Topical antifungal therapies have been tested in patients with mild onychomycosis. Cure rates of 29-85% have been observed with ciclopirox 8% nail lacquer in non-diabetic populations with mild disease;10 in diabetic populations using open label methodology cure rates of approximately 54% are reported.11,12 Novel topical forms of terbinafine with various penetration-enhancing compounds are also under development.13-15 Early studies report effective nail penetration of these formulations, but there is a lack of data on clinical efficacy of topical terbinafine. One preliminary study reported 90% mycological cure after 12 weeks of treatment with a terbinafine spray, but less than half had a sustained cure at 36 weeks post-treatment.16 Although effective for mild to moderate superficial onychomycosis, because of poor nail penetration topical agents are generally not recommended where fungus appears to infect more than 50% of the nail surface.7 One recent review has suggested that monotherapy with topical agents should be avoided altogether.17 Systemic antifungal agents are often used to treat more severe onychomycosis. Two of the most common systemic agents are itraconazole and terbinafine. Itraconazole is a newer agent with the added advantage of covering Candida species in addition to dermatophytes. Both agents are associated with cure rates of approximately 50% when given for a full three month course.18 These agents have significant limitations given the potential for drug-drug interactions via inhibition of cytochrome P450 enzyme subtypes.19 Itraconazole and terbinafine are associated with increased risk of bleeding with warfarin, itraconazole with increased risk of rhabdomyolysis with statins and of hypoglycemia with oral agents for diabetes and terbinafine with metoprolol, propafenone, and tricyclic antidepressants.19 Due to the significant limitations of topical and systemic treatments for onychomycosis, there is a critical need for alternative and replacement therapies. While surgical techniques such as avulsion and nail plate removal can be employed for severe and resistant infections, these treatments are quite invasive and painful.7,20 Other device-based therapies for onychomycosis include UV light therapy21-23 and photodynamic therapy.24-27 While these modalities show evidence of in vitro efficacy, there have been no robust studies conducted yet that demonstrate any clinical effectiveness.