Why Is Toenail Fungus So Difficult to Treat?

Fungal infections of the toenails are very common, affecting up to 20 percent of people. Medically known as onychomycosis, it can affect both men and women, young and old and is very difficult to cure once it starts. Foot and ankle specialist, Jessica Milliman, DPM, discusses what causes toenail fungal infections, how to treat them with both medical and homeopathic remedies, and the steps you can take to prevent them in the first place.

How Does Nail Fungus Start?

Damaged, injured or loosened toenails offer the perfect entry point for fungi. “These microscopic organisms are everywhere, living on surfaces both indoors and outdoors and always looking for a new place to live and reproduce,” says Dr. Milliman. “Because feet are a warm, moist and often enclosed body part, they provide the ideal habitat for fungi.”

Toenail damage may be caused by repetitive friction experienced with sports such as running or it can be the result of injury. However the damage occurs, it provides a way for fungi to enter and take hold under and between the layers of the nail. Over time, fungi may even invade the nail matrix – special cells that are responsible for growing new fingernails and toenails.

Additional risk factors for the development of toenail fungus include:

• Wearing tight shoes
• Walking barefoot in moist areas like swimming pools, saunas and public showers
• Poor circulation in the legs
• Weakened immune system
• Other skin conditions, such as psoriasis
• Other medical conditions, such as diabetes and cancer

Symptoms of Nail Fungus

Usually, the first sign of a fungal toenail infection is a small, white, yellow or brown spot under the tip of the nail. As the fungi grows and burrows deeper, the nail may become thickened, brittle, crumbly and discolored. Over time, the infection can spread to adjacent nails.

“Although the symptoms listed above can indicate a fungal infection it is not definitive. A sample of the affected nail must be examined under a microscope to confirm if fungi are present, and which type. This information can help the doctor determine how to treat the infection, if at all,” says Dr. Milliman.

For many people, nail fungus is primarily a cosmetic concern. You should consult a doctor or podiatrist if any of the following situations exist or develop along with the nail symptoms:

• You have diabetes, an immune disorder or poor circulation in your legs
• There is bleeding, swelling or pain around the affected nail(s)
• You have difficulty walking

Treatment Options for Nail Fungus

If your infection is not causing any pain and you don’t have any underlying medical conditions, you may not need treatment. “My patients often ask if their immune system might kick in and the condition will clear up on its own,” says Dr. Milliman. “I tell them it’s possible but unlikely. The immune system will try to fight the infection but is often ineffective because it’s busy fighting off other things,” she adds.

Like many conditions, the earlier treatment begins, the more likely it is to be successful. Treatment options may include:

• Oral Medications. This is the most studied and most likely to be successful treatment for fungal nail infections. Known as Lamisil (brand name) or terbinafine (generic), these antifungal tablets are prescribed for 90 days. “I always tell patients that the course of treatment is actually six months,” says Dr. Milliman. “Three months of taking the medication, followed by three months for the nail to grow out and return to normal.” Lamisil is generally safe if there are no concurrent medical conditions. However, because the medication can put stress on the liver, bloodwork to evaluate liver function is required before and during treatment. Oral therapy is typically successful 70-80 percent of the time although some patients may need two courses of treatment or pulse dosing - periodic “top-ups” of the medication. If fungal infection is confirmed with biopsy prior to treatment, insurance will usually cover the cost.
• Topical Treatments. Prescription strength antifungal cream may be prescribed to treat the fungus. Over-the-counter products to treat athlete’s foot are not effective on toenail fungus.
• Laser Treatments. Although some people may want to try this, there is little data to support its effectiveness and the treatments are not covered by insurance.
• Toenail Removal. This is usually only considered as a last resort. If the toenail is removed, it must be followed up with antifungal therapy or the fungus will come back as the nail regrows. Permanently removing the toenail so that it doesn’t grow back has some risks as well.

Homeopathic Remedies

Although largely anecdotal, there are a few at-home remedies have helped some patients to manage their toenail fungus. These include soaking your feet in a solution of apple cider vinegar or Listerine antiseptic mouthwash. Generally, one part vinegar or Listerine to one part water is a good ratio for a foot soak. In addition, some people report that applying Vick’s VapoRub to the affected nail is helpful over time.

“There are no guarantees, however” says Dr. Milliman. “These treatments work for some and not for others, but there is no potential harm in trying them. I always recommend that patients file down the top surface of the nail before trying any topical or homeopathic treatment to help the product penetrate the nail.”

Prevention Is the Best Medicine

As with most medical conditions, it is always preferable to prevent rather than treat. Dr. Milliman recommends that everyone follow some simple foot hygiene practices to reduce their chances of contracting a toenail fungal infection:

• Don’t share nail trimmers, files or tools with other people. If you get professional pedicures, ask the technician about their process to sterilize and disinfect their tools between customers.
• Choose footwear that is made of natural fabric or leather. Mesh shoes or shoes with mesh panels are ideal as they allow air to circulate.
• Rotate shoes and change socks frequently during the day.
• Spray Lysol disinfectant in shoes and allow it to dry completely before wearing them again.
• Wash your feet at least once daily, being sure to dry them completely, especially between the toes.
• Always wear flip flops or shower shoes when using public showers, swimming pools or saunas.

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University Hospitals has a wide network of foot and ankle specialists at convenient locations throughout the region. Our experts have the advanced training and experience to treat a wide range of podiatric problems, including onychomycosis.