In this issue of JAMA Dermatology, Mikailov et al1 challenge our propensity to automatically order costly confirmatory diagnostic testing before initiating systemic therapy with terbinafine hydrochloride for onychomycosis. There are 2 issues of importance here: safety and cost-effectiveness.
The issue of cost-effectiveness is relatively straightforward now that the price of generic terbinafine for an entire treatment course has fallen from $547 to $10. Mikailov et al1 have shown that it is more cost-effective to treat every presumptive case of onychomycosis with oral terbinafine rather than prove that the abnormality of the toenail is in fact due to onychomycosis.