Antifungal pulse therapy for onychomycosis: a narrative review
Abstract
PURPOSE: Onychomycosis is a common chronic fungal infection of the nail unit that may be associated with significant functional impairment and impaired quality of life. Systemic antifungal drugs remain the cornerstone of treatment for moderate-to-severe disease, with continuous oral terbinafine and pulse itraconazole being the most widely used systemic antifungals. Pulse regimens involve intermittent administration of relatively high doses of antifungals with the aim of reducing cumulative drug exposure, treatment costs, and treatment burden while maintaining efficacy. However, the comparative effectiveness of pulse and continuous regimens remains unclear. This narrative review summarizes the current evidence regarding antifungal pulse therapy for onychomycosis. METHODS: A literature search was conducted using PubMed and Scopus databases to identify relevant randomized trials, comparative studies, systematic reviews, meta-analyses, observational studies, and case reports/case series published between March 2001 and April 2026. Evidence relating to treatment regimens, pharmacologic rationale, efficacy, and safety was reviewed and synthesized. RESULTS: The available evidence suggests that pulse therapy is an effective treatment option for onychomycosis. Among the currently available pulse regimens, itraconazole has the strongest supporting evidence and has demonstrated clinical and mycological outcomes comparable to continuous therapy in selected patient populations. Modified…
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