All About Nail Fungus

Nail fungus, scientifically known as onychomycosis affects 5% of people worldwide.  It is more common in the elderly and amongst families, with a 45% chance of passing it along to a family member. 

A number of other conditions can cause discoloration and malformation of the nails.  Other than fungus, yeast, bacteria and blood are the most common things that cause discoloration of a nail.   Blood tends to look more red/brown and some bacteria will cause a blue green discoloration. Other than discoloration, toenails can “lift up” in a condition called onycholysis.  Sometimes disorders like psoriasis affect the nails as well.  When nails are growing abnormal, but are not infected, we call that nail dystrophy.  

To differentiate the causes of abnormal nails, I often recommend clipping the patient’s nail for a biopsy.  Once we have a definitive answer, we can proceed with treatment options.  It usually takes 10-14 days to get a nail biopsy result.

Treatment for toenail fungus is difficult.  It takes 6 months for a fingernail to grow out and 12 months for a toenail to grow out on average.  Treatment regimens are often long and require dedication.

There are a number of topical agents available both over the counter and by prescription.  Most of these require that a topical medication is applied daily for 12 months.  WOW, that’s a LONG time and a LOT OF WORK. FDA approved topical treatments are cicloprox lacquer and solutions Jublia and Kerydin.  Complete cure rates with topicals are 5-20%.  Call me lazy, but that is a lot of work to do daily for a year for a max of 20% success.   Medications that claim to improve your nails in days are weeks are false advertising.  

The most common oral medication used to treat nail fungus is Lamisil (generic terbinafine).  Treatment times are 6 weeks for fingernails and 12 weeks for toenails.  Complete cure rate with Lamisil orally is reported to be 59% for fingernails and 38% for toenails. Most common side effect is rash and rarely a taste disturbance occurs.  Lamisil can irritate the liver in some individuals.  We routinely check that the liver is normal before starting treatment with oral Lamisil.  Labs are rechecked at 4-6 weeks during therapy.  

Laser treatment of toenail fungus is a newer option with 1064 NdYAG being the most common laser used.  The laser targets pigment in the fungus and also heats the fungus to kill it. Laser results in lower complete cure rates than standard therapy, however it has less risk and less compliance requirements. Laser is not covered by insurance, and we currently do not offer this service in our office. 

There are tons of OTC treatments and home remedies.  There is only one that I regularly recommend.  Vinegar soaks are not an exact science, but here’s the recipe.  Combine ½ cup vinegar with any temperature water in a foot basin and soak for 15 minutes a few times a week.  After soaking, use a toothbrush to remove any debris in and around the toenails.  Do not scrape or probe underneath the toenails with anything sharp.  This will not cure the nails but can curtail an infection.

Because of repeat exposure and susceptibility, toenail fungus recurs after complete cure in about 25% of cases.  One study showed a reduced likelihood of recurrence by applying a topical antifungal a few times a week after cure is achieved. Therefore, we recommend applying Lamisil cream once a week to toenails after treatment is completed.  

It generally takes a whole year for toenails to grow from bottom to top, so it takes a while to see improvement if the entire nail is involved. Beautiful nails require patience and diligence.