Forget over the counter topical treatments when it comes to nail fungus, you need medication by mouth.

Recently I had a young man come to me with thickened, discolored, flaky toenails. This had been going on for a few years, worsening with time and he was getting tired of the appearance. A few months ago, I had an older man come to me, fearing that the finger tips of one his his hands were going to “rot off!” The nails were discolored and flaking, and there was irritation of the finger tips, around the edges of the affected nails. He was a dialysis patient and thought he was going to get gangrene of his fingertips. The last case I had recently was a young woman who recently noticed thickening and discoloration of several of her toenails. She usually kept them polished so she didn’t realize until recently that she was having this problem, and she was horrified.

All the patients mentioned above had fungal infections of the affected nails. Fungal infection of the nails, also called onychomycosis, is relatively common. Approximately 15 to 20% of persons aged 40 to 60 years are affected, but people at any age are at risk, though it is rare in children under 12 years old. Toenails are 4 times more likely to be infected than fingernails, probably because the feet tend to be locked up in shoes.

How do fungal nail infections arise?

There is a variety of different fungal organisms which may infect the nails. Infection usually arises from direct spread of fungal infection from the skin. Therefore, someone with ‘athlete’s foot’ for example, can have spread of the fungal infection from between their toes, to the toenails.

People with fungal infections of the scalp have a higher likelihood of fungal nail infections as repeated scratching of the infected scalp can cause infection of the fingernails.

Sometimes nail fungal infections occur after repeated contact with a contaminated environment, such as a shower stall or a manicure/pedicure basin.

What are some of the risk factors for fungal infection of the nails?

– Repeated moisture of the hands and feet is one of the big risk factors. Fungi love moist, warm environments. Wearing tight-fitting, non-breathable shoes all the time, increases the risk.
– Use of medications which weaken the immune system is also a risk factor.
– Advanced age increases risk for fungal nail infection, probably for a combination of reasons including weaker immune system, poor circulation, and increased likelihood of trauma to the nail.
– Repeated exposure to wet/damp environments including spa mani- and pedicures, and being in communal baths, also increase the risk.

What is the best treatment for fungal infections of the nails?

Topical therapies for nail fungus infection are disappointingly ineffective, therefore treatment is usually with an anti-fungal medication taken by mouth. The reason topical treatments fail is that nails are dry and dense, therefore the medication is not able to penetrate through the nail to kill all of the fungus.

Medications by mouth work because they get into the tissue, including the new nail as it comes from the nail-bed, preventing it from becoming infected. A few weeks after start of therapy, one can see a line demarcating infected nail and new, uninfected nail at the base.

Treatment duration is 6 weeks for fingernail infections, sometimes up to 3 months. For toenail infections, treatment usually takes about 3 months, but sometimes may last up to 6 months. Essentially, treatment duration is the length of time it takes for the infected nail to grow out and be completely replaced by a new, uninfected nail.

In the past, and still in developing countries today, the infected nail is surgically removed, and topical anti-fungal medications applied to the nail-bed until the new nail grows in. However that is not a cosmetically attractive option for most people, and the new nail may grow back deformed.

What is the best way to prevention fungal infections of the nails?

– keep nails short and clip straight across to prevent them from becoming ingrown (especially toenails)
– use gloves for prolonged work with water
– use different nail clips for cutting infected nails and normal nails
– carry your own instruments to the salon/spa
– avoid tight, narrow toed shoes so that toes have room to breath without sweating
– use anti-fungal powder on feet, between toes, if prone to athletes foot

In conclusion…

Nail fungal infection is a common problem, but people often do not bother to seek medical attention for it. This is probably because it is felt to be more of a cosmetic problem than anything else. Nevertheless, people waste a lot of money on over the counter topical anti-fungal treatments, that usually have no clinical effect.

Fortunately, there are several safe anti-fungal medications, that can be prescribed by a doctor to be taken by mouth. A cure usually occurs within weeks, to a few months.