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Toenail Fungus: Treatment and Prevention
Christine Dobrowolski, DPM MS
A thick, yellowish nail with splotchy white areas is a classic
presentation for a fungal toenail. In the early stages the toenail is
only slightly discolored, or slightly thickened. In the late stages
the nail can become very thick and has a tendency to "grow up" more
than in grows out. The nail will be very discolored, typically dark
yellow-brown and will start to change shape and crumble. In some cases
the nail becomes very loose and many will lose the nail, only for it
to regrow with the fungus.
The medical term for toenail fungus is "onychomycosis," pronounced on
* EE * ko * my * ko * sis. The prevalence in America is about 2-3%,
but some have reported it as high as 13%. Toenail fungus affects men
twice as often as it affects women and the prevalence among elderly
individuals and diabetics is 25%. In the 1800s, fungal toenails were
very rare. The increased prevalence is linked to the increased
exposure to fungus through the use of showering facilities in gyms,
the use of hot tubs, saunas and public pool areas. There has also been
an increase in the number of individuals participating in sporting
activities and wearing occlusive footwear. More individuals have
diabetes and there has been an overall increase in age of the general
population, both of which are associated with a less than optimal
immune system. It is no surprise that the risk factors for developing
toenail fungus are increasing age, male gender, nail trauma, sweaty
feet, poor circulation, poor hygiene, foot fungus and a compromised
immune system. Athletes will also have a higher risk.
There are a number of treatments for toenail fungus. 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 can be quite expensive as they need to be taken once daily
for 3 months. The effectiveness of the medications ranges from 60 to
80%, with a recurrence rate of 15%. 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. Serious adverse events are very rare, less
than 0.5%, but do include hepatitis and acute hepatic necrosis.
There are many other options besides oral anti-fungal medications.
Unfortunately, they are not very effective. The most effective topical
medication is Ciclopirox (Penlac ®) lacquer. Some studies have
shown
cure rates up to 60%, but in my experience the effectiveness is about
10-15%. Side effects occur in less than 2% of patients and include
burning and redness around the nail. This medication is only available
by prescription and is also quite expensive. A few other prescription
medications that help decrease the thickness of the fungal nails are
Carmol® 40 and Keralac® Nail Gel. You should not expect to see
complete cures with these products, but they can decrease the
thickness and discoloration of the nail in some cases.
There are many home remedies and over the counter products that you
can purchase. Some home remedies that can be used include bleach, tea
tree oil, grapeseed extract, and Vics VapoRub®. With any home
remedy
or non-prescription topical, you must understand that the
effectiveness of the treatment is fairly low, less than 10%. If you do
try one of these therapies make sure to use it every day. Roughen up
the nail surface with a file and apply the medication with a q-tip.
Bleach can cause skin irritation and some individuals have had skin
reactions to the Vics VapoRub®. In general these treatments are
considered very safe.
Combination therapy can help increase the effectiveness of the
treatment. If you choose to take an oral medication, make sure you use
a topical anti-fungal agent as well. Nail removal is also an option.
Once the nail is removed, the topicals can reach the nail bed and they
become more effective. The nail will grow back in over a period of
8-10 months. Permanent nail removal is reserved for those with chronic
ingrown nails, ulceration under the nails or pain from the fungal
nails.
The best form of treatment is prevention and preventing the fungus
from spreading to other toenails may be the best treatment option. I
recommend choosing a topical that you feel comfortable with and use it
once a week. No matter which treatment option you choose, you should
take the following steps to avoid re-infection.
1. Place an anti-fungal powder or spray in the shoes to help fight off
the fungus.
2. Make sure you rotate your shoes often and keep them in a cool dry
place.
3. Change your insoles frequently, and make sure they dry out between
use.
4. Bleach out the shower on a weekly basis.
5. Wash your shower mat regularly in hot water.
6. If you belong to a gym or health club, wear sandals in the locker
room and don't walk around barefoot.
7. Don't keep your shoes in the gym locker where they cannot dry out.
8. Make sure your athletic shoes fit well to prevent jamming at the
toes. Jamming at the toes leads to microtrauma at the nails and
increases the chance for fungal infection.
9. If your feet sweat excessively, try using an antiperspirant spray
on your feet before your workout.
10. Cut your toenails straight across. Don't cut too short and 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 is that prevention is easier than treatment. Treating
toenail fungus is very difficult and will take months regardless of
the type of treatment you choose. If you have fungal toenails that
cause pressure, pain or infection, consider talking to your doctor
about prescription medications or nail removal. If your fungal
toenails are only unsightly and don't cause any discomfort, consider
topical therapy for treatment. The last option is to prevent the nails
from becoming worse or becoming a problem. Try a weekly application of
an over the counter topical along with methods to prevent
re-infection.
Christine Dobrowolski is a podiatrist and the author of Those Aching
Feet: Your Guide to Diagnosis and Treatment of Common Foot Problems.
To learn more about Dr. Dobrowolski and her book visit
http://www.skipublishing.com/ To learn more about products for
toenail fungus visit http://www.northcoastfootcare.com
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