Fungal infections can make for unsightly, embarrassing toenails: One or more nails (usually on the big toe) can become discolored, oddly shaped, brittle, abnormally thick or separated from the nail bed. Left untreated, fungus can spread to the fingernails and skin.
Such infections, called onychomycosis, are stubborn and difficult to cure. Onychomycosis is most common in adults older than 60 and can sometimes be more than a cosmetic concern: The infection, triggered by fungus under the nail bed, can be painful, sometimes impairing walking ability.
The trouble with treatment
Many treatment options are available for toenail fungus, but few are guaranteed to cure the infection permanently. First, your doctor must identify the type of fungus causing the infection to determine the best course of treatment. He or she will also rule out causes like psoriasis or iron deficiency.
Prescription antifungal drugs taken by mouth are the most potent and effective treatment. They work by killing the fungus at the nail root and allow a new, infection-free nail to grow.
However, some oral antifungal drugs can cause a skin rash, result in liver damage (though rarely), and interact with other prescription medications like beta-blockers, certain antidepressants, calcium channel blockers, and blood thinners—a concern for many older adults who take several drugs for chronic conditions.
You typically take the drugs for about three months, and it could take another nine months before your entire nail is fungus-free.
During the months you take the drug, you may need periodic blood tests to check your liver function. If you have liver disease or congestive heart failure, you shouldn’t use the drugs.
Among oral antifungals, terbinafine (Lamisil) and itraconazole (Sporanox) boast the best cure rate, with Lamisil having a slight edge in long-term cure. Another option, posaconazole (Noxafil), has similar effectiveness rates and is less likely to interact with other drugs, but it can be more expensive than Lamisil.
Fluconazole (Diflucan) is less effective than Lamisil, but some patients prefer its once-weekly dose to Lamisil’s daily doses. Another oral drug, griseofulvin (Grifulvin V), used more commonly in the past, tends to be less effective—and more costly—than Lamisil and Sporanox.
Alternatives to oral antifungals are topical drugs applied with a dropper or brushed on, under, and around the nail. Ciclopirox (Penlac) is sometimes used for mild to moderate onychomycosis, but it cures only about 7 percent of patients who use it. You have to apply it every day, clean the nail weekly with alcohol to prevent buildup, and have your doctor clip the nail once a month—and it may take almost a year before you know whether it’s been effective. Once the drug is stopped, the infection tends to recur.
Because of difficulties penetrating the nail, cure rates for topical drugs when used alone have been low. Other options include efinaconazole (Jublia) and Tavaborole (Kerydin), which, when used consistently and applied to the nail and surrounding areas, cured up to 18 percent of patients and 9 percent of patients, respectively, after 48 weeks in clinical trials.
Laser and light therapies have emerged as possible treatment options, although more research is needed. Some small, poorly designed clinical trials have shown limited success rates, but it’s not clear how severe the cured infections were. Laser therapy is approved for use in the United States for cosmetic improvements only and may not be covered by insurance.
The possibility of liver complications and the need for monitoring while taking certain oral antifungal medications—not to mention the potential for drug interactions—leave many patients understandably concerned about oral treatment for toenail fungus. This often leads them to search for home remedies or over-the-counter products.
It’s important to note that today’s class of prescription oral antifungal drugs feature shorter treatment durations, higher cure rates, and fewer side effects than their predecessors.
And while some research has suggested that home remedies such as applying Vicks VapoRub, bleach, vinegar, tea tree oil, or similar products to the affected nail can help treat the infection, no studies have proved they work.
The bottom line
The best chance at curing toenail fungus is with both a pill and a topical drug. Even with the most effective remedies, diligence is necessary, as treatments may need to be taken or applied more than once a day, and regimens can take several weeks to months to complete.
Toenail fungus recurs in up to 50 percent of patients, and some people are never cured. You may have to regularly visit the podiatrist to cut and file down the nail.
Your doctor may recommend applying topical urea (available over the counter) ointment or lotion to the nail. While it’s not a cure, it may help reduce your nail’s thickness and render the area less painful. If your nail is extremely painful or the infection is severe, your doctor may suggest surgically removing it.