So your tootsies are just dying to slip into a cute pair of toe-bearing wedges or your favorite comfy flops, but are your toenails ready for the task at hand? For people suffering with fungus ridden or just funky looking toenails, sneakers may be the only home your toes will touch. Nonetheless, you don’t have to accept defeat against toenail funk. For conditions like fungus, treatments are abundant.
The Life and Habitat of Fungus (AKA Onychomycosis/Tinea Unguium)
Fungus can be transferred from one person to another through direct contact or by contact with a fomite (inanimate object). Fungal babies (spores) can live in an environment like carpets (hotels or homes), socks, shoes, and shower or gym facility floors for up to five years. Thus, reinfection after treatment can easily occur, especially since those who get this dermatophyte tend to have a genetic propensity for such. Fungus thrives in most environments; which is why it is less common in shoe deficient countries, but abundant in places where the dank, dark habitus of closed toed shoes is the norm. It also likes to crawl in under damaged toenails, which can be a typical occurrence in runners, dancers, or otherwise injured feet.
Fungus can appear as a chalky white discoloration on the nail surface or a thick, yellow to white, crumbly appearance under the nail.
Many topical medications like creams, solutions, foams, polishes, and gels are available OTC. For a mild-moderate infection they may serve well, but for thick and hearty fungus, a prescription oral medication is optimal. The most common ingredients in OTC remedies are terbinafine, undecylenic acid, tolnaftate, urea, and hydroxy acids. Several studies advise the effectiveness of all such to be similar, but ranging in the gamut of 15-50% improvement rates. Kerasal Fungal Nail Renewal works through the use of urea and lactic acid as active ingredients. These molecules are keratolytic, thus peeling nail layers and smoothing. Funginail uses a 10% undecylenic acid, which is a fatty acid that prevents fungal growth. Similarly, Emoninail provides undecylenic acid along with tea tree and sunflower seed oil. It’s also considered antiviral and antibacterial. Formula 3 Anti-Fungal Solution includes Tolnaftate 1%, which is thought to break down fungal walls and destroy them. All of these topicals must be applied to the toes daily and expect a 6-12 month treatment duration for the nails to look normal…if they work. For superficial fungus (white, chalky appearance on top of nail) try buffing the area first before applying antifungal, this helps penetration. Also, don’t forget to use an antifungal spray inside the shoes to rid or attached spores. Nonetheless, even after use of such products, many nails become diseased again over time. An antifungal may become like a cyclic routine for some.
For those who opt for a homeopathic or folkloric remedy approach, there are a few plausible alternatives. Interestingly enough, Vick’s Vapo Rub applied to toenails daily for months, has proven efficacious in studies. Additionally, it contains thymol which has antiseptic, antimicrobial, and antibacterial properties. Tea Tree Oil is an organic option, with mixed reviews for results. Brands like Radha makes a 100% dropper solution. Tea Tree foot soaks are also in stores with brands like Majestic Pure. A common household ingredient foot soak using vinegar, can also be an easy mix. Use one part vinegar to two parts water, fifteen minutes a day may clear the fungus away. Terrasil Foot & Nail Ointment is a new kid on the block, blending organic ingredients (like Volcanic Clay (Bentonite), Zinc Oxide, Silver Oxide and Magnesium Oxide) with traditional medicinals (clotrimazole).
OTC topicals have mixed results for toenail fungus, yet the older prescription topicals fare only slightly better. Options like Ciclopirox (Penlac) may take 12-15 months, but in clinical practice their efficacy by many has been laughable. The newer generation nail antifungals have a better track record like Efinaconazole (Jublia) or Tavaborole (Kerydin), but often insurance plans create an astronomical co-pay. Oral Medications like Terbinafine (Lamisil) or Sporonox (Itraconazole) show marked efficacy, but the pills must be taken over 3-6 months, and have a possibility of side effects. Although, the risk of such may be minimal for healthy individuals, many clinicians will monitor a patient’s bloodwork while on this medication.
Non-surgical nail removal may be elicited with a urea based compound which will soften the nail and prepare it for scraping with a debridement instrument. After the nail is quite thin, a topical antifungal will penetrate more easily into a thinned nail bed and show greater outcomes than a topical without such procedure. Yet, the thinning process with a cream may be quite timely.
Surgical Nail Removal
Full surgical removal paired with local anesthesia is another option for a severely diseased nail. However, fungal spores may still inhabit the skin area and often a topical treatment is needed to clear the skin from its presence. Post treatment may present with bleeding, pain, bandaging.
The latest gadget for targeting fungus is laser therapy with various Nd:Yag devices. It is most appropriate when fungus is severe and/or other options are not plausible. Studies have shown positive improvement in treating nails, which is again variable upon individuals. Yet, in the research arena there is very little data to support a measurable value. Treatments must be done over six months and will cost on average $1000. Insurance does not cover this procedure.
Nowadays, it is common for insurance companies to require a nail biopsy for proof of true fungus, before medications will be covered. This may fare a prudent decision as there are many other diseases that can mimic nail fungus, yet are completely different entities. Read more about non-fungal funky nails….in the next blog.