Over six million Americans have toenail fungus. The medical term for toenail fungus is “onychomycosis,” pronounced on * EE * ko * my * KO * sis. “Onycho” means pertaining to the nails and “mycosis” refers to a disease caused by a fungus. The fungus causes the nails to become thickened and yellow. Sometimes they appear white and splotchy, and sometimes yellowish-brown. The nails can curve in at the sides and thicken substantially at the center. Many times the nails can be uncomfortable, cause pain or result in ingrown toenails. Diabetics, and those with depressed immune systems, have a higher risk of developing toenail fungus. Others with an increased risk of developing toenail fungus are the elderly, athletes and individuals with sweaty feet. The risk of developing toenail fungus increases with age. Athletes have a higher risk because of more wear in occlusive shoes combined with repeated nail trauma. This is especially true for hikers, runners, backpackers, soccer, basketball and tennis players. Fungus likes to grow in moist, warm areas. This increases the chance of infection for those with excess sweating of their feet, also known as hyperhidrosis.
There are a number of treatments for onychomycosis. Unfortunately, many are not very effective. The most aggressive and effective way to treat the fungus is with oral anti-fungal medications. The most common oral anti-fungal medications are Itraconazole (Sporonox ®) and Terbinafine (Lamisil ®). Both medications are expensive and insurance companies tend to consider onychomycosis a cosmetic problem. If you are diabetic, your insurance company may consider onychomycosis a medical problem, and will cover the treatment. If you are experiencing pain or have developed ingrown toenails as a result, then your insurance company may cover treatment. The medication needs to be taken once daily for 3 months. The effectiveness of the medications ranges from 60 to 80%, with a recurrence rate of about 10-15%. Complete cure rates have been reported as low as 28%. Lamisil® appears to be more effective and has fewer drug interactions than Sporonox®.
With both medications, there is a long list of benign side effects including nausea, vomiting, abdominal pain, diarrhea, rash, headache, taste disturbances and dizziness. A recent study published in the American Journal of Geriatric Pharmacotherapy found the most common side effects with three months of Lamisil®, tin individuals over 65 years of age, were nausea, sinusitis, joint pain and high cholesterol. Serious problems can develop, which is why many doctors will recommend other therapies first. The problems are rare and occur less then 0.5% of the time, but include serious liver diseases like hepatitis and acute hepatic necrosis.
Topical therapies are much safer, but also much less effective and sometimes quite expensive. Popular prescription topicals include Ciclopirox laquer (Penlac ®), Carmol® 40 and Keralac® Nail Gel. Don’t expect miracles from these medications, but they can help decrease discoloration and thickness, prevent progression and are a great adjunct therapy.
Over The Counter and Home Remedies
There are many OTC (Over The Counter) products which can be purchased online or at the drug store. A few include Tineacide®, which combines lavender oil and tea tree oil, Lamisil® topical nail treatment, Dr. Scholl’s® Nail Management Kit, and Restore® which is, in my opinion, one of the best medications you can purchase over the counter. Some home remedies that can be used include melaleuca oil (tea tree oil), bleach, grapeseed extract, and Vics VapoRub®. I have had many patients claim complete cures with Vics VapoRub®, popularized by Dr. Gott, but I have yet to see any complete cures with Vics treatment. Vics tends to decrease the thickness of the nails and will sometimes contribute to peeling off of layers of the nail. Most topicals, prescription medications, OTCs and home remedies, tend to have similar effectiveness. One key is to purchase a product that is a gel, solution, laquer or spray. Creams tend to not be as effective. Roughen up the nail surface with a file before application for better penetration. Use treatment daily and plan on going through therapy for 6-8 months. Make sure you take steps to prevent the fungus from worsening, spreading and re-infecting. Follow these steps:
1. Place an anti-fungal powder or spray in the shoes every other day.
2. Make sure you rotate your shoes often and keep them in a cool dry place. Use a shoe dryer in the winter if necessary.
3. Change your insoles frequently, and make sure they dry out between use.
4. Try using an antiperspirant spray on your feet before your workout, if your feet sweat excessively.
5. Wash your shower mat regularly in hot water, or step out of the shower, onto a towel, which is washed after each use.
6. Bleach out the shower on a weekly basis.Bleach works better than antimicrobial cleaners.
7. Make sure your shoes fit well.Ill-fitting shoes can lead to jamming at the toes. Jamming at the toes leads to microtrauma at the nails and increases the chance for fungal infection.
8. If you belong to a gym or health club, wear sandals in the locker room and don’t walk around barefoot. Don’t keep your shoes in the gym locker where they cannot dry out.
9. Ladies, avoid wearing toenail polish.Toenail polish can increases chances of and/or worsen a fungal infection. If you can’t bear to go without polish, keep them painted for only 3-4 days, remove all polish and then go without polish for 2-3 days. Repeat this cycle through the summer.
10. Cut your toenails straight across. Cutting too short can cause breaks in the skin. This will increase the chance for fungal infection. Don’t let the toenails grow too long or they will jam against the shoe and cause bleeding under the nail, again increasing the chance for fungal infection.
The Bottom Line
Toenail fungus is very difficult to treat. If you have fungal toenails that cause pressure, pain or infection, consider talking to your doctor about prescription medications or nail removal. Make sure you take precautions to prevent re-infection and take multiple approaches to eradicate the problem. If your fungal toenails are only unsightly and don’t cause any discomfort, try a weekly application of an over the counter topical along with methods to prevent re-infection.