Innovation in Onychomycosis Treatment Through Creative Compounding

Onychomycosis is a common fungal nail infection, often presenting with nail discoloration, thickening, and brittleness. Despite the availability of oral and topical antifungal agents, recurrence rates remain high, and systemic therapies can pose risks such as hepatotoxicity and drug interactions. This case report describes an innovative treatment approach using a compounded topical preparation made by combining a crushed 250 mg oral terbinafine tablet with an over-the-counter 1% tolnaftate nail lacquer. A healthy 28-year-old female presented with diffuse toenail onychomycosis affecting all digits. After declining oral therapy, she initiated daily application of the compounded lacquer for 10 months. Weekly complete removal and reapplication were performed, and the vial was shaken before each use to maintain a homogenous mixture. The patient documented progress photographically and reported high satisfaction with a significant improvement in nail appearance. No adverse effects were noted. This topical use of pulverized terbinafine takes advantage of the drug's favorable molecular profile for nail penetration, offering targeted treatment with minimal systemic absorption. The estimated daily delivery of terbinafine per nail was approximately 0.4 mg, a potentially therapeutic dose when applied consistently over time. This case supports the potential of creative compounding in expanding safe and patient-friendly treatment options for onychomycosis, especially for individuals who are unable or unwilling to take oral antifungals. Further studies are needed to evaluate the efficacy, pharmacokinetics, and broader applicability of this approach.