Treating Onychomycosis with Efinaconazole: Considerations for Diverse Patient Groups

Onychomycosis is a common nail disease that manifests with varying severity and frequency in specific patient populations, warranting a personalized treatment approach. Novel topical antifungals, such as efinaconazole 10% approved for use in North America and Japan, offer a safe treatment option for many of these patients, though real-world use requires special considerations. In this scoping review, a literature search was conducted in October 2025 using PubMed, Embase (Ovid), the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science (Core Collection). In children and adolescents (≥6 years), efinaconazole 10% has shown higher efficacy rates than in adults, possibly attributed to less nail trauma, thinner nail plates, and faster nail growth. In the elderly, a mycological response can precede visual nail improvements, which may require extending treatment beyond the standard 48-week regimen, along with intermittent maintenance therapies. Although antifungal resistance is a concern, dermatophytes—including terbinafine-resistant strains—have generally shown high susceptibility to efinaconazole. In diabetic individuals, onychomycosis should be treated promptly to prevent secondary complications. Efinaconazole 10% showed similar efficacy in this population, regardless of glycemic control. In historically underserved populations, efinaconazole 10% showed no significant difference in efficacy for Latino/Hispanic patients, though further research is needed. Overall, efinaconazole 10% solution was well-tolerated across patient groups, with application-site reactions occurring without systemic sequalae. Healthcare providers are advised to check for concomitant tinea pedis, which increases the risk of relapse or re-infection, and advise patients on nail polish use, which may degrade after topical antifungal application. A shared decision-making framework can help improve treatment compliance and patient satisfaction.