group (18.75%). The clinical laboratory data on all three drug groups did not show any statistically or clinically significant intra-group changes from baseline values at the endpoint (p > 0.05).

This comparative study of systemic fluconazole, itraconazole and terbinafine showed that all three drugs were effective and safe in the treatment of onychomycosis. However, fluconazole, at these doses and treatment durations, was the least effective. With regard to cost-effectiveness, side effects and the cure rates, terbinafine could be the drug of choice in the short-term treatment of toenail onychomycosis.