Antifungal pulse therapy for onychomycosis: a narrative review

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 pulse schedules, prolonged regimens, and combination approaches incorporating topical antifungal agents have also shown promising results. In contrast, evidence supporting pulse terbinafine is less consistent, with several randomized controlled trials favoring continuous terbinafine, particularly in dermatophyte toenail onychomycosis. Fluconazole administered in weekly regimens appears to be less effective than terbinafine- or itraconazole-based regimens and is generally considered a second-line option. From a safety perspective, pulse and continuous regimens demonstrate safety profiles comparable to those of continuous therapy, with gastrointestinal adverse effects being the most frequently reported events.

Conclusion: The current evidence supports continuous terbinafine as the preferred first-line systemic treatment for dermatophyte onychomycosis, whereas pulse itraconazole remains an important alternative for patients who are unable to tolerate terbinafine, have contraindications to its use, or have failed previous therapy. Further well-designed randomized studies with standardized outcome measures and long-term assessment of recurrence are required to better define the optimal role of pulse antifungal therapy in onychomycosis management.