Toenail Fungus Treatment (Onychomycosis)

Toenail Fungus is known as Onychomycosis (also known as “toenail fungus,” “fingernail fungus,” “dermatophytic onychomycosis,” “ringworm of the nail,” and “tinea unguium”) means fungal infection of the nail. It is the most common disease of the nails and constitutes about a half of all nail abnormalities.

This condition may affect toenails or fingernails, but toenail infections are particularly common. The prevalence of onychomycosis (toenail fungus) is about 6-8% in the adult population, although estimates are as high as 18% in the American (United States) adult population.

There are four classic types of onychomycosis (toenail fungus):

Distal subungual onychomycosis (toenail fungus) is the most common form of tinea unguium, and is usually caused by Trichophyton rubrum, which invades the nail bed and the underside of the nail plate.
White superficial onychomycosis (WSO) is caused by fungal invasion of the superficial layers of the nail plate to form “white islands” on the plate. It accounts for only 10 percent of onychomycosis (toenail fungus) cases. In some cases, WSO is a misdiagnosis of “keratin granulations” which are not a fungus, but a reaction to nail polish that can cause the nails to have a chalky white appearance. A laboratory test should be performed to confirm.
Proximal subungual onychomycosis (toenail fungus) is fungal penetration of the newly formed nail plate through the proximal nail fold. It is the least common form of tinea unguium in healthy people, but is found more commonly when the patient is immuno-compromised.
Candidal onychomycosis is Candida species invasion of the fingernails, usually occurring in persons who frequently immerse their hands in water. This normally requires the prior damage of the nail by infection or trauma.

Signs and Symptoms of Toenail Fungus

The nail plate can have a thickened, yellow, or cloudy appearance. The nails can become rough and crumbly, or can separate from the nail bed. There is usually no pain or other bodily symptoms, unless the disease is severe.

Dermatophytids are fungus-free skin lesions that sometimes form as a result of a fungus infection in another part of the body. This could take the form of a rash or itch in an area of the body that is not infected with the fungus. Dermatophytids can be thought of as an allergic reaction to the fungus.

Patients with onychomycosis (toenail fungus) may experience significant psychosocial problems due to the appearance of the nail. This is particularly increased when fingernails are affected.

Causes of Toenail Fungus

The causative pathogens of onychomycosis (toenail fungus) include dermatophytes, Candida, and nondermatophytic molds. Dermatophytes are the fungi most commonly responsible for onychomycosis (toenail fungus) in the temperate western countries; while Candida and nondermatophytic molds are more frequently involved in the tropics and subtropics with a hot and humid climate.

Dermatophytes

Trichophyton rubrum is the most common dermatophyte involved in onychomycosis (toenail fungus). Other dermatophytes that may be involved are T. interdigitale, Epidermophyton floccosum, T. violaceum, Microsporum gypseum, T. tonsurans, T. soudanense (considered by some to be an African variant of T. rubrum rather than a full-fledged separate species) and the cattle ringworm fungus T. verrucosum. A common outdated name that may still be reported by medical laboratories is Trichophyton mentagrophytes for T. interdigitale. The name T. mentagrophytes is now restricted to the agent of favus skin infection of the mouse; though this fungus may be transmitted from mice and their danders to humans, it generally infects skin and not nails.

Other

Other causative pathogens include Candida and nondermatophytic molds, in particular members of the mold generation Scytalidium (name recently changed to Neoscytalidium), Scopulariopsis, and Aspergillus. Candida spp. mainly cause fingernail onychomycosis (fingernail fungus) in people whose hands are often submerged in water. Scytalidium mainly affects people in the tropics, though it persists if they later move to areas of temperate climate.

Other molds more commonly affect people older than 60 years, and their presence in the nail reflects a slight weakening in the nail’s ability to defend itself against fungal invasion.

Risk factors of Toenail Fungus

Risk factors for onychomycosis (toenail fungus) include family history, increasing age, poor health, prior trauma, warm climate, participation in fitness activities, immunosuppression (e.g., HIV, drug induced), communal bathing, and occlusive footwear.

Diagnosis of Toenail Fungus

To avoid misdiagnosis as nail psoriasis, lichen planus, contact dermatitis, trauma, nail bed tumor or yellow nail syndrome, laboratory confirmation may be necessary. The three main approaches are potassium hydroxide smear, culture and histology. This involves microscopic examination and culture of nail scrapings or clippings. Recent results indicate the most sensitive diagnostic approaches are direct smear combined with histological examination, and nail plate biopsy using periodic acid-Schiff stain. To reliably identify nondermatophyte molds, several samples may be necessary.

Treatment of Toenail Fungus

Treatment of onychomycosis (toenail fungus) is challenging because the infection is embedded within the nail and is difficult to reach. As a result, full removal of symptoms is very slow and may take a year or more.

Pharmacological Treatment of Toenail Fungus

Most treatments are either systemic antifungal medications, such as terbinafine and itraconazole, or topical, such as nail paints containing ciclopirox or amorolfine. There is also evidence for combining systemic and topical treatments.

For superficial white onychomycosis (toenail fungus), systemic rather than topical antifungal therapy is advised.

Other methods include oral medication, such as: itraconazole (Sporanox), fluconazole (Diflucan), or terbinafine (Lamisil). These medications permit the nail to grow infection-free, gradually replacing the infected part of one’s nail. These medications must be consumed for six to twelve weeks, but the final result will not be seen until the nail fully grows out. However, it may take four months or longer to eliminate an infection, depending on the severity of the infection, as well as the rate at which one’s nails grow. Future infections are likely to occur, principally if one continues to expose the nails to warm and/or moist conditions. Drawbacks of this method include side effects, such as headache, upset stomach, skin rashes, or allergic reactions to ingredients in the medication. Other side effects (of a more serious nature) include: liver damage and heart failure.

Relative effectiveness of toenail fungus treatments

Amorolfine is currently the most effective topical treatment for onychomycosis (toenail fungus), but is not approved in the United States or Canada. Amorolfine 5% nail lacquer in once-weekly or twice-weekly applications has been shown in well designed, placebo-controlled studies to be between 60% and 71% effective in treating toenail onychomycosis (toenail fungus); complete cure rates three months after stopping treatment (after six months of treatment) is estimated to be between 38% and 46%.

Itraconazole is effective for oral treatment of onychomycosis (toenail fungus). Pulse dosing (escalating drug levels early in the dosing interval followed by a prolonged dose-free period) is 61% to 75% effective in providing a complete cure.

In July 2007, a meta-study reported on clinical trials for topical treatments of fungal nail infections. The study included six randomized, controlled trials dating up to March 2005.

The main findings are:

There is some evidence ciclopiroxolamine and butenafine are both effective, but both need to be applied daily for prolonged periods (at least 1 year).
There is evidence topical ciclopiroxolamine has poor cure rates, and that amorolfine might be substantially more effective.
Further research into the effectiveness of antifungal agents for nail infections is required.

A 2002 study compared the efficacy and safety of terbinafine in comparison to placebo, itraconazole and griseofulvin in treating fungal infections of the nails. The main findings were for reduced fungus, terbinafine was found to be significantly better than itraconazole and griseofulvin, and terbinafine was better tolerated than itraconazole.

A small study in 2004 showed ciclopirox nail paint was more effective when combined with topical urea cream.
A study of 504 patients in 2007 found aggressive debridement of the nail, combined with oral terbinafine, significantly reduced symptom frequency over terbinafine alone.
A 2007 randomized clinical trial with 249 patients showed a combination of amorolfine nail lacquer and oral terbinafine enhanced clinical efficacy and is more cost-effective than terbinafine alone.

Drug pipeline of toenail fungus treatments

Most drug development activities are focused on the discovery of new antifungals and novel delivery methods to promote access of existing antifungal drugs into the infected nail plate. Active clinical trials investigating onychomycosis (toenail fungus):

Phase III

A medicinal nail lacquer, MycoVa from Apricus Biosciences, contains terbinafine as the active ingredient and a permeation enhancer DDAIP which facilitates the delivery of the drug into the nail bed where the fungus resides.
A comparison of delivery methods for itraconzole
Safety and tolerability of topical terbinafine
Laser-based treatments
Topical IDP-108
Bifonazole cream application after nail ablation with urea paste

Phase II

A topical treatment, AN-2690, is being developed by Schering-Plough Corp and Anacor Pharmaceuticals. It is active against Trichophyton species.[30]
Posaconazole, taken orally.[31]
A topical treatment, NB-002, is being developed by NanoBio Corporation.[25] It has completed Phase II trials.

Drug-free treatments of toenail fungus

Nd:YAG lasers are being used for treatment of toenail fungus. These lasers target the fungus while leaving surrounding nail and tissue undamaged. Published research has shown an effectiveness between 70 and 80%, and in many cases, a single treatment is sufficient. This treatment is safe and has no side effects, since the laser is applied directly to the infection.

A Noveon-type laser, already in use by physicians for some types of cataract surgery, is used by some podiatrists, although the only scientific study on its efficacy, while showing positive results, included far too few test subjects for the laser to be proven generally effective.

The Ontario Osteopathic and Alternative Medicine Association in Ontario, Canada, have developed a laser-based method, “LAFT”, which is claimed to have a 96% success rate based on “hundreds of treatments given”. However, no scientific studies seem to have been performed and the website promoting the treatment has shown to contain biased and false information on the efficacy of conventional treatments.

To date, there are several lasers seeking approval and one that has been cleared by the Food and Drug Administration.

Natural remedies for toenail fungus

As with many diseases, there are also some scientifically unverified folk or alternative medicine remedies.

Australian tea tree oil has been tested, but there is insufficient information to make recommendations for its use for onychomycosis (toenail fungus).
Grapefruit seed extract as a natural antimicrobial is not demonstrated. Its effectiveness is scientifically unverified. Multiple studies indicate the universal antimicrobial activity is due to contamination with synthetic preservatives that were unlikely to be made from the seeds of the grapefruit.
Thymol, an ingredient common in mouthwashes and medicated chest rub ointments, has been shown to have a potential to be effective against the fungus that commonly infects toenails.
Snakeroot leaf extract has, in studies, shown ability to treat superficial onychomycosis (toenail fungus), although the results show it is less effective, and equal to conventional drugs ciclopirox and ketaconazole, respectively.

Readers Write About Toenail Fungus

Home remedies for toenail fungus

Onychomycosis (toenail fungus) can be caused by many different fungi, and many other conditions like a psoriatic nail and paronychia can look so much like it that dermatologists still need to have a lab workup done. What was the causal agent, if any, of the wife’s onychomycosis (toenail fungus) that was relieved with vinegar? How can anyone possibly give universal medical advice based on one person’s kitchen experiments with the application of 19th century hygiene principles to an (I strongly suspect) undiagnosed condition?

Mercurochrome contains mercury and is banned in the US. All sorts of these common home disinfectants were tested against fungal skin and nail infections in the 1910’s to 1950’s and the only one that stood out as somewhat effective was Whitfield’s ointment, with the active ingredient benzoic acid. But even it doesn’t stand up to scientific comparison as a serious onychomycosis (toenail fungus) remedy. The common fungi causing dermatophyte onychomycosis are too deeply seated in the nail to be affected by materials applied to the surface (unless the materials are combined with chemical nail softeners under occlusion). Mercurochrome is commonly used in developing countries to treat fungal ear canal infestation (otomycosis), but there the fungus is right at the surface. Mercurochrome can’t even penetrate to kill the endospores within spore-forming bacteria.

Toenail fungus isn’t life-threatening but casual treatment recommendations based on anecdotes are no more helpful here than they are in any other disease. No doubt carrot juice and staying optimistic cured somebody’s wife’s cancer somewhere, but there’s a serious ethical problem with extending this observation into a general prescription. Yes, any individual could make a novel observation — but there’s nothing novel about applying vinegar, iodine, garlic, lemon peel, oregano, etc. against fungal skin infections. It’s been done. Tea tree oil is still being investigated but results are mixed (for references go to Entrez PubMed website and search on keywords: tea tree oil onychomycosis (or toenail fungus). Also: tea tree oil tinea. Also: tea tree oil dermatophyte). Keywords for the otomycosis statement above are otomycosis mercurochrome.

Summerbell 18:32, 26 September 2006
Remember, Wikipedia does not exist to provide medical or health advice. For medically oriented articles such as this one the focus of the article is etiology and the popular treatments, peer reviewed scientifically proven treatments as well as popular folk remedies. Even if these folk remedies are totally useless or even counter productive and dangerous. This provides those reading the article a good overview of all the available “treatments,” and more importantly the place of the disease within our society as a whole. Besides anyone reading Wikipedia as their sole source of diagnoses and treatment information has greater problems. 9 October 2007

What is the life cycle of toenail fungus?
Mercurochrome cured it for me. Unfortunately, this probably counts as original research. — ProveIt 4 January 2006

Anyone interested in a picture for this article?
I could get one. The question is, would anyone really want to see it?
The article lacks a good quality image, go for it. Pgr 21 October 2006

Vinegar
My wife had an infection and cured it by soaking the infected toe for 30 minutes in vinegar every day for 3 months. She would keep the nail as trimmed as possible the whole time. Don’t cause your body stress with something like Lamisil. Save your money and health.

FDA Topical Antifungal Monograph
I wanted to add something on the FDA OTC Topical Antifungal Monograph, but all I could find were some very general bits of info on the FDA website. I also haven’t been able to find anything on the FDA’s 1994 ruling that said that no OTC anti-fungal product was effective on nails, and required the wording “this product is not effective on scalp or nails” on all OTC anti-fungal products (even if they were still allowed to use trademarks such as Fungi-Nail!). The closest I could find was this DOC file Comparison of Labeling for All Topical Antifungals Treating Athlete’s Foot. Can anyone provide better information? BlankVerse 29 August 2006

Ineffectiveness of Tea-tree oil – evidence?
Tea tree oil is a known antifungal. The topical application of high levels is a verified remedy for some dermatophytic skin infections although not for onychomycosis (toenail fungus), where the fungus is often too deeply nested in dense subsurface nail tissue to be full expunged by topically applied materials of any kind.

The article that is referenced does not say that tea-tree oil doesn’t work because the fungus is too deep subsurface. This needs more evidence or is WP:OR. 13 June 2007

Removal of passage
The section related to tea tree oil was removed from the ‘natural remedies’ section via this edit by User:Was this removal in accordance with consensus? –User:Ceyockey 1 July 2007

I think it was because of the WP:OR reference to the fungus being too deep to be treated by Tea tree oil. If you want to put it back in and either find a source for this claim or remove it feel free. Personally I tried treating my fungus militantly with Tea tree oil, with four treatments a day. During this period the fungus, which had been advancing, went into remission in all my nails, but the fungus under a few toe nails was persistent. I eventually stopped treatment and the fungus has not returned in any nails, but has grown back in the nails where it was still present. 9 October 2007

Here is a summary of this topic from a 2002 article in the Journal of Antimicrobial Chemotherapy:

Based on both its inhibitory and fungicidal action, tea tree oil may be a useful agent for treating dermatophyte infections. However, exactly how this in vitro activity translates into in vivo effectiveness is unclear.
[… summary of two clinical trials …]
Given that onychomycosis (toenail fungus) rarely responds to topical therapy and is therefore usually treated systemically, it is perhaps not surprising that the topical application of tea tree oil was of limited effectiveness in these two clinical trials. This emphasizes the need for more clinical trial data, particularly in relation to tinea pedis, which can often be treated successfully topically.

So it seems there is little-to-no evidence to support the claim either way. Furthermore, given topical treatments don’t really work for toenail fungus, there are grounds for believing tea-tree oil won’t work either. Pgr 94 9 October 2007

Crocodile Oil
Crocodile Oil: There is something amazing in the crocodile’s immune system, there are strings of peptides that were only discovered very recently in the last eight or nine years and they are a powerful mechanism for fighting bacteria and fungal infections. Repcillin Crocodile Skin Balm is made in South Africa and uses the fat from CITES approved Crocodile farms in Africa.
Is this verifiable? WP:V Pgr94 26 June 2007

This completely unverifiable: the only sources discussing Crocodile Oil are those selling it, usually trying to blind with pseudo-science. For more on this see the discussion for Crocodile Oil Almost-instinct 19 April 2008

Wanted: images for each type of onychomycosis (toenail fungi)
There are different types of onychomycosis. It would be good to get images of each type. For example see Pgr94 18 September 2007

Different types of toenail fungus will look mostly the same, be somewhat misleading (as for the most part, this is not a tool used to diagnose the type of fungus… and may be somewhat trivial to categorize. Certainly additional fungi photos of a general nature are always of value. -Preceding unsigned comment added by Spamwatch (talk contribs) 13 November 2007

Vinegar passage removed. As no evidence has been found for vinegar since Feb. 2007, I have removed it.

Distilled white vinegar. Drops are applied to the cuticle twice a day. This method does not kill the fungus, but the vinegar allegedly changes the pH (acid content) of the new nail formed in that 12-hour period. (The scientific perspective, however, is that vinegar is unlikely to penetrate the dense keratinous tissue thoroughly enough to have any significant effect. Instead, it may be absorbed by the skin above the nail and work its way to where the nail is actually forming.) As the old, infected nail grows and is cut away, it is said to be replaced by an acidic nail, uninhabitable by fungi. Several months of consistent application are involved. 29 November 2007

I went to a podiatrist who told me to soak my foot in white vinegar for three months but I won’t see the results for one year. June 1 2009. -Preceding unsigned comment added 13 May 2009

Fungus location
If someone with access to good sources could examine these issues and possibly amend the article it would be appreciated.
The fungus “infects” the nail. Could this be clarified as to whether fungus is growing under and around the nail, or within the material of the nail itself?
Also the difficulty of treatment seems to be because of the difficulty of getting the treating agent to the best location. Is drilling holes in, or filing of, the toenail a workable option?

Thanks, Wanderer57 30 March 2008

Recent reviews (Aug 2008)
Short of time right now so this a note to self, or anyone who else wants to follow recent developments. see reviews PubMed and PubMed… check differential diagnosis of psoriatic nails. 20 October 2008

Listerine and vinegar
I’ve had severe toenail fungus for just over forty years. It started when I lived in the tropics.
At this writing, the fungus is completely expelled in two nails, is almost done being expelled in four others, and halfway gone in the big toes. Two were already clear.

How? I soak the toes in 50% Listerine, 50% white vinegar, for 30-45 minutes every night. I started about four months ago. I didn’t make this up – a Google search for “Listerine toenail fungus” finds many testimonials, and occasional discussions of the method of operation. It seems that the fungi can’t handle eucalyptol and thymol, plus the other assorted toxins that make Listerine lethal when a lot is swallowed.
Not sure if a photo of the half-clear big toes would be helpful. – Preceding unsigned comment added by MoonDJ 31 July 2010

Undiluted Bleach

On recommendation from my GP, using a cotton swab, applying a single drop of undiluted bleach twice a day underneath my toenail is rapidly removing the fungus. Half of the nail bed has recovered in 6 months. Application is quick and there seems to be no tissue damage. If considered, use caution though… RudiBosbouer 14 January 2011

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