Toenail fungus is an infection that involves the nail plate and the skin of the nail bed. Though this is a non-life threatening infection, it does cause problems like pain, shoe fit issues and social stigmas.  Other conditions can also cause changes in toenails, that's why diagnosis by a doctor is so important. Consult a physician before starting any treatment plan whether it's over the counter or prescribed. Not sure if fungus is your issue check out "Nail Woes" another C+C blog for more information on other conditions that can affect toenails. 

Onychomycosis is an infection of the nail most commonly caused by fungi but moulds and yeasts likeCandida can also be the culprit. 80% of the toenail infections are caused the class of Fungus called Dermatophytes with the most common species being- Trichophyton rubrum.

How did it get on your toes ? 

Some of the risks of developing toenail fungus include:

• Wearing closed-toe shoes. Fungus yeast and molds can grow in dark, moist environments- think gym shoes. 

• Getting pedicures with improperly sanitized tools or basins.

• Having a chronic illness, such as diabetes or HIV. Advanced age and poor circulation.

• Having a deformed nail from previous trauma or a nail disease from other dermatologic conditions.

TREATMENT 

Several things make it especially challenging to treat toenail fungus. The thickness of the nail plate can pose a barrier between treatment and the fungus sequestered beneath the nail. Additionally, the slow growth of the nail itself, the time it takes for a healthy nail to grow varies from person to person. A toenail grows at an average rate of 0.1 mm/day (1 cm every 100 days). Finger nails require 3 to 6 months to re-grow completely while toenails require 12 to 18 months. The actual growth rate can even vary depending upon the age, season, exercise level and a hereditary factor. 

This means that even after the fungus has been eliminated, healthy nail regrowth can sometimes take a year or longer.

Treatment options for fungal nails are separated into 3 categories:

• Topical anti-fungal agents applied directly to the nail 

• In office laser therapy

• Oral medication

Topical medications are widely available. You can find them online, in pharmacies, nail salons and doctor’s offices. They come in the form of liquids, solutions, nail lacquers and polishes; and are applied directly to the nail plate.  I have come across a lot of different treatments and success will vary depending on how dramatic the involvement of the nail is. If you are catching this fairly early you have a greater chance of success with the topical medications.  If this is something you have been struggling with for years- you will likely need to pair the topical with either the laser or oral therapies.  

There are hundreds if not thousands of nail treatments on the market. Some of the common active ingredients to look for are medications such as : Clotrimazole, Terbinafine, Ciclopirox, Efinaconazole, Terbavole. Some formulations are only available with a prescription or from a doctors office. Insurance coverage for these medications has also been a struggle- so don’t be surprised if there is some out-of-pocket cost associated with the doctor prescribed medications. 

Jublia is a prescription topical that has shown some of the best results- but again insurance coverage for this medication hasn’t been offered for a lot of plans over the past 2 years.  

Tolcylen has been my top recommendation since the prescription drugs were so out of reach. It is only available from a doctor’s office but is not prescription. It uses a combination of anti-fungals and other cosmetic agents to improve the appearance of nails while treating. It is my top pick- for 2020 until something better comes out. 

For over the counter treatments available outside of the doctors office - I recommend looking for a product that contains Tolnaftate as the active ingredient. Nail lacquers and polishes are hard to use daily and will likely result in treatment fatigue and you abandoning treatment. Anti-fungal creams are formulated to treat the skin and will likely not be successful treating the nail. The addition of some compounds like lactic acid, urea, acetic acid and salicylic acid will help with penetration of the medication through the hard nail plate. NFT20 is the best I could find meeting these recommendations, it uses Tolnaftate as the anti-fungal with acetic acid (found in vinegar) to aid in penetration.

For natural and holistic options- tea tree oil has been top of the list. Citronella, geranium, lemongrass, eucalyptus, and peppermint, among others, have been tested specifically against fungi and found to be effective antimicrobials for that purpose- Check out www.healthline.com/antifungal essential oils  for a complete guide on how to use essential oils to treat fungal infections. 

Prescription Oral Lamisil (Terbinafine) is a pill taken once daily and has been proven to be the most effective oral therapy. Cure rates have been reported from 57.8% to 73% when taking this medication daily for 3 months.  Whether or not taking a pill for treatment of this condition is right for you should be determined by you and your doctor. 

Laser therapy is an in-office treatment that has been shown to increase the effectiveness of topical medications. Some studies show it is able to achieve similar or even greater success than oral medications alone. However when used alone as monotherapy it has not been very effective. 

The appeal for the laser is that you can potentially achieve the same results from the oral pill without the associated side effects that inevitably come with any oral treatments.  I always tell patients the most common side effect from the laser is out of pocket cost. Laser treatments are not covered by insurance and cost varies widely. 

“managing the fungus in your environment and your exposure is the key to successful treatment”

By the numbers:

A cure rate of 71.88% was found with the laser and nail lacquer combined-therapy group at 16 weeks which was significantly higher than the 20.31% in the nail lacquer alone. This was a cure rate similar to the 60%~76% for oral systemic antifungal therapies such as Terbinafine and Itraconazole. 

Many patients ask about removing the toe nails. Although nail surgery may be useful in some cases, it is a painful and a disfiguring process. It should be limited to one or only a few nails if used at all. This would be a true last resort and only if there were severe symptoms associated with the current nail issue such as pain. 

Recurrence is also a common problem with onychomycosis.  In general whether you are seeking pharmaceutical, laser or holistic treatments; managing the fungus in your environment and your exposure is the key to successful treatment.  - ( Can we hyperlink to “ 3 tips to fighting fungus” ) 

 - Be well, Dr. D

NFT20 Nail Fungus Treatment

Sources

• Gupta et.al., Onychomycosis Therapy: Past, Present, Future, Journal of Drugs in Dermatology, Vol.9, 9, 2010.

• Gupta AK, Ryder JE, Johnson AM. Cumulative meta-analysis of systemic antifungal agents for the treatment of onychomycosis. Br J Dermatol. 2004;150:537–544. [PubMed]

• Amorolfine vs. ciclopirox – lacquers for the treatment of onychomycosis. Katarzyna Tabara,corresponding author Anna E. Szewczyk, Wojciech Bienias, Agnieszka Wojciechowska, Marta Pastuszka, Magdalena Oszukowska, and Andrzej Kaszuba

• Onychomycosis: Pathogenesis, Diagnosis, and Management. Boni E. Elewski* Clin Microbiol Rev. 1998 Jul; 11(3): 415–429.

• Scher R. K.  Onychomycosis: a significant medical disorder. J. Am. Acad. Dermatol. 35 Part 2 1996 S2 S5 

• Onychomycosis: Pathogenesis, Diagnosis, and Management Boni E. Elewski Clinical Microbiology Reviews Jul 1998, 11 (3) 415-429; DOI: 10.1128/CMR.11.3.415