Toenail fungus is probably the topic that readers have asked us most about over the years. That’s not surprising since it is so common, so unpleasant and so hard to treat. The fungus causes the toenail, particularly on the big toe, to thicken and discolor; the end may separate from the nail bed. Often, the nail is so thick you can’t cut it. In severe cases, the nail may detach and fall off.
Medically known as onychomycosis, toenail fungus is increasingly common, possibly because of lifestyle changes and an aging population. Though estimates vary, about 10 percent of Americans have it, and this increases to about 20 percent in people over 60 and up to 50 percent of those over 70. More men than women get it.
Diabetes, vascular problems and impaired immunity are risk factors. About one-third of people with diabetes have toenail fungus. Smokers are at increased risk, too. It may be related to being sedentary, poor foot hygiene, nail trauma, family history and genetics. There’s also a strong link between toenail fungus and athlete’s foot. Moist socks and shoes present an ideal environment for fungi, which helps explain why toenail fungus is less common in societies where people don’t wear shoes. On the other hand, going barefoot in damp areas also increases the risk.
Though usually just a cosmetic issue, toenail fungus can cause pain and difficulty walking, not to mention self-consciousness when wearing sandals or going barefoot. The diseased nails can cause ulcerations or breaks in the skin, which, by serving as an entry for bacteria, can result in serious infections (for example, cellulitis). This can be especially problematic in people with diabetes, who are already predisposed to foot problems and infections.
Toenail fungus is notoriously difficult to cure and rarely goes away on its own. Standard treatments are only moderately effective and, even when they work, the fungus may return. Which treatment you choose depends on the severity of the condition, the cost and other medical conditions you may have.
Mainstream toenail fungus treatments
Oral antifungal drugs have been considered the gold standard treatment. The most common one used in the U.S. is terbinafine (Lamisil), which kills the fungus directly, rather than just halting its growth. Though more effective and safer than other oral antifungals, it still has potential side effects, including stomach upset, rash, headaches and, rarely, liver damage (thus, periodic blood tests are usually advised). Terbinafine can interact with other drugs and can’t be used by certain people, including women who are or may become pregnant and anyone with liver disease. Some health care providers now use “pulse dosing”—where the drug is taken daily for only one week a month for several months.
Topical medications are clear nail lacquers that you apply for 6 to 12 months. They have few side effects. The only one sold in the U.S. is ciclopirox (Penlac), which has a far lower cure rate than oral drugs, especially for thick nails, and so is best used for milder cases. The medication penetrates better if your podiatrist files, trims and debrides the nail and you apply topical urea (40 percent solution). Sometimes oral and topical drugs are combined for better results.
As an alternative to ciclopirox, you might talk to your doctor about amorolfine (Loceryl, Curanail), which can be ordered online from Canada or the U.K. as a do-it-yourself kit, with disposable nail files, cleaning pads, applicators and instructions. It has a cure rate nearly as high as oral terbinafine. Another promising topical drug, efinaconazole, is undergoing final clinical testing in the U.S.
High-tech toenail fungus treatment
Laser treatment is growing in popularity, thanks to marketing pitches that claim high cure rates in just one or a few sessions. Several devices, including the PinPointe Footlaser, have received Food and Drug Administration (FDA) clearance for the “temporary increase of clear nail in onychomycosis,” with an emphasis (ours) on temporary. Preliminary research suggests laser treatments may be promising, according to a 2012 review paper in Lasers in Medical Science, though they can’t claim to be cures. More recently, a study in the Journal of the American Podiatric Medical Association reported good results with a specific laser (Noveon), but there was no control group, and the investigator was a former employee of the manufacturer who still has a financial interest in the device.
Larger, well-controlled trials are needed to determine the benefits and risks of laser therapy. You can try it—if you can afford the high cost (typically $1,000, not covered by insurance). Another emerging (but also understudied) technology is photodynamic therapy, which involves a photosensitizing agent that is activated by light.
Should you try alternative therapies?
And then there are countless alternative remedies, including tea tree oil, olive oil, vitamin E, Campho-Phenique, oil of bitter orange and Listerine. Many products sold online (such as Fungavir) are a witch’s brew of ingredients. But there’s little or no evidence that any are effective. Some, such as dipping toes in beer, are innocuous, but dipping them in bleach can be harmful. Despite our knocking of Vicks VapoRub in the past, a small pilot study in 2011 suggested it might have some benefit, possibly due to its thymol, menthol, camphor and oil of eucalyptus. A Finnish study in 2012 suggested that conifer tree resin may also help, though the authors are shareholders of a company that develops and markets resin-based products for medical purposes.
Bottom line: If you have toenail fungus that is causing pain or other problems, see your primary care provider, dermatologist or podiatrist. Anyone with diabetes, circulation problems or an immune disorder who develops any type of foot infection should get immediate medical attention. Whatever treatment you choose, be patient, since the nail has to grow out before you can see if it is working, and that takes months.