Onychomycosis is a public health concern because of its high worldwide incidence and prevalence, and its potential for spread of fungal elements to others, as well as complications such as
cellulitis,
bacterial infection,
pain, and extensive dermatophytic
infections. The incidence of
onychomycosis has been increasing, particularly in individuals over 60 years of age, patients with
HIV infection, and patients with
diabetes mellitus.
Onychomycosis may impact upon physical, functional, psychosocial, and emotional aspects of life.
Difficulty walking, wearing shoes, and embarrassment are common complaints. Quantification of such quality-of-life changes are significant to clinical practice in that many factors can affect overall patient health. In light of the potential clinical implications on physical and mental health,
onychomycosis should be considered a medical condition that deserves rigorous clinical management.
Onychomycosis can be treated effectively and with comparative safety with the new generation of oral
antifungal agents (
itraconazole,
fluconazole and
terbinafine). Significantly improved pharmacokinetic and pharmacodynamic profiles permit markedly reduced duration of administration, individual
drug exposure, and ultimately enhanced patient compliance and satisfaction with
therapy. In addition, a number of pharmacoeconomic studies have documented the cost effectiveness of these newer agents compared with both traditional pharmacologic treatment and topical
therapies. The currency figures quoted are 1997 values. With regard to continuous oral antifungal regimens,
terbinafine therapy has been found to be most cost effective in the treatment of toenail
onychomycosis, with a
drug acquisition cost of $US522.50. However, improved safety, tolerability, efficacy and cost effectiveness have been documented with
itraconazole intermittent, pulse regimens. With
itraconazole pulse
therapy, the
drug acquisition cost decreases to $US488.90. Additionally, the total cost of medical management is less for
itraconazole therapy compared with that of
terbinafine ($US261.00 vs $US306.00). Because sensitivity analyses for
itraconazole and
terbinafine have been found to be somewhat comparable in terms of mycological cure, clinical response, and relapse rates, other variables such as safety and efficacy profiles, and patient attitudes and expectations toward
therapy need to be considered when formulating an
onychomycosis pharmacologic treatment plan. The
drug aquisition cost of
fluconazole given as
a 300 mg dose once weekly for 6 months is $US562.76 and given as a 150 mg dose once weekly (for 6 months) $US281.38.