Fungal infections of the skin, nails and hair, are caused by a group of fungi collectively known as dermatophytes. Toenail infections are particularly difficult to treat for several reasons:
- The environment around the feet is often enclosed, warm, and damp, providing an ideal environment for fungal growth.
- Once established under the nail, fungi are protected from externally applied medicines.
- Many people quit treatments before the infection is cured.
Although the condition is unsightly, toenail fungus treatments are rarely covered by health insurance since the condition is largely cosmetic. It may be covered when the patient is diabetic, has cellulitis (bacterial skin infection), or an immune system disorder.
Home Remedies for Toenail Fungus
Homeopathic remedies are rarely effective. However, if the patient is dedicated to frequent applications of an externally applied remedy, there is a chance it will work, or at least keep the infection in check. There is little or no clinical evidence that any of these remedies are effective and most information on their use comes from anecdotal reports.
- Tea Tree Oil. Treatment consists of applying 100% tree oil to the nail and surrounding area for many months.
- Vicks VapoRub. This soft paste contains camphor, eucalyptus, menthol, thymol and turpentine oil and one or a combination of these ingredients may inhibit fungal growth. Treatment is recommended daily for up to a year.
- Vinegar. Vinegar is a weak acid, but fungi are generally tolerant of acidic conditions so it is not clear why this would work. Treatment consists of soaking the feet for 15-20 minutes a day in a vinegar solution (one part vinegar to two parts warm water).
Topical Drugs for Toenail Fungus Treatment
Topical treatments are marginally effective since the fungus is protected to some extent under the nail. But they are readily available and safe, and they may work.
- Medicated Nail Laquer. Topical application of a lacquer containing ciclopirox or amorolfine twice a week may be prescribed for moderate cases. Data indicate that ciclopirox is more effective.
- Nystatin. Nystatin was one of the first antifungal compounds discovered and developed for clinical use. It is effective in those cases where the fungus Candida albicans is the causative agent.
- Whitfield's Ointment. Containing benzoic and salicylic acids, this is an old treatment for athlete's foot. It has been used under the nail to treat onchyomycosis. It is not recommended for long-term use because it irritates the skin.
- Imidazoles. Miconazole nitrate and cotrimazole are available over-the-counter ointments for treating nail fungi. Consistant application until the nail grows out fungus free can be effective.
- Terbinatine. Terbinafine in a cream for topical application is effective against skin fungi, less so against nail fungi.
- Tolnafate. Availabe as a cream, powder or aerosol, it's effective for athlete's foot and jock itch; not so much for toenail fungus.
Oral Drugs for Treating Toenail Fungus
Prescription oral medications deliver antifungal compounds through the bloodstream to the site of infection. They are more effective than topicals. Oral antifungals can be harmful to the liver, so some people will not use them. In the absence of underlying liver problems, they are generally safe. Even when a cure is achieved, the infection may return.
- Azoles. Itraconazole and diflucanazole (for Candida albicans) are used to treat a variety of fungal infections including toenail fungus. Treatment usually lasts three to four months.
- Terbinafine. This compound is also formulated as an oral medicine, which is much more effective against toenail fungus that the topical form.
- Griseofulvin. An early antifungal, griseofulvin needs to be taken for up to six months, and has more side effects than recent drugs such as the azoles.
Laser Treatment for Toenail Fungus
Laser treatment is a new option for treating toenail fungus. There is some controversy as to whether or not lasers are properly approved by the U.S. Food and Drug Administration for this purpose, but even so, some podiatrists offer the procedure.
Laser treatment requires several visits to a doctor's office, with each session lasting about half an hour. Light from a red laser is directed through the nail onto the fungus, which is killed by heat. Early results are promising but more clinical research is needed before laser treatment is proven to be more effective than current methods.
The is no single "best" way to treat fungal nail infections. The best way to approach a case of toenail fungus is in consultation with an experienced and informed medical professional.
References:
Anonymous, Nail Fungus, http://www.mayoclinic.com/health/nail-fungus/DS00084 (accessed January 17, 2009)
Krejci-Manwaring,J., 2009, Toenail fungus difficult to treat, but Vicks VapoRub seems effective, http://www.mysanantonio.com/health/columnists/ask_ut_medicine/Toenail_fungus_difficult_to_treat_but_Vicks_VapoRub_seems_effective.html, (accessed January 16, 2010)
Monti, L. et al, , 2009, Hydrosoluble medicated nail lacquers: in vitro drug permeation and corresponding antimycotic activity, British Journal of Dermatology, Nov. 3
Rodgers, P. and Bassler, M., 2001, Treating Onychomycosis, American Family Physician, 63: 663–72,677–8
Singer, N., , 2009, False Start on a Laser Remedy for Fungus, New York Times, pg B, March 20 (accessed January 17, 2009)
Wilson, J. W. and Plunkett, O. A., 1965, The Fungous Diseases of Man, University of California Press, Berkeley, CA
Philip McIntosh - The author holds a B.Sc. in Botany and Chemistry and an M.A in Biology and he has thirty + years of experience in science and industry.
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