Can Patients Wear Nail Polish With The New Topicals For Onychomycosis?

When we as a profession were prescribing the first FDA approved topical antifungal lacquer, ciclopirox 8% solution, the concurrent use of nail polish was prohibited. This left many of our patients frustrated that they lacked a therapeutic option in which they could use a cosmetic camouflage concurrently with the topical antifungal.

With the advent of the two new topical antifungal medications for onychomycosis, tavaborole (Kerydin^™, Anacor Pharmaceuticals) and efinaconazole (Jublia^®, Valeant Pharmaceuticals), we now potentially have a solution to the issue of using toenail polish along with an antifungal topical solution. Before I launch into the research that has occurred with both topicals, it is important for me to state that there is currently no data on how the concurrent use of toenail polish influences the mycological or clinical cure rates of these products. I can assure you that the data is forthcoming for both products. For now, read the current research and decide on your own if this is something you want to recommend to your patients.  

Jublia (efinaconazole 10% solution). Zeichner and colleagues studied radiolabeled efinaconazole 10% solution and its in vitro nail absorption in cadaveric human nails coated with and without nail polish.¹ For non-diseased thumbnails, researchers applied two coats of nail polish or no nail polish. The nail polish consisted of three different brands of red color: Dior 999 Red Royalty, Essie 488 Forever Yummy and Revlon 550 Cherry. After drying thoroughly, all sets of nails were subject to a coating of (¹⁴C)-efinaconazole solution on days one, two, three, four and seven (avoiding a weekend application). After this seven-day period, authors removed the nail polish from the nail surface completely. Further testing determined how much of the radiolabeled efinaconazole penetrated into the nail plate.

Ultimately, “the level of efinaconaozle permeating through the nails either uncoated or coated with nail polish was not significantly different,” which means that the nail polish did not seem to obstruct efinaconazole in this lab simulation.¹ In this study, nail polish color was visible on the applicator tip of the product. If you have your patient use nail polish concurrently with efinaconazole, you should alert her of this possibility.

If you read the package insert for efinaconaozle, you will notice it discourages the use of nail polish and pedicures. As a principal investigator in the Phase III study of this product, I can attest that patients were not allowed to use nail polish during the yearlong study.¹ Further studies will assess what effect nail polish has, if any, on the mycologic outcome of this topical.   

Kerydin (tavaborole 5% solution). How does nail polish affect the penetration of tavaborole solution? Two studies have examined the use of nail polish with this product. One study consisted of tavaborole once daily in non-diseased human cadaveric fingernails that had either one coat of over-the-counter nail polish or none.² In the second study, researchers assessed five different nail polish options in cadaveric nails. These options were as follows:

1. four coats (base coat, two coats of polish, and top coat) of salon polish
2. one coat of salon polish
3. two coats of over-the-counter polish
4. one coat of over-the-counter polish
5. no nail polish

I am going to focus on the second study as this recreates the protocol our patients use. All of these nails were subject to once daily dosing of tavaborole over 14 days and researchers monitored nail penetration of tavaborole throughout. On day 15, the mean cumulative penetration of tavaborole for the groups that received any nail polish was numerically higher than the group that received no nail polish. 

Am I allowing my patients to use nail polish with these prescription topicals? Yes, but I am encouraging them to leave nails bare whenever possible until we have more data. Certainly, this is a relief for many of my patients to continue using the therapy while attending events that involve wearing open-toed shoes or those wanting to mask their nail disease in general. Am I encouraging my patients to run out and get a pedicure? Absolutely not. That is a whole other blog (and a great book, Death by Pedicure, by my colleague Robert Spalding, DPM). 

References

1. Zeichner, JA, Stein Gold L, Korotzer A. Penetration of (¹⁴C)-efinaconazole topical solution, 10%, does not appear to be influenced by nail polish. J Clin Anesthet Dermatol. 2014; 7(9):34-36.

2. Vlahovic T, Merchant T, Chanda S, Zane L Coronado D. In vitro penetration of tavaborole topical solution, 5% through nail polish on ex vivo human fingernails. Accepted for publication. J Drugs Dermatol, 2015.