Terbinafine for toenail fungus

Contents

What is terbinafine used for?

Terbinafine tablets are prescribed to treat fungal nail infections and fungal skin infections, such as ringworm (tinea corporis), jock itch (tinea cruris) and athlete’s foot (tinea pedis).

Terbinafine tablets are used to treat infections that haven’t cleared up with antifungal creams and for infections that are severe or widespread.

How does terbinafine work?

Terbinafine hydrochloride is an antifungal medicine that kills the fungi that are causing an infection. It does this by causing holes to develop in the fungal cell membranes.

The cell membranes of fungi are vital for their survival. They keep unwanted substances from entering the cells and stop the contents of the cells from leaking out. By causing holes to appear in the cell membranes, terbinafine kills the fungi and hence clears up the infection.

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Key facts about terbinafine tablets

  • Terbinafine tablets are only available on prescription.
  • Lamisil is a brand name for terbinafine tablets.
  • Terbinafine tablets are only licensed for adults but may sometimes be prescribed for children aged over one year.
  • Adults should take one terbinafine 250mg tablet once a day.
  • Treatment may be needed for two to six weeks for skin infections and six weeks to six months for nail infections.
  • Always complete the prescribed course.
  • The most common side effects are reduced appetite, indigestion, feeling sick, stomach ache, diarrhoea, rash and aching muscles or joints.

Who should not take terbinafine tablets?

Terbinafine tablets are not suitable for:

  • Women who are breastfeeding. Terbinafine passes into breast milk.
  • People with liver problems.
  • People who are allergic to any ingredients of the tablets.

Some people might need a lower terbinafine dose or extra monitoring. Make sure your doctor knows if you have:

  • kidney problems (your doctor may prescribe a lower dose)
  • psoriasis (terbinafine can sometimes make psoriasis worse)
  • a long-term autoimmune disease affecting connective tissue, called systemic lupus erythematosus (SLE).

Can I take terbinafine tablets while pregnant?

Only if your doctor thinks it’s essential. The safety of terbinafine tablets for use during pregnancy has not been established. Tell your doctor if you are or think you could be pregnant.

How do I take terbinafine tablets?

The usual dose for adults is one terbinafine 250mg tablet taken once a day. Children will be prescribed a lower dose depending on their age and body weight. Follow the instructions given by your doctor.

Try and take your dose at the same time each day. You can take terbinafine tablets either with or without food.

The usual length of treatment is as follows:

  • Athlete’s foot: between two and six weeks
  • Ringworm: four weeks
  • Jock itch: two to four weeks
  • Nail infections: between six weeks and three months. Some toenail infections need treatment for six months or more.

Always follow the instructions given by your doctor.

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If you forget to take a terbinafine dose at your usual time don’t worry, just take it as soon as you remember that day. If you don’t remember until the following day just leave out the missed dose and take your next tablet at your usual time. Don’t take a double dose to make up for a missed dose.

Make sure you take terbinafine tablets regularly and complete the course as directed by your doctor, even if your symptoms have cleared up, otherwise there is a risk of the infection returning.

What are the side effects of terbinafine tablets?

Medicines and their possible side effects can affect people in different ways. The following are some of the side effects that may be associated with terbinafine tablets. Just because a side effect is stated here doesn’t mean that all people taking this medicine will experience that or any side effect.

Very common side effects (affect more than 1 in 10 people)

  • Decreased appetite.
  • Disturbances of the gut such as indigestion, feeling bloated, feeling sick, vomiting, diarrhoea or abdominal pain.
  • Itchy skin rash.
  • Pain in the muscles and joints.

Common side effects (affect between 1 in 10 and 1 in 100 people)

  • Headache.

Rare side effects (affect between 1 in 1000 and 1 in 10,000 people)

  • Dizziness.
  • Changes in sensation such as tingling or numbness.
  • Liver problems, such as jaundice, hepatitis or liver failure. Your doctor may want to take a blood test to check your liver function before you start treatment and again after four to six weeks of treatment. See your doctor if you develop unexplained itching or fatigue, yellowing of the skin or eyes (jaundice), unusually dark urine or pale stools, nausea and vomiting, upper right abdominal pains or loss of appetite during treatment, as these could be signs of liver problems.

Very rare side effects (affect fewer than 1 in 10,000 people)

  • Decreased levels of white blood cells or platelets in the blood. See your doctor if you get any unexplained bruising or bleeding, or signs of infection such as a fever.
  • Serious skin reactions. See your doctor if you experience skin blistering or peeling or a skin rash that is getting worse.

Read the leaflet that comes with the medicine or talk to your doctor or pharmacist if you want any more information about the possible side effects of terbinafine tablets. If you think you have experienced a side effect, did you know you can report this using the yellow card website?

Can I take other medicines with terbinafine tablets?

It is important to tell your doctor or pharmacist what medicines you are already taking, including those bought without a prescription and herbal medicines, before you start treatment with terbinafine. Similarly, check with your doctor or pharmacist before taking any new medicines while taking terbinafine, to make sure that the combination is safe.

Some key points are:

Painkillers

If you need to take a painkiller while you’re taking terbinafine it’s fine to take paracetamol or ibuprofen.

Contraception

Terbinafine doesn’t affect hormonal contraceptives such as the pill. However, if you experience vomiting or diarrhoea while taking this antifungal, this can potentially make your pill less effective at preventing pregnancy. If this happens to you, follow the instructions for vomiting and diarrhoea described in the leaflet provided with your pills.

Other medicines

Terbinafine may increase the blood levels of the following medicines. If you are taking one of these, tell your doctor if you get any new or increased side effects after starting terbinafine as your doses may need adjusting:

  • atomoxetine
  • dapoxetine
  • some beta-blockers, such as propranolol, metoprolol, timolol
  • SSRI antidepressants, eg paroxetine, citalopram
  • tricyclic antidepressants, eg amitriptyline, clomipramine, nortriptyline, imipramine, lofepramine.

Terbinafine may make the following medicines less effective:

  • codeine
  • tamoxifen
  • tramadol.

Rifampicin, a medicine for tuberculosis, may make terbinafine less effective. If you are taking rifampicin your doctor may need to prescribe a larger than normal dose of terbinafine to treat your fungal infection.

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Last updated 01.08.2018

Lamisil Tablets

Generic Name: terbinafine
Product Name: Lamisil Tablets

Indication: What Lamisil Tablets is used for

Lamisil tablets are used to treat:

  • Fungal infections of the fingernails and toenails;
  • Tinea (ringworm) infections of the groin and body;
  • Tinea infections of the feet, commonly called “athlete’s foot“.

These infections are caused by a group of fungi called dermatophytes.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Your doctor may have prescribed it for another reason.

Lamisil tablets are only available with a doctor’s prescription.

This medicine is not addictive.

There is not enough information to recommend the use of this medicine in children.

Action: How Lamisil Tablets works

Terbinafine, the active ingredient in Lamisil tablets, works by killing the dermatophytes.

Terbinafine interferes specifically with fungal sterol biosynthesis at an early step. This leads to a deficiency in ergosterol and to an intracellular accumulation of squalene, resulting in fungal cell death. Terbinafine acts by inhibition of squalene epoxidase in the fungal cell membrane. The enzyme squalene epoxidase is not linked to the cytochrome P450 system. When given orally, the drug concentrates in skin and nails at levels associated with antifungal activity.

Lamisil tablets contain 250 mg terbinafine (as the hydrochloride salt) per tablet.

Lamisil tablets also contain magnesium stearate (E 572), silica-colloidal anhydrous, hypromellose (E464), sodium starch glycollate, and cellulose-microcrystalline (E 460).

Lamisil tablets do not contain lactose, sucrose, gluten, tartrazine, or any other azo dyes.

Dose advice: How to use Lamisil Tablets

Before you take Lamisil tablets

When you must not take it

Do not take Lamisil if you have ever had an allergic reaction to:

  • Terbinafine, the active ingredient, or to any of the other ingredients listed here;
  • Any other medicines, foods, preservatives or dyes.

Your doctor will want to know if you are prone to allergies.

Some of the symptoms of an allergic reaction may include:

  • Shortness of breath;
  • Wheezing or difficulty breathing;
  • Swelling of the face, lips, tongue or other parts of the body;
  • Rash, itching or hives on the skin.

Do not take Lamisil tablets:

  • If you have any problems with your kidneys;
  • If you have or ever had a problem with your liver.

This medicine is not recommended if you currently have a liver problem because it may make the problem worse. If you had a liver problem in the past and your liver is functioning normally now, your doctor may prescribe Lamisil tablets but may want to check your liver function before and during treatment with this medicine. Your doctor might take blood tests to monitor your liver function. In case of abnormal test results, he or she may ask you to stop taking Lamisil.

Do not take Lamisil tablets after the expiry date printed on the pack, or if the packaging is torn or shows signs of tampering. In that case, return it to your pharmacist.

Before you start to take it

Tell your doctor if you:

  • Are pregnant or intend to become pregnant. There is no experience with the use of Lamisil tablets during pregnancy. If your doctor thinks it is necessary for you to take it, they will discuss with you the benefits and risks involved;
  • Are breastfeeding. Breastfeeding is not recommended since terbinafine, the active ingredient in Lamisil tablets passes into breast milk. There is a possibility that your baby could be affected;
  • Have any skin problems such as rash, red skin, blistering of the lips, eyes or mouth, skin peeling, fever (possible signs of serious skin reactions), rash due to high level of a specific type of white blood cells (eosinophilia);
  • Have any blood disorders or experience weakness, unusual bleeding, bruising or frequent infections;
  • Have or experience thickened patches of red/silver skin (psoriasis) or facial rash, joint pain, muscle disorder, fever (cutaneous and systemic lupus erythematosus).

If you are not sure whether you should start taking Lamisil tablets, talk to your doctor or pharmacist.

Taking other medicines

Tell your doctor if you are taking any other medicines, including any that you buy without a prescription from a pharmacy, supermarket or health food shop.

Some medicines and Lamisil tablets may interfere with each other. These include:

  • Some medicines used to treat depression and other mental disorders, including obsessive-compulsive disorders and panic attacks (e.g. some antidepressants such as tricyclic antidepressants, selective serotonin reuptake inhibitors including class 1A, 1B and 1C, monoamine oxidase inhibitors Type B, desipramine);
  • Some medicines for Parkinson’s disease;
  • Some medicines used to treat an irregular heartbeat, heart problems, high blood pressure and migraines (e.g. metoprolol);
  • Some medicines used to treat stomach ulcers (e.g. cimetidine);
  • Some medicines called antibiotics used to treat infectious diseases (e.g. rifampicin);
  • Caffeine;
  • Cyclosporin, a medicine used to help prevent organ transplant rejection or to treat certain problems with the immune system;
  • Oral contraceptives (birth control pills). You may have problems, such as bleeding between periods, while you are taking Lamisil tablets;
  • Warfarin, a medicine used to prevent blood clots.

You may need to take different amounts of your medicines or you may need to take different medicines.

Your doctor and pharmacist have more information.

If you have not told your doctor about any of these things, tell them before you start taking this medicine.

How to take Lamisil tablets

Follow all directions given to you by your doctor and pharmacist carefully. These directions may differ from the information contained here.

If you do not understand the instructions on the label, ask your doctor or pharmacist for help.

How much to take

Follow your doctor’s instructions on how many Lamisil tablets to take.

The usual dose of Lamisil is one tablet (250 mg) each day. If you have kidney problems, the dose may be reduced to one-half a tablet each day.

How to take it

Take the Lamisil tablet with a full glass of water. If you find that the Lamisil tablet upsets your stomach, try taking it immediately after a light meal.

Take the tablet at about the same time each day. Taking your tablet at the same time each day will have the best effect. It will also help you remember when to take it.

How long to take it

The length of your treatment will depend on the type of infection you have, what part of the body is affected and how well you respond to treatment.

Fungal skin infections (tinea)

If you have a tinea infection of the feet (athlete’s foot), you will usually take the tablets for 2 to 6 weeks.

If you have a tinea infection of the body or groin, you will usually take the tablets for 2 to 4 weeks.

The signs and symptoms of infection may last for several weeks after the fungi (dermatophytes) have been killed.

Fungal nail infections

Fungal nail infections usually take longer to heal than fungal skin infections. You will usually take the tablets for anywhere from 6 weeks to 3 months. But, if you have a nail infection of the big toe or your nails grow very slowly, you may need to take the tablets for up to 6 months.

It may take several months after you stop taking Lamisil tablets for your nail to look completely normal. That is because the deformed part of the nail has to grow out and be replaced by a healthy nail.

If you forget to take it

If it is almost time for your next dose (within 4 hours), skip the dose you missed and take the next dose when you are meant to. Otherwise, take it as soon as you remember, and then go back to taking it as you would normally.

Do not take a double dose to make up for the one that you missed. This may increase the chance of you getting an unwanted side effect.

If you are not sure what to do, ask your doctor or pharmacist. If you have trouble remembering when to take your medicine, ask your pharmacist for some hints.

If you take too much (overdose)

Immediately telephone your doctor or Poisons Information Centre (telephone number 13 11 26), or go to Accident and Emergency at your nearest hospital if you think that you or anyone else may have taken too many Lamisil tablets. Do this even if there are no signs of discomfort or poisoning. Keep the telephone numbers for these places handy.

Some of the symptoms of an overdose may include a headache, nausea (feeling sick), stomach pain and dizziness.

While you are taking Lamisil tablets

Things you must do

Make sure to take your tablet every day and continue taking it until your doctor tells you to stop. This will ensure that all of the infection is gone and will lessen the chance of the infection coming back once you stop taking this medicine.

Make sure to have any blood tests done that are ordered by your doctor. Any side effects on your liver, kidneys or blood can be detected by blood tests.

Tell your doctor immediately if you notice any of the following:

  • Fever;
  • Sore throat;
  • Mouth ulcers;
  • “Flu-like” symptoms (chills, aching joints, swollen glands, lack of energy);
  • Any other signs of infection, apart from the fungal infection you are being treated for.

If you become pregnant while taking Lamisil tablets, tell your doctor immediately. Your doctor can discuss with you the risks and benefits of taking it during pregnancy.

Remind your doctor and pharmacist that you are taking Lamisil tablets if you are about to be started on any new medicine.

Tell any other doctor, dentist or pharmacist, who treats you that you are taking Lamisil tablets.

Things you must not do

Do not give this medicine to anyone else, even if their condition seems similar to yours.

Do not use it to treat any other complaints unless your doctor tells you to.

Things to be careful of

Be careful driving, operating machinery or doing jobs that require you to be alert while you are taking Lamisil tablets until you know how it affects you. This medicine can cause tiredness, sleepiness, dizziness or lightheadedness in some people. If you have any of these symptoms, do not drive, use machines, or do anything else that could be dangerous.

Be careful to keep the infected areas dry and cool and change clothing that is in direct contact with the infected areas every day. This will help to clear up the infection and make sure that it does not return.

After using Lamisil tablets

Storage

Keep your medicine in the original container until it is time to take it.

Store it in a cool, dry place below 30°C and protected from light. Do not store Lamisil tablets or any other medicine in the bathroom or near a sink. Do not leave it in the car or on window sills.

Keep the medicine where children cannot reach it. A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking this medicine or the expiry date has passed, ask your pharmacist what to do with any medicine you have left over.

Schedule of Lamisil Tablets

Lamisil Tablets is a Schedule 4 – prescription only medicine.

Side effects of Lamisil Tablets

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking Lamisil tablets, even if you do not think it is connected with the medicine. All medicines can have side effects. Sometimes they are serious, but most of the time they are not. You may need medical treatment if you get some of the side effects.

Do not be alarmed by these lists of possible side effects. You may not experience any of them.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor immediately or go to Accident and Emergency at your nearest hospital if you notice any of the following:

  • Chest pain;
  • Signs of a severe allergic reaction such as swelling of the face, lips, tongue, throat or other part of the body; shortness of breath, wheezing or troubled breathing; dizziness, redness, itching or rash on the skin; flushing, crampy abdominal pain, loss of consciousness; joint pain, stiffness, rash, fever or swollen/ enlarged lymph nodes;
  • Possible signs of a serious liver problem such as persistent nausea, loss of appetite, unusual tiredness, vomiting, pain in the upper right abdomen, yellowing of the skin and/or eyes, dark urine or pale bowel motions;
  • Possible signs of a serious skin reaction such as painful red areas, large blisters, peeling of layers of skin, bleeding in the lips, eyes, mouth, nose or genitals. These signs may be accompanied by fever and chills, aching muscles and feeling generally unwell;
  • Possible signs of a blood problem such as constant “flu-like” symptoms (fever, sore throat, mouth ulcers, chills, swollen glands, lack of energy);
  • Possible signs of diseases that affect certain types of blood cells: unusual bleeding or bruising;
  • Possible signs of a disease that affects the level of red blood cells including abnormal pale skin, mucosal lining or nail beds, unusual tiredness or weakness or breathlessness on exertion;
  • Possible signs of blood vessel inflammation: rash, fever, itching, tiredness or if you notice appearance of purplish-red spots under the skin surface;
  • Possible signs of pancreas inflammation: severe upper stomach pain with radiation to the back;
  • Possible signs of muscle necrosis: unexplained muscle weakness and pain or dark (red-brown) urine.

The above are serious side effects that need medical attention. Serious side effects are rare.

Tell your doctor if you notice any of the following and they worry you:

  • Nausea (feeling sick) or vomiting;
  • Upset stomach (heartburn, cramps, wind, belching);
  • Loss of appetite;
  • Diarrhoea;
  • Aching joints or muscles;
  • Headache;
  • Light headedness;
  • Tiredness, sleepiness;
  • Skin rash due to high level of a specific type of white blood cells;
  • Loss of or change in sense of taste, which usually returns to normal within several weeks of stopping Lamisil tablet treatment;
  • Blurred vision, decreased sharpness of vision;
  • Other skin problems;
  • Psoriasis (thickened patches of red skin, often with silvery scales);
  • Hair loss;
  • Tingling or numbness;
  • Decreased physical sensitivity;
  • Smell disorders or loss of smell;
  • Anxiety (with symptoms such as sleep disturbances, fatigue, loss of energy or diminished ability to think or concentrate) and depressive symptoms (e.g. depressed mood) due to taste disturbances;
  • Decreased hearing, impaired hearing and/or perception of noises in the absence of sound (e.g. hissing, ringing) in ears.

Tell your doctor if you notice anything else that is making you unwell. Some people may have other side effects not yet known or mentioned in this leaflet.

For further information talk to your doctor.

  1. Lamisil Tablets Consumer Medicine Information (CMI). Macquire Park, NSW: Novartis Pharmaceuticals Australia Pty Ltd. January 2018.
  2. Lamisil Tablets Product Information (PI). Macquire Park, NSW: Novartis Pharmaceuticals Australia Pty Ltd. April 2016.

Are you currently using Lamisil topical?

Use this medication on the skin only. Clean and thoroughly dry the area to be treated. Apply a thin layer of the medication on and around the affected area, usually once or twice daily as directed on the product package. If you are uncertain about any of the information, consult your doctor or pharmacist. Wash your hands after using unless the area being treated includes the hands. Do not wrap, cover, or bandage the area unless directed to do so by your doctor.

Do not apply the medication in the eyes, nose, or mouth, or inside the vagina. If you do get the medication in those areas, flush with plenty of water.

Do not apply this medication on the scalp or nails unless otherwise directed by your doctor.

The dosage and length of treatment depends on the type of infection being treated.

Do not apply more often or use longer than directed. This may increase the risk of side effects.

Use this medication regularly to get the most benefit from it. To help you remember, use it at the same time(s) each day.

Continue to use this medication until the full treatment period is finished, even if symptoms disappear after a few days. Stopping the medication too early may result in a return of the infection.

Your condition may continue to improve after the full treatment is finished. It may take several weeks after treatment for the infection to completely heal. Inform your doctor if your condition worsens or does not improve within 2 weeks for jock itch and ringworm and within 4 weeks for athlete’s foot.

Do your toenails split, peel, and turn yellow? If so, you may be one of an estimated 40 million Americans who live with toenail fungus. The good news is, you don’t have to live like this. A number of remedies can help you walk with confidence. Here are 10 that you can buy at your local drugstore. You may even have some of them in your medicine cabinet. Although these may not be as effective as medicines your doctor can prescribe, they might be worth a try:

Undecylenic Acid

This fungus fighter is the main ingredient in many over-the-counter (OTC) products. You can buy it at your local drugstore as a liquid or a polish you paint onto your nails. It eases the raw, irritated skin that can come with a fungus.
Tolnaftate

This is a staple in OTC products for athlete’s foot, ringworm, and jock itch. It comes in a cream, powder, spray, or liquid. You may feel relief after 2 to 3 days, but keep using it for at least 2 weeks after symptoms disappear.

Clotrimazole

You’ll find this in many OTC yeast infection creams. But it’s also used to treat toenail fungus. Scientists in the U.K. found it worked for most of the patients who used it in a 12-week trial.

You can buy it as a cream or lotion.

Terbinafine

You may know this by its brand name, Lamisil. You can buy it over the counter as a cream, gel, spray, or powder. Or you can ask your doctor for the tablets. Take one tablet each day for 12 weeks. It’ll kill toenail fungus, but it may take a few months to see full results.

Tea Tree Oil

This oil comes from a tree in Australia. It’s a popular treatment for many conditions, including foot fungus. Research shows it works as well as clotrimazole, which is found in many OTC treatments.

Mentholated Cream

You probably already use this to treat chest colds. But did you know vapor rub is also a popular home remedy for toenail fungus? There’s not a lot of proof that it works. But in one very small study — just 18 people — more than half said it did.

About terbinafine

Type of medicine Antifungal
Used for Fungal skin infections in adults
Also called Lamisil®
Available as Cream, topical solution, gel, and spray

Although many types of fungi live harmlessly on our skin, some can cause infections. The most common fungi to cause skin infections are the tinea group of fungi. For example, tinea pedis (athlete’s foot) is a common fungal infection of the toes and feet, and tinea cruris (fungal groin infection) is a fungal infection which affects the groin area. Infections caused by a fungus or a yeast (a type of fungus) can affect other parts of the body too.

Terbinafine is an antifungal medicine which is applied to the skin (topically) as a cream, gel, solution, or spray. It works by killing the fungus causing the infection. Although terbinafine is available on prescription, you can also buy some preparations without a prescription at pharmacies and other retail outlets.

If your fungal infection is widespread, or if it is in a place that is difficult to treat (such as a nail infection), it may require treatment with tablets prescribed by a doctor. There is a separate medicine leaflet called Terbinafine tablets which gives more information about this.

Before using terbinafine

To make sure this is the right treatment for you, before you start using terbinafine it is important that your doctor or pharmacist knows:

  • If you are pregnant or breastfeeding. This is because, while you are expecting or feeding a baby, you should only take/use medicines on the recommendation of a doctor.
  • If you are taking any other medicines or using any other creams. This includes any medicines which are available to buy without a prescription, as well as herbal and complementary medicines.
  • If you have ever had an allergic reaction to a medicine or cream.

How to use terbinafine

  • Before you start this treatment, read the manufacturer’s printed information leaflet from inside your pack. The leaflet will give you more information about terbinafine and how to apply it.
  • Wash and dry the infected area of skin before you apply terbinafine.
  • If you are using cream or gel, apply a thin layer once or twice daily and then rub it in gently. You will need to use it regularly for one to two weeks. Once all signs of your infection have gone, continue to use it for a further two or three days to prevent the infection from coming back.
  • If you are using spray, use it once each day for a week and be careful to make sure that all of the infected area has been covered by the spray.
  • If you are using solution, this is applied once only. Treat both of your feet at the same time by applying a thin layer of solution, making sure you apply it between your toes, on the soles of your feet and up the sides of your feet for about 1.5 cm. The solution will dry to form a film. Do not wash your feet for 24 hours after you’ve applied the solution.

Getting the most from your treatment

  • Remember to wash your hands carefully after using terbinafine, as this will help to prevent the infection from spreading to other parts of your body. Also, use a separate towel to other people until your infection clears up.
  • Fungal infections often occur in warm, moist areas of the body. After washing or showering, make sure that all areas of your skin are dried well, particularly areas such as skin folds and between your toes.
  • As a guide, athlete’s foot usually clears up within a week of treatment, and infections affecting the groin area within two weeks of treatment. If there are no signs of improvement after these times, you should make an appointment to see your doctor for further advice.

Can using terbinafine cause problems?

Along with their useful effects, all medicines can cause unwanted side-effects although not everyone experiences them. The table below lists some of the most common ones associated with topical use of terbinafine. You will find a full list in the manufacturer’s information leaflet supplied with your medicine. The unwanted effects often improve over the first few days of using a new medicine, but speak with your doctor or pharmacist if any of the following side-effects continue or become troublesome.

Possible terbinafine side-effects What can I do if I experience this?
Irritation, redness, or itching If this continues or becomes troublesome, speak with your doctor

If you experience any severe skin reactions or other symptoms which you think may be due to this medicine, speak with your doctor or pharmacist.

How to store topical terbinafine

  • Keep all medicines out of the reach and sight of children.
  • Store in a cool, dry place, away from direct heat and light.

Important information about all medicines

This preparation is for use on the skin only. If someone swallows some of it, go to the accident and emergency department of your local hospital. Take the container with you, even if it is empty.

This medicine is for you. Never give it to other people even if their condition appears to be the same as yours.

Do not keep out-of-date or unwanted medicines. Take them to your local pharmacy which will dispose of them for you.

If you have any questions about this medicine ask your pharmacist.

Dear Doctor: I had toenail fungus two years ago, and my doctor prescribed Lamisil. It took a long time, but it worked. Now the fungus, which is so ugly, is back again. Why is it so hard to get rid of, and are there any new treatments available?

Dr. Elizabeth Ko and Dr. Eve Glazier

Dear Reader: Toenail fungus is fairly common, but that’s not much consolation to the 6 million or so people in the United States who have to put up with it. It’s an often-unsightly infection caused by a microscopic organism called a dermatophyte that lives beneath the toenail. More precisely, it colonizes the portion of the nail known as the matrix, which is underneath the cuticle.

Initial symptoms are a yellowish or brownish discoloration of the toenail. As the infection progresses, nails will often become thickened, crumbly and malformed. Although the fungus affects the appearance of the nails, it actually lives on the layer directly beneath the toenail. That’s why it’s so difficult to treat.

Your nails are made up of keratin, a tough, fibrous protein. The same hard shell that protects your toes is giving shelter to the fungus. For topical medications to be successful in killing the fungus, they have to be able to reach it.

Anti-fungal creams and liquids are available, both in over-the-counter preparations and by prescription. But because nails are not porous, it’s difficult for the medication to reach the infection in concentrations great enough to kill the fungus. As a result, success rates for topical treatments are low.

Systemic medications, like the Lamisil your physician prescribed, take a more direct approach. You swallow the pill, it gets digested, and the medication enters your bloodstream. Your circulatory system delivers the medication directly to the fungus living beneath your toenail and, in the best-case scenario, kills it.

However, there are drawbacks. Side effects can include headache, nausea and diarrhea. In rare cases, the drug can cause liver damage, so blood tests to monitor potential toxicity are needed. These infections are quite persistent, and your experience with recurrence is fairly typical. Although oral medications are the most effective, reported failure rates are as high as 20 to 30 percent.

Nail growth is slow, which means treatment is a lengthy process. A big toenail can take anywhere from a year to 18 months for new growth to completely replace the old, infected nail. Oral treatment for toenail fungus generally lasts 12 weeks. Topical preparations must be applied for at least a year.

Nail fungus is not a health risk to most people. But anyone with a compromised immune system, such as a diabetic who contracts nail fungus, is at risk of developing serious complications like foot ulcers. Therefore, it’s vital that diabetics seek medical treatment.

As for your question about new treatments, some physicians and podiatrists offer laser treatment of toenail fungus. Although some patients report good results, reliable data about the long-term efficacy of laser treatment is scarce.

Our recommendation is that you meet with your primary care physician, who will want to do a physical exam of the affected area. Then you can discuss the specifics of the recurrence and evaluate which of the existing treatments are best for you at this time.

Eve Glazier, M.D., MBA, and Elizabeth Ko, MD., are internists and assistant professors of medicine at UCLA Health.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Terbinafine

Generic Name: terbinafine (ter BIN na feen)
Brand Name: LamISIL

Medically reviewed by Drugs.com on Oct 30, 2019 – Written by Cerner Multum

  • Overview
  • Side Effects
  • Dosage
  • Professional
  • Interactions
  • More

What is terbinafine?

Terbinafine is an antifungal medication that fights infections caused by fungus.

Terbinafine tablets are used to treat infections caused by fungus that affect the fingernails or toenails.

Terbinafine oral granules are used to treat a fungal infection of scalp hair follicles in children who are at least 4 years old.

Terbinafine may also be used for purposes not listed in this medication guide.

Important Information

Some people taking terbinafine have developed severe liver damage leading to liver transplant or death.

Call your doctor at once if you have symptoms of liver damage, such as nausea, upper stomach pain, vomiting, loss of appetite, tiredness, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes). These events can occur whether or not you have ever had liver problems before.

Before taking this medicine

You should not use terbinafine if you are allergic to it, or if you have:

  • liver disease.

To make sure terbinafine is safe for you, tell your doctor if you have ever had:

  • liver problems;

  • weak immune system (caused by disease or by using certain medicine); or

  • lupus.

It is not known whether terbinafine will harm an unborn baby. You should wait until after your pregnancy to start treating your nail or scalp infection with terbinafine. Tell your doctor if you are pregnant or plan to become pregnant during treatment.

Terbinafine can pass into breast milk and may harm a nursing baby. You should not breast-feed while using this medicine.

How should I take terbinafine?

Follow all directions on your prescription label. Do not take this medicine in larger or smaller amounts or for longer than recommended.

You may take the terbinafine tablet with or without food.

Terbinafine granules should be sprinkled into a spoonful of pudding or mashed potatoes (do not mix with applesauce, fruit juice, or other fruit-based or acidic foods). Swallow this mixture right away without chewing. Do not save the mixture for later use.

Terbinafine is usually taken for 6 weeks to treat scalp or fingernail infections, and for 12 weeks to treat a toenail infection.

Use this medicine for the full prescribed length of time. Your symptoms may improve before the infection is completely cleared. Skipping doses may also increase your risk of further infection that is resistant to antifungal medicine. Terbinafine will not treat a viral infection such as the flu or a common cold.

While using terbinafine, you may need frequent blood tests.

It may take several months for your nails to return to their normal appearance after your treatment with terbinafine.

Store at room temperature away from moisture, heat, and light. Keep the terbinafine oral granules in their sealed packet until you are ready to use.

What happens if I miss a dose?

Take the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose.

What happens if I overdose?

Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

Overdose symptoms may include headache, dizziness, vomiting, stomach pain, rash, and increased urination.

What should I avoid while taking terbinafine?

Avoid coffee, tea, cola, energy drinks or other sources of caffeine while taking terbinafine.

Avoid exposure to sunlight or tanning beds. Terbinafine can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when you are outdoors.

Terbinafine side effects

Get emergency medical help if you have signs of an allergic reaction (hives, difficult breathing, swelling in your face or throat) or a severe skin reaction (fever, sore throat, burning in your eyes, skin pain, red or purple skin rash that spreads and causes blistering and peeling).

Seek medical treatment if you have a serious drug reaction that can affect many parts of your body. Symptoms may include: skin rash, fever, swollen glands, flu-like symptoms, muscle aches, severe weakness, unusual bruising, or yellowing of your skin or eyes. This reaction may occur several weeks after you began using terbinafine.

Some people taking terbinafine have developed severe liver damage leading to liver transplant or death. It is not clear whether terbinafine actually caused the liver damage in these patients. In most cases, the patient had a serious medical condition before taking terbinafine.

Call your doctor at once if you have symptoms of liver damage, such as nausea, upper stomach pain, vomiting, loss of appetite, tiredness, dark urine, clay-colored stools, or jaundice (yellowing of the skin or eyes). These events can occur whether or not you have ever had liver problems before.

Also call your doctor if you have:

  • changes in your sense of taste or smell;

  • depressed mood, sleep problems, lack of interest in daily activity, feeling anxious or restless;

  • pale skin, easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin;

  • swelling, rapid weight gain, little or no urinating;

  • blood in your urine or stools;

  • weight loss due to taste changes or loss of appetite; or

  • skin sores, butterfly-shaped skin rash on your cheeks and nose (worsens in sunlight).

Common side effects may include:

  • diarrhea, nausea, gas, stomach pain or upset;

  • rash;

  • headache;

  • abnormal liver function tests.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

What other drugs will affect terbinafine?

Other drugs may interact with terbinafine, including prescription and over-the-counter medicines, vitamins, and herbal products. Tell your doctor about all your current medicines and any medicine you start or stop using.

Further information

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Copyright 1996-2018 Cerner Multum, Inc. Version: 13.03.

Medical Disclaimer

More about terbinafine

  • Side Effects
  • During Pregnancy or Breastfeeding
  • Dosage Information
  • Drug Images
  • Drug Interactions
  • Compare Alternatives
  • Support Group
  • Pricing & Coupons
  • En Español
  • 370 Reviews
  • Drug class: miscellaneous antifungals

Consumer resources

  • Terbinafine Tablets
  • Terbinafine Tablets and Hydroxypropyl-Chitosan Nail Lacquer
  • Terbinafine Oral Granules
  • Terbinafine (Advanced Reading)

Other brands: Lamisil, Terbinex

Professional resources

  • Terbinafine Hydrochloride (AHFS Monograph)
  • … +2 more

Related treatment guides

  • Onychomycosis, Toenail
  • Tinea Capitis
  • Cutaneous Candidiasis
  • Onychomycosis, Fingernail
  • … +3 more

Terbinafine Side Effects

Medically reviewed by Drugs.com. Last updated on Nov 17, 2018.

  • Overview
  • Side Effects
  • Dosage
  • Professional
  • Interactions
  • More

In Summary

Commonly reported side effects of terbinafine include: headache. Other side effects include: diarrhea, dyspepsia, and skin rash. See below for a comprehensive list of adverse effects.

For the Consumer

Applies to terbinafine: oral tablet

Along with its needed effects, terbinafine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur while taking terbinafine:

More common

  • Fever

Less common

  • Body aches or pain
  • chills
  • cough
  • diarrhea
  • difficulty with breathing
  • ear congestion
  • general feeling of discomfort or illness
  • headache
  • joint pain
  • loss of appetite
  • loss of voice
  • nasal congestion
  • nausea
  • runny nose
  • shivering
  • skin rash or itching
  • sneezing
  • sore throat
  • sweating
  • trouble with sleeping
  • unusual tiredness or weakness
  • upper abdominal or stomach pain
  • vomiting

Rare

  • Dark urine
  • difficulty with swallowing
  • pale skin
  • pale stools
  • redness, blistering, peeling, or loosening of the skin
  • stomach pain
  • unusual bleeding or bruising
  • yellow skin or eyes

Incidence not known

  • Black, tarry stools
  • bleeding gums
  • bloating
  • blood in the urine or stools
  • chest pain
  • constipation
  • cough or hoarseness
  • dizziness
  • fast heartbeat
  • feeling of discomfort
  • flu-like symptoms
  • general feeling of tiredness or weakness
  • hair loss
  • high fever
  • hives
  • indigestion
  • inflammation of the joints
  • large, hive-like swelling on the face, eyelids, lips, tongue, throat, hands, legs, feet, or sex organs
  • light-colored stools
  • lower back or side pain
  • muscle aches
  • painful or difficult urination
  • pains in the stomach, side, or abdomen, possibly radiating to the back
  • persistent loss of appetite
  • pinpoint red spots on the skin
  • puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
  • red skin lesions, often with a purple center
  • red, irritated eyes
  • red, scaling, or crusted skin
  • sores, ulcers, or white spots on the lips or in the mouth
  • sores, welting, or blisters
  • stomach pain, continuing
  • swollen glands
  • swollen lymph glands
  • tightness in the chest
  • troubled breathing with exertion
  • ulcers, sores, or white spots in the mouth
  • unexplained bleeding or bruising

Some side effects of terbinafine may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

More common

  • Stomach pain (mild)

Less common

  • Acid or sour stomach
  • bad, unusual, or unpleasant (after) taste
  • belching
  • change of taste or loss of taste
  • heartburn
  • toothache

Incidence not known

  • Decreased vision
  • difficulty with moving
  • discouragement
  • feeling sad or empty
  • irritability
  • lack of appetite
  • loss of interest or pleasure
  • loss of sense of smell
  • muscle cramps or spasms
  • muscle stiffness
  • tiredness
  • trouble concentrating

For Healthcare Professionals

Applies to terbinafine: oral granule, oral tablet

General

In general, side effects have been mild to moderate and transient; however, this drug has been associated with serious life-threatening events such as hepatic failure, anaphylaxis, and severe neutropenia. Unless otherwise specified, the listed side effects were reported with the tablets.

Nervous system

Taste disturbances were typically noticed 5 to 8 weeks after starting therapy and returned to normal within several weeks after stopping the medication. The taste alteration has been rarely accompanied by a discoloration of the tongue and/or a disturbance in the sense of smell.

Hypogeusia (including ageusia) usually recovered within several weeks after this drug was stopped. Isolated cases of prolonged hypogeusia have been reported.

Taste disturbance (including taste loss), paresthesia, hypoesthesia, tinnitus, and vertigo have also been reported during postmarketing experience. Some cases of taste disturbance were severe enough to cause decreased food intake, weight loss, anxiety, and depressive symptoms.

Very common (10% or more): Headache (12.9%)

Common (1% to 10%): Taste disturbance/dysgeusia (including taste loss/ageusia), dizziness

Uncommon (0.1% to 1%): Hypogeusia, ageusia, paresthesia, hypoesthesia, tinnitus

Very rare (less than 0.01%): Vertigo, sedation, lightheadedness

Frequency not reported: Taste alteration

Postmarketing reports: Smell disturbance (including loss of smell), paresthesia, hypoesthesia, hearing impairment, hypoacusis, anosmia (including permanent anosmia), hyposmia

Gastrointestinal

Very common (10% or more): Gastrointestinal symptoms, feeling of fullness, abdominal distension, diarrhea, dyspepsia/gastritis, nausea, abdominal pain, flatulence, vomiting, mild abdominal discomfort, abdominal cramps, belching

Common (1% to 10%): Upper abdominal pain

Uncommon (0.1% to 1%): Toothache

Very rare (less than 0.01%): Parotid swelling

Frequency not reported: Mild to moderate gastrointestinal discomfort, gastritis, gastric fullness, nausea and vomiting, discoloration of the tongue, hypogeusia, ageusia, metallic taste, severe sialadenitis

Postmarketing reports: Pancreatitis

Vomiting, upper abdominal pain, and toothache have been reported with the oral granules. Vomiting has also been reported during postmarketing experience with the tablets.

Dermatologic

An 81-year-old male who had been treated with topical antifungal agents for tinea pedis started this drug (125 mg orally daily) as the lesions did not respond to topical therapy. He was not taking any other medications and had no history of skin disease. No other skin lesions were observed at that time. Two weeks later, he developed erythematous and pustular lesions on his fingers and toes, and an erythematous macular eruption on the limbs. This drug was discontinued, but the eruptions continued to worsen. Histopathology of a punch biopsy from his toe showed intraepidermal sterile pustules containing neutrophils, so-called Kogoj’s spongiform pustules. He was then diagnosed with having acrodermatitis continua of Hallopeau and was treated with corticosteroids therapy.

An 80-year-old female experienced DRESS secondary to severe sialadenitis coincident with this drug. The patient was admitted with a generalized pruriginous eruption. She presented with erythematous and edematous widespread confluent plaques, with a scaly annular border. She had initiated therapy 14 days before onset of the generalized rash, for a nonspecific squamous plaque of the trunk. DRESS induced by this drug was diagnosed and therapy was discontinued. Topical therapy was started with 0.5% clobetasol propionate cream applied to the whole body. The rash progressively improved and blood eosinophilia decreased.

A 68-year-old male experienced acute generalized exanthematous pustulosis coincident with this drug. He presented with a symmetrical maculopapular eruption on both lower anterior legs. Within 2 days, the rash generalized with facial involvement. He developed the rash 20 days after initiating oral therapy for onychomycosis. After withdrawal of this drug, the exanthema abated within 10 days under topical therapy with corticosteroids.

Serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, exfoliative dermatitis, bullous dermatitis), psoriasiform eruptions or exacerbation of psoriasis, acute generalized exanthematous pustulosis, hair loss, and photosensitivity reactions have also been reported during postmarketing experience.

Very common (10% or more): Nonserious forms of skin reactions, rash, urticaria

Common (1% to 10%): Pruritus, erythema

Uncommon (0.1% to 1%): Photosensitivity reactions

Very rare (less than 0.01%): Serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, exfoliative dermatitis, bullous dermatitis), photosensitivity (e.g., photodermatosis, photosensitivity allergic reaction, polymorphic light eruption), alopecia/hair loss, psoriasiform eruptions or exacerbation of psoriasis, acute generalized exanthematous pustulosis, toxic skin eruption

Frequency not reported: Reversible alopecia areata of the scalp, pustular psoriasis, acrodermatitis continua of Hallopeau

Postmarketing reports: Serious skin reactions (e.g., drug reaction with eosinophilia and systemic symptoms syndrome)

Metabolic

Very common (10% or more): Decreased appetite/anorexia

Frequency not reported: Hypoglycemia, decreased food intake (due to taste disturbance)

Arthralgia and myalgia have also been reported during postmarketing experience.

Musculoskeletal

Very common (10% or more): Musculoskeletal reactions, arthralgia, myalgia

Very rare (less than 0.01%): Cutaneous and systemic lupus erythematosus

Postmarketing reports: Rhabdomyolysis, increased blood creatine phosphokinase, precipitation and exacerbation of cutaneous and systemic lupus erythematosus

Hepatic

Liver enzyme abnormalities (at least 2 times the upper limit of normal) have been reported in 3.3% of patients.

In most liver failure cases, patients had serious underlying systemic conditions; causal association with this drug was unclear.

A 57-year-old male with chronic hepatitis B virus (HBV) infection developed drug-induced acute autoimmune hepatitis coincident with this drug. He was given 250 mg once daily over a 12-week period for dermatophyte toenail onychomycosis. He developed the side effect just prior to completing the course of therapy. He was not taking any other drugs or herbal supplements, did not drink alcohol, and did not appear to suffer a flare of HBV infection. Liver function studies began to normalize 6 weeks after this drug was discontinued.

Cases of liver failure (some leading to death or liver transplant), hepatitis, cholestasis, and increased hepatic enzymes have also been reported during postmarketing experience.

Common (1% to 10%): Liver enzyme abnormalities

Rare (0.01% to 0.1%): Serious liver dysfunction (including hepatic failure, increased hepatic enzymes, jaundice, cholestasis, liver decompensation, hepatitis), transient increases in liver enzymes, hepatobiliary dysfunction, cholestatic jaundice, liver failure (some cases leading to death or liver transplant)

Frequency not reported: Development of idiosyncratic and symptomatic hepatobiliary dysfunction, drug-induced autoimmune hepatitis

Postmarketing reports: Idiosyncratic and symptomatic hepatic injury

Psychiatric

Common (1% to 10%): Depression

Very rare (less than 0.01%): Anxiety

Frequency not reported: Insomnia

Postmarketing reports: Anxiety (independent of taste disturbance), depressive symptoms (independent of taste disturbance), anxiety (secondary to taste disturbances), depressive symptoms (secondary to taste disturbances)

Other

Common (1% to 10%): Pyrexia, tiredness/fatigue

Uncommon (0.1% to 1%): Weight decreased

Rare (0.01% to 0.1%): Malaise (secondary to dysgeusia)

Very rare (less than 0.01%): Chest pain

Frequency not reported: Weight loss (due to taste disturbance), weight decreased (secondary to hypogeusia)

Postmarketing reports: Influenza-like illness

Pyrexia has been reported with the oral granules; it has also been reported during postmarketing experience with the tablets.

Malaise and fatigue have also been reported during postmarketing experience.

Respiratory

Common (1% to 10%): Nasopharyngitis, cough, upper respiratory tract infection, influenza, pharyngolaryngeal pain, rhinorrhea, nasal congestion

Nasopharyngitis, cough, upper respiratory tract infection, influenza, pharyngolaryngeal pain, rhinorrhea, and nasal congestion have been reported with the oral granules.

Ocular

Changes in the ocular lens and retina have been reported; however, the clinical significance is unknown.

Dyschromatopsia, whereby the patient reported a greenish hue in her vision, and photopsia have occurred in a patient after 3 weeks of therapy. This problem resolved within 1 week of discontinuing the drug.

Common (1% to 10%): Visual disturbance

Frequency not reported: Changes in ocular lens and retina, dyschromatopsia, photopsia

Postmarketing reports: Reduced visual acuity, visual field defect, blurred vision

Hematologic

Agranulocytosis, thrombocytopenia, anemia, and pancytopenia have also been reported during postmarketing experience.

Uncommon (0.1% to 1%): Anemia

Very rare (less than 0.01%): Neutropenia, agranulocytosis, thrombocytopenia, pancytopenia

Frequency not reported: Leukopenia, lymphopenia, transient decreases in hematocrit, transient decreases in hemoglobin, transient decreases in leukocytes

Postmarketing reports: Severe neutropenia, altered prothrombin time (prolonged and reduced) with concomitant warfarin

Hypersensitivity

Very rare (less than 0.01%): Anaphylactoid reactions (including angioedema)

Frequency not reported: Anaphylaxis, hypersensitivity reactions

Postmarketing reports: Serious hypersensitivity reactions (e.g., angioedema, allergic reactions ), anaphylactic reaction, serum sickness-like reaction

Renal

Frequency not reported: Renal function test impairment, transient increases in serum urea, transient increases in serum creatinine

Genitourinary

Frequency not reported: Hematuria, transient erectile dysfunction in male patients

Cardiovascular

Postmarketing reports: Vasculitis

1. “Product Information. Lamisil (terbinafine).” Sandoz Pharmaceuticals Corporation, East Hanover, NJ.

2. Villars VV, Jones TC “Special features of the clinical use of oral terbinafine in the treatment of fungal diseases.” Br J Dermatol 126(suppl (1992): 61-9

3. Amichai B, Grunwald MH “Adverse drug reactions of the new oral antifungal agents – terbinafine, fluconazole, and itraconazole.” Int J Dermatol 37 (1998): 410-5

4. del Palacio Hernandez A, Lopez Gomez S, Gonzalez Lastra F, Moreno Palancar P, Iglesias Diez L “A comparative double-blind study of terbinafine (Lamisil) and griseofulvin in tinea corporis and tinea cruris.” Clin Exp Dermatol 15 (1990): 210-6

5. Shear NH, Gupta AK “Terbinafine for the treatment of pedal onychomycosis: a foot closer to the promised land of cured nails?” Arch Dermatol 131 (1995): 937-42

6. Abecassis S, Roujeau JC, Bocquet H, et al. “Severe sialadenitis: a new complication of drug reaction with eosinophilia and systemic symptoms.” J Am Acad Dermatol 51 (2004): 827-30

7. Beutler M, Hartmann K, Kuhn M, Gartmann J “Taste disorders and terbinafine.” BMJ 307 (1993): 26

8. Stricker BHC, Vanriemsdijk MM, Sturkenboom MCJM, Ottervanger JP “Taste loss to terbinafine: a case-control study of potential risk factors.” Br J Clin Pharmacol 42 (1996): 313-8

9. Ottervanger JP, Stricker BH “Loss of taste and terbinafine.” Lancet 340 (1992): 728

10. Juhlin L “Loss of taste and terbinafine.” Lancet 339 (1992): 1483

11. Balfour JA, Faulds D “Terbinafine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in superficial mycoses .” Drugs 43 (1992): 259-84

12. Bennett ML, Jorizzo JL, White WL “Generalized pustular eruptions associated with oral terbinafine.” Int J Dermatol 38 (1999): 596-600

13. Verros CD, Rallis E “The role of terbinafine in induction and/or exacerbation of psoriasis.” Int J Dermatol 52 (2012): 1155-6

14. Wach F, Stolz W, Hein R, Landthaler M “Severe erythema anulare centrifugum-like psoriatic drug eruption induced by terbinafine.” Arch Dermatol 131 (1995): 960-1

19. Papa CA, Miller OF “Pustular psoriasiform eruption with leukocytosis associated with terbinafine.” J Am Acad Dermatol 39 (1998): 115-7

20. Todd P, Halpern S, Munro DD “Oral terbinafine and erythema multiforme.” Clin Exp Dermatol 20 (1995): 247-8

21. Wilson NJE, Evans S “Severe pustular psoriasis provoked by oral terbinafine.” Br J Dermatol 139 (1998): 168

22. Carstens J, Wendelboe P, Sogaard H, Thestrup-Pedersen K “Toxic epidermal necrolysis and erythema multiforme following therapy with terbinafine.” Acta Derm Venereol 74 (1994): 391-2

23. “Itracanazole, terbinafine possibly linked to liver failure.” Am J Health Syst Pharm 58 (2001): 1076

25. Fernandes NF, Geller SA, Fong TL “Terbinafine hepatotoxicity: Case report and review of the literature.” Am J Gastroenterol 93 (1998): 459-60

26. Paredes AH, Lewis JH “Terbinafine-induced acute autoimmune hepatitis in the setting of hepatitis B virus infection.” Ann Pharmacother 41 (2007): 880-4

27. Gupta AK, DelRosso JQ, Lynde CW, Brown GH, Shear NH “Hepatitis associated with terbinafine therapy: three case reports and a review of the literature.” Clin Exp Dermatol 23 (1998): 64-7

28. Lowe G, Green C, Jennings P “Hepatitis associated with terbinafine treatment.” BMJ 306 (1993): 248

29. Cerner Multum, Inc. “UK Summary of Product Characteristics.” O 0

30. Gupta AK, Gonder JR, Shear NH, Dilworth GR “The development of green vision in association with terbinafine therapy.” Arch Dermatol 132 (1996): 845-6

33. Shapiro M, Li LJ, Miller J “Terbinafine-induced neutropenia.” Br J Dermatol 140 (1999): 1196-7

34. Kovacs MJ, Alshammari S, Guenther L, Bourcier M “Neutropenia and pancytopenia associated with oral terbinafine.” J Am Acad Dermatol 31 (1994): 806

35. Grunwald MH, Amichai B “Thrombocytopenia associated with oral terbinafine.” Int J Dermatol 37 (1998): 634

36. Beltraminelli HS, Lerch M, Arnold A, Bircher AJ, Haeusermann P “Acute generalized exanthematous pustulosis induced by the antifungal terbinafine: case report and review of the literature.” Br J Dermatol 152 (2005): 780-3

37. Rossetti G, Livio F, Roulet E, Hofer MF “Anaphylactic reaction and unrelated, subsequent, known side effects during therapy with thiethylperazine.” Pediatr Allergy Immunol 16 (2005): 453-5

38. Gupta AK, Kopstein JB, Shear NH “Hypersensitivity reaction to terbinafine.” J Am Acad Dermatol 36 (1997): 1018-9

39. Hull PR, Vismer HF “Treatment of cutaneous sporotrichosis with terbinafine.” Br J Dermatol 126 Suppl (1992): 51-5

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Some side effects may not be reported. You may report them to the FDA.

Medical Disclaimer

Incidence not known

Black, tarry stools

bleeding gums

bloating

blood in the urine or stools

chest pain

constipation

cough or hoarseness

dizziness

fast heartbeat

feeling of discomfort

flu-like symptoms

general feeling of tiredness or weakness

hair loss

high fever

hives

indigestion

inflammation of the joints

large, hive-like swelling on the face, eyelids, lips, tongue, throat, hands, legs, feet, or sex organs

light-colored stools

lower back or side pain

muscle aches

painful or difficult urination

pains in the stomach, side, or abdomen, possibly radiating to the back

persistent loss of appetite

pinpoint red spots on the skin

puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue

red skin lesions, often with a purple center

red, irritated eyes

red, scaling, or crusted skin

sores, ulcers, or white spots on the lips or in the mouth

sores, welting, or blisters

stomach pain, continuing

swollen glands

swollen lymph glands

tightness in the chest

troubled breathing with exertion

ulcers, sores, or white spots in the mouth

unexplained bleeding or bruising

Staying one step ahead of toenail fungus

Updated: November 5, 2019Published: May, 2015

An established fungal infection is hard to eradicate, but you can stop its spread and improve your toenail’s appearance.

Toenail fungus isn’t a pressing health problem. Yet a fungal infection can ruin the appearance of your nails and cause pain as it lifts the nail away from the nail bed. And fungal infections are notoriously difficult to get rid of. “You may want to consider fungal toenail a condition to be managed rather than cured,” says Dr. James P. Ioli, chief of the podiatry service at Harvard-affiliated Brigham and Women’s Hospital.

How fungi infect the nail

Onchomycosis, or toenail fungal infection, is an invasion by a microscopic organism that thrives in warm, damp environments. Fungal spores are in the air, and they will grow if they land on a receptive surface like your toenail. They feed off the nail tissues, burrowing into the skin under the nail. Over time the nail thickens and may lift off the nail bed as fungal debris accumulates. Once your nail is raised off the nail bed, it won’t reattach, and a new nail won’t grow from that part of the nail bed. However, your nail will continue to grow from the root at the base.

Diagnosing toenail fungus

A number of conditions can masquerade as fungal infections. Age alone thickens and yellows the nail. Psoriasis can cause the nail and the surrounding skin to flake. Injuries can create bruising under the nail. Even the chemicals in nail polish can discolor the nail. “But you don’t want to wait until your toenail is gnarly and raised off the nail bed,” says Dr. Ioli. You should see a podiatrist as soon as you notice your nail changing, he advises.

Only a lab test on a scraping from your toenail can show for certain that fungus is responsible for your nail distortion. Misdiagnosing toenail fungus can cost you time and money trying over-the-counter products that won’t have an effect.

How to protect your toenails

Whether you’re trying to clear up a fungal infection or hoping to avoid getting one, the following can help.

  • Wear socks that wick away perspiration. Although it seems counterintuitive, acrylic is much better at carrying off moisture than cotton.
  • Use antifungal foot powder daily.
  • Avoid shoes that keep your feet from breathing or that press on your nail.
  • Wear sandals or flip-flops in shower rooms at gyms or pools to avoid infection.

Toenail fungus treatments

There are a myriad of treatments for fungal infections, which vary widely in cost and effectiveness. To be fully effective, the antifungal drug has to penetrate the nail and often the nail bed as well.

Over-the-counter products. Antifungal preparations that are applied on and under the nail with the same type of brush used for polish are widely available. They don’t promise a cure but instead suggest that they can improve the appearance of fungal nails. There is no evidence that any one is particularly effective. “These are usually a waste of time and money,” Dr. Ioli says.

Prescription topical treatments. Effective products include efinaconazole (Jublia), tavaborole (Kerydin) and ciclopirox (Penlac). All require daily applications, and it may take as long as a year to see noticeable improvement. These products may work for early, superficial fungal infections because they kill fungi on the surface of the nail. Filing down the surface of the nail may enable them to penetrate more deeply into the nail or the nail bed. In studies, their cure rate averaged around 35%.

Oral medications. Itraconazole (Sporanox) and terbinafine (Lamisil) eliminated the fungus in 10 months for 55% to 70% of people in the studies required for FDA approval, but for 15% to 20% of users, the fungus returned within a few months. Either of these drugs can harm the liver, so your doctor will check your liver function at the beginning of treatment and again after six weeks. Itraconazole also interacts with a number of other drugs. If you take one of these drugs you’ll also need to avoid drinking alcohol and stay out of the sun. “If you have diabetes, vasculitis, or another condition that could be worsened by fungus, these medications might be a good choice, but otherwise, the benefits may not be worth the risks,” Dr. Ioli says.

Have realistic expectations

Don’t expect any product to give you toenails like those in the advertisements. However, if you adopt a daily routine of washing and drying your feet thoroughly, filing down your nails if needed, and applying a topical antifungal remedy, you should see a distinct improvement.

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It’s Costing A Lot Of Money To Make Those Toenails Fungus-Free

You might be able to get fungus-free toenails, but it could cost you. Shelly Strazis/Uppercut/Getty Images hide caption

toggle caption Shelly Strazis/Uppercut/Getty Images

You might be able to get fungus-free toenails, but it could cost you.

Shelly Strazis/Uppercut/Getty Images

The bills can rack up fast when trying to cure toenail fungus, and it’s not always easy to know which drug to use. Costs can range from over $2,000 for treating one nail to just $10 for a pill that treats all 10 toes but could have bad side effects. Then there are the costly lab tests to confirm that the curling yellow rot chewing through a toenail is in fact mold.

Right now, the most effective treatment for toenail mold or onychomycosis is a pill called terbinafine. It costs about $10 for a full treatment, which can take up to six months. It’s so cheap that it would be more cost-effective to administer the drug to everyone that clinicians think has toenail fungus, rather than spending extra money to confirm the diagnosis in a lab, which can cost up to $148, according to a study published in JAMA Dermatology on Wednesday.

Considering that at least 10 percent of Americans have toe fungus, the health care system could be saving between $18 million and $90 million by skipping the testing, the researchers say.

But some people are reluctant to use terbinafine because there’s a risk of liver damage, a fact that was emphasized when it came on the market decades ago.

“Practitioners were uncomfortable giving it because of the consequences, and we unfairly discouraged a lot of people from taking it,” says Dr. Arash Mostaghimi, a dermatologist at Brigham and Women’s Hospital and Harvard Medical School and senior author on the study. That’s the reason why doctors almost always order lab tests, so that people without a fungal infection wouldn’t be taking that risk.

Dermatologists know now that the chance for liver damage from terbinafine is less than 1 in 100,000, and yet the message persists. “I think that ‘people’ think that terbinafine is dangerous because their primary care doctors and even dermatologists have told them that!” Dr. Matt Kanzler, a dermatologist at Palo Alto Medical Foundation, tells Shots in an email.

Under the influence of this misconception, Kanzler says both physicians and patients elect to use more expensive topical treatments, like a new drug called Jublia that costs thousands of dollars per nail and works about 15 percent of the time. They want to avoid any potential liver injury and malpractice lawsuits. “The problem with this drug is that it isn’t ‘lifesaving’ like cardiac medicine,” he says. “As soon as there are articles mention ‘you should use this safe topical medicine,’ doctors say, ‘I am not going to put myself at risk.'”

The cumulative cost of all these decisions results in a needless burden on the health system, says Ankur Pandya, a health decisions scientist at Harvard University who was not involved with the study. “These extra health care costs are coming from somewhere. Either our tax dollars or our paychecks as we pay more in premiums and deductibles increase. These are dollars that could trickle back into our pockets on a societal level.”

This is part of the reason why health care is so expensive. Insurance premiums hurt, even for cheap plans. The cost to treat even minor nuisances can skyrocket. Then, a toenail fungus is not just a toenail fungus. It becomes an insatiable cash-scarfing beast latched onto the end of your foot. It would be better, Pandya says, to slash procedures that don’t make economic sense.

But other doctors say it’s not that simple. “Just assuming is safe, let’s prescribe it for every clinical diagnosis for onychomycosis doesn’t translate perfectly into practice,” says Dr. Chris Adigun, a dermatologist practicing in North Carolina who did not work on the study.

For one, the pills work only about half of the time and must be taken for up to six months, depending on how severe the fungus is, and Adigun says there’s still a 2 percent chance for other side effects. “The incidence of liver injury is low, but causes stomach upset, taste disturbance, fatigue — it’s often enough that people discontinue the drug.”

Adigun thinks that’s good enough reason to order the lab tests to make sure the patient really does have toenail fungus. “It damages the patient-doctor relationship to go on six months of a systemic drug for something they might not need.”

What’s more, Adigun says, this study doesn’t take into account that the elderly and people with other complications are more likely than healthy people to have toenail fungus. ” are often on a lot of other medications, so adding terbinafine to the mix without taking that into account is not totally responsible,” she says.

But Mostaghimi thinks it could be irresponsible not to recommend terbinafine as the front-line treatment for toenail fungus. “We’re spending 18 percent of our GDP on health care,” he says. “As a society, when we decide we’re going to spend an additional $80 million of testing for terbinafine, that’s $80 million we’re not spending on things that could be more valuable for us.”

Adigun agrees there’s a significant cost issue, but that doesn’t mean the decision is simple. “The take one for the team mentality is tough when it comes to your health and you’re the one swallowing that pill,” she says. “I think fiscally responsible medicine needs to be ingrained in us.”

At the same time, she says, she took an oath to do no harm. That means doing whatever she can to protect each patient from needless suffering, including side effects from a drug they didn’t need.

Which oral antifungal is best for toenail onychomycosis?

EVIDENCE-BASED ANSWER

Terbinafine, 250 mg taken daily for 12 weeks, is the best regimen for toenail onychomycosis due to better clinical and mycologic cure rates, tolerability, and cost effectiveness (strength of recommendation : A, meta-analyses).

Clinical commentary

This expensive treatment is not always a high priority
José E. Rodríguez, MD
Florida State University College of Medicine, Tallahassee

In my practice of mostly uninsured patients, onychomycosis treatment is not a high priority. The recommended drug, terbinafine, is costly and not available as a generic. Since this is primarily a cosmetic problem, we usually don’t treat it in my population. In the rare case that someone is willing to pay out of pocket, however, I will now use terbinafine, based on this review. At one of my practices, itraconazole was available at a reduced price, but that discount is outweighed by the superior safety profile of terbinafine.

Evidence summary

Fungal infections of the nail (onychomycosis) are often treated for relief of local symptoms and cosmetic reasons. Griseofulvin, fluconazole, itraconazole, and terbinafine have all been used orally.

A meta-analysis comparing the efficacy of terbinafine (Lamisil), pulse-dosed and continuous-dosed itraconazole (Sporanox), fluconazole (Diflucan), and griseofulvin showed mycological cure rates of varying degrees for each treatment (TABLE).1 Another meta-analysis of 6 studies comparing terbinafine with itraconazole reported odds ratios ranging from 1.8 (95% confidence interval , 1.1–2.8) to 2.9 (95% CI, 1.9–4.1), indicating an 80% to 190% increased likelihood of clinical cure with terbinafine compared with itraconazole.2

Lower relapse rates with terbinafine

Longer-term mycologic cure and clinical relapse rates have also been reported. A 5-year blinded prospective study found long-term mycologic cures of 46% for terbinafine vs 13% for itraconazole (number needed to treat =4.3). This study also showed a lower clinical relapse for terbinafine (21% vs 48%; NNT=3.7).3 A cost-efficacy analysis of terbinafine, itraconazole, and griseofulvin found terbinafine to be the most cost-effective (TABLE).4

Terbinafine is well-tolerated by most patients. A telephone survey after treatment with daily terbinafine or pulse-dose itraconazole reported greater ease and convenience, and higher overall satisfaction with continuous terbinafine vs pulse-dose itraconazole.6

A multicenter trial of diabetic patients with onychomycosis (mean±SD age, 55.7±11.7 years) revealed that terbinafine had comparable efficacy and caused no hypoglycemic reactions in this group, who were being treated with insulin or oral hypoglycemics.7 The terbinafine prescribing information suggests not using the drug for patients with chronic or active liver disease and recommends checking a pretreatment AST and ALT.8

TABLE
Efficacy and cost of treating toenail onychomycosis1,4

Recommendations from others

Guidelines from the British Association of Dermatologists point out that terbinafine is superior to itraconazole, and consider it a first-line treatment because it has a better cure rate and lower relapse rate.9 UpToDate suggests oral terbinafine as initial treatment for onychomycosis at a dose of 250 mg daily for 12 weeks.10

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