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
Prescription oral antifungal drugs. Terbinafine (Lamisil) is more effective and safer than other oral antifungals, but it still has potential side effects, including stomach upset, rash, headaches, and, rarely, liver damage (thus, periodic blood tests are usually advised). It works by killing the fungus directly, rather than just halting its growth. 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.
Prescription topical medications. Applied for 6 to 12 months, these clear nail lacquers have few side effects. Ciclopirox (Penlac) has a far lower cure rate than oral drugs, especially for thick nails, and is best used for milder cases. Two new topical treatments were recently approved for treating nail fungus: tavaborole (Kerydin) and efinaconazole (Jublia), which appear to be as effective as oral drugs. You might also 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. Sometimes oral and topical drugs are combined for better results.
High-tech toenail fungus treatment
Laser treatment. Several laser devices have received FDA clearance for the “temporary increase of clear nail in onychomycosis,” with an emphasis (ours) on temporary. Preliminary research suggests they may be promising, but overall the evidence is still limited and studies have been of poor quality. You can try this—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 applying a topical agent that is then activated by light.
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.
Alternative Remedies for Toenail Fungus
Countless remedies have been tried to combat toenail fungus, including tea tree oil, olive oil, vitamin E, Campho-Phenique, oil of bitter orange, and Listerine. You may be surprised to learn that one popular OTC product may actually work.
Originally published September 2013. Updated July 2016.
Published July 21, 2016