What is the best oral medication for toenail fungus?

In this article:

• Best oral medications for toenail fungus
• Can you get oral antifungals OTC?
• Toenail fungus risk factors
• What kills toenail fungus permanently?
• The bottom line

In this article

• Best oral medications for toenail fungus
• Can you get oral antifungals OTC?
• Toenail fungus risk factors
• What kills toenail fungus permanently?
• The bottom line

Toenail fungus, also known as onychomycosis, develops when fungi enter the toenail through small cracks or cuts in the surrounding skin.“It often starts with some discoloration, like a yellow or white spot, and over time, the nail can become thick, brittle, crumbly, or even lift off the nail bed,” explains Gail Clifford, MD, MMM, CPE, an internist and medical consultant at ARRC LED in Orlando, Florida. “It is usually not painful early on, but can become uncomfortable if left untreated.”

Oral antifungal medications, such as terbinafine and itraconazole, are first-line treatments for toenail fungus.

Best oral medications for toenail fungus

The preferred oral medications for treating toenail fungus are terbinafine and itraconazole, which work from the inside out, says Roni DeLuz, PhD, ND, RN, a naturopathic doctor, registered nurse, wellness expert, and founder of H.E.A.L.E.D Retreat and Spa of Vineyard Haven, Massachusetts. “Unless you treat it internally, you’re likely not going to clear it up fully,” she says.

Terbinafine

Terbinafine (brand names Lamisil and Terbinex) is a prescription antifungal medication used to treat fungal infections of the scalp, skin, and nails. “Terbinafine tends to be the go-to—it is practical, well-tolerated, and has a solid success rate,” Dr. Clifford explains. The antifungal medication works by inhibiting the production of ergosterol, a crucial component of the fungal cell membrane, which prevents the fungus from spreading. The medication comes in the form of once-daily tablets.

A 2002 study involving 151 patients aged 18 to 75 years with toenail fungus revealed that a daily dosage of 250 milligrams (mg) of terbinafine for 12 or 16 weeks cured the condition in 46% of patients without the need for a second medical intervention. Of those who received a second course of treatment, 88% were cured. This was a higher cure rate than those treated with itraconazole.

Like any medication, terbinafine can cause some unwanted side effects, such as:

• Headache
• Runny or stuffy nose
• Change in or loss of taste or smell
• Stomach upset
• Rash or skin irritation, especially with sun exposure

Less common but more serious side effects include:

• Unusual bleeding or bruising
• Weakness
• Severe allergic reaction (itching or hives, swelling in your face, hands, mouth, or throat, tightness in chest, or trouble breathing)
• Low blood counts

In rare instances, terbinafine may also cause liver problems, such as acute liver injury, that can be life-threatening and sometimes fatal.

There are some drug interactions to take note of with terbinafine. These include:

• Pimozide
• Thioridazine
• Beta blockers
• Caffeine
• Certain medications for mental health conditions, such as antipsychotics and antidepressants
• Cimetidine
• Cyclosporine
• Rifampin
• Warfarin
• Other medications for fungal infections, such as fluconazole and ketoconazole
• Medications for arrhythmia (irregular heartbeat), like amiodarone, flecainide, and propafenone

Tell your doctor about all prescription and over-the-counter medications you take before starting terbinafine.

Terbinafine should be avoided in people who:

• Have active or chronic liver disease
• Have an allergic reaction to the antifungal medication
• Have a weakened immune system
• Have blood problems, such as neutropenia (low levels of specific white blood cells)
• Are pregnant or trying to get pregnant 
• Are breastfeeding
• Have systemic lupus erythematosus (SLE)

Itraconazole 

Itraconazole (Sporanox, Onmel, Sporanox Pulsepak) is another oral medication used to treat toenail fungus. “Itraconazole is sometimes used instead [of terbinafine], especially if there are concerns about drug interactions,” Dr. Clifford says. The drug belongs to the class of antifungals called triazoles, which slow the growth of fungi that cause infections. It is available in capsule, tablet, and liquid form, but tablets are typically prescribed for toenail fungus.

A randomized, placebo-controlled trial compared a 200 mg dose of itraconazole taken once daily to a 100 mg dose taken twice daily over 12 weeks for the treatment of toenail fungus. Researchers found that both dosing schedules were equally effective in achieving a complete cure by the end of the 12 weeks. The 200 mg daily dose is most commonly prescribed today since it is easier to take.

A large review study in 2017 concluded that both terbinafine and itraconazole were effective in treating toenail fungus. Terbinafine was found to be slightly more effective, and both medications had a similar rate of side effects.

Common side effects of itraconazole include:

• Diarrhea
• Stomach upset
• Headache
• Blurred or double vision
• Dizziness

More serious side effects of this antifungal medication include:

• Numbness, tingling, or burning pain anywhere in your body
• Chest pain
• Trouble breathing
• Coughing up blood
• Cold sweats
• Bluish-colored skin
• Severe allergic reactions
• Hearing loss
• Blistering, peeling, red skin rash
• Rapid weight gain
• Swelling in your face, hands, ankles, or feet

Like terbinafine, itraconazole has interactions with certain drugs, including:

• Methadone
• Disopyraminde
• Dronedarone
• Quinidine
• Ergot alkaloids
• Irinotecan
• Pimozide
• Triazolam and midazolam
• Felodipine
• Lovastatin and simvastatin
• Colchicine 
• Other antifungal medications

This is only a snippet of a more extensive list of drug interactions with this antifungal medication. Tell your doctor about all prescription and over-the-counter medications you take, including herbs and supplements.

Taking itraconazole may be unsafe for people who have the following medical conditions or situations:

• Heart disease
• History of arrhythmia
• Weakened immune system
• Liver or kidney disease
• Lung or breathing problems
• Allergic reactions to antifungal medications 
• Pregnant or trying to conceive
• Breastfeeding 

Before taking terbinafine or itraconazole, share your medical history and any medications you’re currently taking with your healthcare provider. They can determine whether these medications are safe for your health and recommend alternative treatments if necessary.

Can you get oral antifungal pills over the counter?

While there are over-the-counter medications for toenail fungus, such as topical antifungals, oral drugs are available by prescription only. “You can get creams and sprays at the drugstore, and sometimes they help, but the strength just isn’t the same,” Dr. DeLuz says. “If you’re dealing with a real case of toenail fungus, get the prescription and pair it with prevention methods.”

Toenail fungus risk factors 

Toenail fungus is a common condition, and several risk factors can increase the likelihood of developing the fungal infection, such as:

• Age: “Fungal infections are more common as we age because nails grow more slowly and circulation may not be as strong,” Dr. Clifford says.
• Climate: Hot and humid climates can increase your risk of a fungal nail infection.
• Medical conditions: Your risk of getting toenail fungus significantly increases if you have any of the following medical conditions or situations:
  • Diabetes
  • Previous nail infection
  • Tinea pedis (athlete’s foot) or a similar fungal skin infection
  • Injured nail or recent nail surgery
  • Cancer or receiving chemotherapy
  • Poor circulation in your toenails
  • Organ transplant recipient
  • Psoriasis
  • Weakened immune system due to conditions like HIV/AIDS or immunosuppressant medications 

Several lifestyle factors can also contribute to the development of toenail fungus, such as:

• Smoking
• Spending a lot of time in water
• Walking barefoot in swimming pools, locker rooms, or public showers
• Wear restrictive, closed-toed shoes—especially if your feet are sweating.

“If you’re cutting your nails too short or sharing pedicure tools with others, that can open the door for fungus to move in,” Dr. DeLuz adds.

What kills toenail fungus permanently?

Even with successful treatment of toenail fungus, there’s a chance that it may return. Research indicates that the relapse rate for toenail fungus ranges from 20% to 25%. Despite the potential for the fungal infection to recur, your best option for a cure is to take oral medications. “Oral medications like terbinafine offer the best shot at a permanent fix because they treat the infection at the source,” Dr. Clifford says. Research supports terbinafine as the most effective oral medication and the best overall treatment for curing onychomycosis.

While terbinafine may eliminate the infection internally, it can take some time for the physical damage to subside, Dr. Clifford says. “Sometimes, we combine oral medications with topical treatments to boost results,” she says. “Moreover, staying on top of prevention is key once you’ve cleared it. That means keeping your feet dry, clean, and protected to lower the risk of it coming back.”

If one treatment doesn’t work, you and your healthcare provider can explore other treatment options. “[Treatment] is not one-size-fits-all,” Dr. DeLuz says. “Pick your treatment based on your body and how deep the infection is.”

The bottom line

Terbinafine and itraconazole are the best treatments for toenail fungus. However, if these oral medications are ineffective, there are other treatments you can explore. “Laser treatments are newer and work for some, but they’re not always covered by insurance,” Dr. DeLuz says. “In severe cases, there’s toenail removal surgery, which is more extreme, but effective. I’ve also seen ozone injections under the nail work.” 

If you’re having difficulty curing toenail fungus, please consult with your healthcare provider to find a more effective treatment.