What oral treatment options would you offer a patient with severe onychomycosis who is also on methotrexate for another condition?  

I prefer pulsed terbinafine at 250 mg daily x1 week every other month. Dr. Zaias showed in a comparative study that pulsed terbinafine works as well as giving it daily for 3 months, and since the patient is only taking this for 1 week every other month, risks for hepatotoxicity are minimal.

Assuming no history of hypersensitivity/allergy to azoles, once weekly pulse doses of fluconazole 300 mg (150 mg to 450 mg) for 6 months for fingernails or 9-12 months for toenails; this would be inexpensive, safe, and does not warrant any additional lab testing beyond routine for methotrexate. Wou...