The Ultimate Guide to Understanding and Treating Finger and Toenail Fungus

I. Nail Fungus Overview

A. What is Nail Fungal Infection

Nail fungus infection, also known as onychomycosis or Tinea Unguium, is a very common condition that is characterized by changes in the nail’s color and texture. The signs of a fungal infection start with the development of black or brown spots and white or yellow streaks under the  toenail or fingernail. As the fungal infection progresses, the discoloration would spread, and the infected nails may change to yellow, green, white, or brown. Infected nails may also appear thickened and have crumbled edges. Although this condition is generally not painful, in rare and severe cases, pain and discomfort has been reported by affected individuals. Detachment of the nail from the nail bed may also occur.

Nail fungus is commonly caused by microscopic fungi (called dermatophytes) that enter your toenails, fingernails, and even the skin under your nail (called the nail bed) through small cuts and cracks in the nail or on the surrounding skin. Nail fungus infection happens when there is an overgrowth of these dermatophytes.

There are several treatment options available for nail fungal infection. Choosing which one to undergo depends on the severity of the case. For mild to moderate cases of onychomycosis, over-the-counter and prescription-only oral medications and topical solutions are available. For severe cases, non-surgical procedures (like laser treatments) and surgical procedures (like avulsion) can be done to the infected nail(s). However, because these fungi are often stubborn to cure, a recurrence of the nail fungus infection is still highly possible even after treatment. Precautionary steps such as proper hygiene and regular application of a recommended topical solution is advised to avoid an onychomycosis relapse.

When diagnosing a fungal nail infection, a medical specialist (such as a dermatologist or a podiatrist) would have to rule out other relevant conditions because of some similarities in their symptoms. The next section discusses these other conditions often confused or mistaken with onychomycosis.

 

B. Differentiating Nail Fungus From Other Nail Abnormalities

A nail fungus infection is also often associated with nail injury, psoriasis, and melanoma due to some similarities in their symptoms.

Nail Injury

Common nail injuries are characterized with the following:

• Black, brown or purple discoloration that may be caused by blood from injuries or melanoma        
• Development of white marks that may last from weeks to months
• Shape/texture changes of the nails such as peeling, splitting, and change in brittleness and thickness, formation of ridges
• Ingrown nails that can cause swelling, irritation, redness, pain, and infection
• Separation from the nail bed
• Other nail deformities and lacerations

There are three mechanisms that commonly cause most nail injuries. These are the following:

• Crushing forces from machinery, hammers, doors, human bites, and more
• Cutting or slicing from box cutters, machinery, knives, and other sharp objects
• Ripping or tearing from incorrect trimming, toe stubbing caused by a collision with a solid object, or nail jamming

It may be confusing to detect the difference between nail injuries and fungal infections due to the very similar nail changes that these two conditions share. Identifying the possible cause of your sudden nail changes can also help you detect your specific nail condition.

However, microscopic fungi can also easily penetrate injured nails and infect them. Therefore, having injured nails can also lead to having onychomycosis.

Psoriasis

Psoriasis, which is an autoimmune disease that causes reddish skin patches, is also often mistaken for a nail fungus infection. Although it is primarily a skin disease,  psoriasis can also cause the following changes in the nails:

• Reddish-yellow nail discoloration under the nail plate, also known as a salmon patch or an oil drop
• Pitting of the nails
• Beau lines on the nail, which are furrows or lines that go across the nails
• Midmatrix disease/leukonychia (which is characterized by the appearance of white spots on the nail plate)
• Nail bed thickening (which can lead to onycholysis — a medical term which refers to the loosening of the nail). This can make the nail bed and nails susceptible to infections.
• Nail crumbling, weakening, and increased brittleness
• Splinter hemorrhages or dilated tortuous capillaries (where the fingertips between the nail, as well as the nail bed, bleed). This creates tiny black lines in your nails from the tip down to your cuticles.
• Spotted lunula (which causes redness of the pale arched area at the bottom of your nails)
• Finger arthritis

Even though you can differentiate nail psoriasis from fungal infections through identifying the causes and other distinct characteristics of onychomycosis, both can also occur together. A study suggested that nail abnormalities are among the predisposing factors to fungal infections.

A 2010 study revealed that 23 out of 48 patients with nail psoriasis also showed evidence of onychomycosis. Psoriasis and Psoriatic Arthritis Alliance also estimated that about 35% of people with nail psoriasis may also suffer from a fungal infection which can worsen their nails’ condition.

While fungal infections often occur in toenails, nail psoriasis occurs more on fingernails than on toenails.

Skin Cancer/Melanoma

Melanoma is a fatal form of skin cancer that is characterized by dark-colored streaks or spots on the skin or within the nail plate. This claims approximately 9,000 lives each year in the United States of America. According to the American Academy of Dermatology, melanoma can be successfully treated if detected early.

Nail melanoma is often discovered later than melanoma in other areas of the body. Its symptoms are either easy to ignore or mistaken as other less serious nail problems. The ABCDE acronym can help you assess if you  potentially have subungual melanoma. These are the following:

• A for Asymmetry: the lesion is asymmetrical.
• B for Border: the lesion has an indistinct, poorly-defined, and shabby border.
• C for Color: the lesion has over one color present in its areas.
• D for Diameter: the lesion’s diameter is more than 6mm.
• E for Evolution: the lesion suspiciously evolves in terms of shape, color, and size

These three conditions typically bear a resemblance to nail fungal infections,but one of the most identifiable difference of onychomycosis from these other nail conditions is the nail’s emission of a foul odor. This can be a symptom more connected to the presence of a nail fungus condition.

 

C. Nail Fungus Statistics

Worldwide

According to an analysis from NC State University, there are an estimated 2%-18% of people who are affected by nail fungal infections worldwide. Another study reported that onychomycosis has an international prevalence range of 3-26% worldwide.

A research report also demonstrated that toenail onychomycosis is the most difficult fungal infection to cure. According to the results they’ve gathered, onychomycosis prevalence rates in different parts of the world are the following:

• 14% in North America
• 23% across Europe
• 20% in East Asia

USA and Canada

The data from NC State University mentioned earlier also reported that about 5% of the people used in their global research are people from the United States, where cases of nail fungal infections continue to rise. Statistics show that the prevalence rate in said country increased from 2.18% in 1979 to 8.7% in 1997. It also increased further to 13.8% in 2000.

Another research included in the October 2000 issue of the Journal of the American Academy of Dermatology revealed that 14% of their participants were discovered to have nail fungal infections. Their study was conducted at 12 locations in Canada and in the U.S. with over 1800 people as respondents. Their results showed a doubled increase from their previous studies on other countries where the report rates of nail fungus only ranged from approximately 3%-7%. Two Canadian studies (one with 15,000 respondents and one with 2,001 respondents) reported onychomycosis prevalence rates that range from 6.5% – 9.1%.

Europe

A 2003 survey of foot diseases in 16 European countries exposed that onychomycosis has an estimated 27% prevalence, which makes it the most common fungal foot infection in those areas. In the UK, a study shows that nail fungal infections occur in 3% – 8% of their population. A similar Finnish study with 800 respondents also reported onychomycosis’ prevalence of 8.4%.

Asia

A 1999 survey called the Achilles project exposed the onychomycosis prevalence of 22% in East Asia. The Achilles project has 43,914 participants from China, Taiwan, and South Korea. Like the growth of cases of onychomycosis in the U.S., an Indonesian study also discovered similar results. From 1997-1998, the 3.5% average incidence of onychomycosis rose to 4.7% in 2003.

D. Pathogenesis: Stages of Nail Fungus Development

Anatomy of the Nail

The nail is an important part of the integumentary organ system that protects and covers the tips of human toes and fingers. It is made of a tough protective protein called keratin. Nails consist of the matrix, lunula, nail bed, nail sinus, nail plate, free margin, hyponychium, onychodermal band, eponychium, perionyx, cuticle, lateral margin, nail groove, nail wall, and paronychium.

The matrix (also called the matrix unguis, nail matrix, onychostroma or keratogenous membrane) is the tissue that the nail protects. It is the part of the nail bed that is underneath the nail which comprises of nerves, blood vessels, and lymph. The matrix is in charge of creating cells that turn into the nail plate. The width and thickness of the nail plate is dependent on the size, length, and thickness of the matrix, while the fingertip’s shape demonstrates if the nail plate is curved, level or snared. The matrix continues to increase its length as it gets nourishment and remains in a healthy condition. As new nail plate cells are made, they push the older plate cells forward. This makes the older cells to become flat, compressed, and translucent — making the capillaries in the nail bed underneath pinkish and noticeable.

The lunula, or what is also referred to as the small moon, is the more visible part of the matrix. This is the white bow molded in the base of your nail. The lunula is most evident in the thumb and may not be seen in the little finger.

Another part is the nail bed, which is the skin underneath the nail plate. It is comprised of two types of tissues: the deeper dermis which includes the glands and capillaries; and the layer beneath the nail plate called the epidermis which moves toward the fingertip with the plate. The epidermis is connected to the dermis by matrix crests which are characterized by small longitudinal grooves. Older individuals have thinner nail plates and more visible matrix crests.

The nail sinus, scientifically called the sinus unguis, is the base of the nail below the skin. It is the area where the nail root is inserted.

The nail plate on the other hand is the thin, strong, flexible, and translucent plate that is made of keratin protein. Most people refer to this as the nail itself.

The free margin, also termed as margo liber or distal edge, is the front edge of the nail plate that is opposite the attached nail root. The epithelium situated underneath the nail plate at the intersection between the free edge and the skin of the fingertip is called the hyponychium or the “speedy.” This creates a seal that protects the nail bed.

The onychodermal band, on the other hand, is the seal between the nail plate and the hyponychium. This is can be found on the part of the nail where the nail bed ends. In fair-skinned people, it may appear lustrous and greyish in shade, while in some individuals, it can be completely unnoticeable.

Two more portions of the nail that form a protective seal are the cuticle and the eponychium. The cuticle is the semi-round layer of dead skin at the base of a fingernail or toenail. This serves as a protection for the nail matrix. The eponychium, on the other hand, is the crease of skin cells that is responsible for cuticle production. Another difference between the two is that the cuticle is the nonliving part that is often detached during a manicure while the eponychium, the living part, should not be touched to avoid the risk of an infection. The eponychium also has a protective edge called the perionyx, which covers the lunula’s proximal strip.

Other parts of the nail are the following:

• The nail wall, or the vallum unguis, is the fold overlapping the lateral and proximal end of the nail.
• The lateral borders of the nail, or the margo lateralis, are the sides of the nail that extends from the proximal to the free borders.
• The nail groove or fold (sulcus matricis unguis) is the furrow between the nail bed and the nail wall where the lateral borders of the nail are embedded.
• The paronychium is the border tissue around the nail.

Nail Fungus Development

Nail fungus typically develops when there is an overgrowth of dermatophytes (a kind of pathogenic fungi that can grow on skin areas and cause skin diseases) in, on, or under the nail. In a few cases, it can also be caused by non-dermatophytic molds and Candida yeasts.

Dermatophytes, mold spores, and yeasts can penetrate the nail through small cuts in the skin surrounding your nail, a crack in your nail, or any separation between your nails, fingers, or toes. Under warm and moist conditions, these microorganisms can thrive and rapidly grow. They will feed on the keratinized tissue of the nail in order to nourish themselves. Aside from that, they will also produce byproducts that are harmful for the nail structure which causes the infection, the changes, and the degradation of the nail. As the fungal colony grows, the rate in which the nail host becomes damaged also increases. Meanwhile, as the body tries to repair the damage that’s happening on the nail, it will increase its production of keratin on the affected area. This in turn is what makes the nail thickened. Eventually, if left untreated and the growth of the fungal colony continues, the nail may become too weak to support itself and can lead to it falling of. In some severe cases, the infection may also cause pain.

A more detailed discussion of the causes of nail fungal infection is discussed in the next section.

 

II. Nail Fungus Causes

An overgrowth of pathogens in your nail area causes nail fungus. As fungus (a kind of pathogen) thrive in warm and moist environments, the feet are more prone to getting in contact with fungus (i.e. by wearing sweaty socks in tight shoes for a long time or by walking barefoot on wet and humid places like the public sauna, spas, community pools, etc.). The toes also have less blood flow than the fingers, which makes it harder for the body’s immune system to detect and block the infection. Thus, toenail fungal infection is more common, and it typically occurs in about 10% of the adult population. However, the occurrence of fingernail fungal infection is still possible if fingers are constantly kept wet or damp and if they are exposed to dermatophytes.

Pathogens typically infect a nail by penetrating it through small cuts in the skin surrounding your nail, a crack in your nail, or any separation between your nails and fingers or toes.

If left untreated, your the condition may become more severe. Fungal infections are also very contagious and can spread to your other nails and skin.

 

A.   Pathogens Causing Nail Fungus

One or a combination of the three types of pathogens can cause nail fungal infections. These pathogens are dermatophytes, candida, and non-dermatophytes. Dermatophytes are the most common cause of onychomycosis. Candida and molds cause 8% and 2% of fungal nail infections respectively.

The skin’s outer layer typically has the ability to discourage microorganism’s colonization. Shedding of epidermal cells also helps in avoiding microbes’ growth. However, due to trauma, maceration, and irritation, the skin’s protection mechanisms may fail. This results to susceptibility to infections.    

Dermatophytes

Dermatophytes are among the types of fungi that invade dead keratin tissues. This is the reason why they are the most common cause of infections in the nails, hair, and skin. Dermatophytes has no ability to penetrate living tissues.

Trichophyton rubrum is the most common type of dermatophyte that causes athlete’s foot and onychomycosis. It accounts for about 70% of the total onychomycosis cases.

rubrum originated in Southeast Asia, Indonesia, Northern Australia, and West Africa, which later spread to the United States of America and Europe in the late 19th and early 20th centuries. Dermatophytes can be spread through direct skin-to-skin contact with infected people, animals, soil, and objects.

Candida

Candida is a type of yeast that also causes fungal infections. Yeasts are normally present on the human body and are usually harmless. However, yeast overgrowth — caused by illness, birth control or antibiotic pill intake, and immune system problems — may lead to a yeast infection.

Candida species may also invade previously damaged nails from trauma or infection. It more commonly affects the hands and typically occurs in individuals who constantly have damp hands.

Non-Dermatophytes/Molds

Non-dermatophytic molds (NDMs) are among the types of fungi that grow in soil, skin, and nails. These do not typically spread through person-to-person contamination. NDMs typically occur together with dermatophyte fungal infections. Conclusions from studies suggest that these are largely considered as contaminating organisms in dermatophyte onychomycosis.

Another study suggests that nails should be tested for non-dermatophyte molds if dermatophyte infection treatments are not effective. Even though an infection has no dermatophyte present, the possibility of an NDM infection should not be omitted. There has been a reported rise of onychomycosis caused by non-dermatophyte molds in Gyeongju Korea (2012) and South-East Rajasthan (2015).

 

B.   Nail Fungus Risk Factors

There are different modifiable and non-modifiable factors that affect your susceptibility to fungal infections. This includes your overall health, your environment’s humidity and heat levels, and the condition of the nail(s) infected, among others.  

Non-Modifiable Factors

Non-modifiable factors that increase your risk of nail fungus infection development are age, gender, and existing condition. Below are some key points that further discuss these factors:

Age

Studies from different countries show that individuals older than 60, are prone to nail fungal infections. As we age, we experience a decrease in our blood’s circulation around our hands and feet. In order to deliver immune fighting bodies which detect and combat invaders, such as fungi, blood flow should be normal. This is why decreased blood flow in older adults is a problem that increases their susceptibility to fungal infections such as onychomycosis.

Gender

Males are reported to be up to three times more likely to acquire nail fungal infections than women, especially those who have a family history of onychomycosis.

Existing Health Condition

Having a nail injury, skin condition like psoriasis, as well as other diseases such as diabetes, peripheral arterial disease, HIV, and cancer increases the susceptibility to fungal nail infections. This is due to spreading of infection, poor circulation problems and a weakened immune system brought by these conditions and some of their medications such as steroids and chemotherapy.

Psoriasis

Individuals with psoriasis are more likely to get infected with nail fungus. A 2012 study showed that the prevalence of onychomycosis among patients with psoriasis increased. Psoriasis in the nails and onychomycosis may share similar symptoms, but both can infect the same nail.

According to a Psoriasis and Psoriatic Arthritis Alliance’s study, about 50% of individuals with psoriasis may also have onychomycosis either in their toenails or fingernails. Psoriasis can cause changes in the nail, which makes it more vulnerable to the penetration and infection of fungus.

Peripheral Arterial Disease/Diabetes

Having illnesses such as Peripheral Arterial Disease or Diabetes that cause a decrease in blood circulation in the feet and legs, may also be a risk for onychomycosis. Our blood carries crucial immune bodies throughout our body to help defend us against infections.Therefore, if you are suffering from Diabetes or Peripheral Arterial Disease, your decreased blood flow due to these diseases will make it harder for you to fight off an invader like fungi.

HIV, Cancer and Weak Immune System

Our immune system is vital in protecting our body against diseases. It is made up of antibodies that assist in killing viruses, bacteria, and other infected cells.

HIV/AIDs and Cancer are known to induce immunodeficiency, a state where the immune system’s ability to combat diseases is compromised or completely absent. Having a compromised immune system due to these diseases increases your susceptibility to nail fungal infections. It will also be challenging to treat this condition.

Medications and other major medical procedures

In addition to the diseases above, medications and treatments such as TNF inhibitors, corticosteroids, chemotherapy, and having major operations and prolonged hospitalization also weaken the immune system. These can escalate to more health problems such as infections from nail fungi.

 

Modifiable Factors

There are numerous factors that you can control and avoid. You must keep in mind that you can develop nail fungal infections through the following:

Walking Barefoot in Public Places

Walking barefoot in moist and warm areas like public showers, community pools and locker rooms, and spas increases your risk for nail fungal infections. These are areas where you can be exposed to fungi from other infected people.  

Working Conditions

As discussed earlier, fungi grow and survive in high moisture environments. Working in hot and moist environments, especially with wet hands or feet, puts yourself at risk for fungi reproduction and infection.

Wearing Heavy Footwear

Wearing heavy footwear that hinder proper ventilation throughout the feet makes them more damp with sweat. Sweaty socks as a result of the lack of airflow on heavy footwear is one of the top causes of fungi growth and multiplication that eventually leads to toenail infection.

Working with abrasive chemicals

Exposing your hands to abrasive chemicals may cause damage to the protective skin at the base of your nail, which makes it more vulnerable to fungal penetration.

Sharing nail care tools

Nail fungus is highly contagious. You can have onychomycosis from someone with infected nails. Sharing a towel or nail care tools with an infected person increases the possibility of being infected by a fungus.

Injuring your nails

If you have injured nails, you are more vulnerable to fungi infection due to easier penetration and infection from cuts, tears, or thin protective layers of your nails.

Going to unhygienic/ unregulated nail salons/spas

As mentioned above, sharing nail care tools with fungi-infected individuals should be avoided. You should ensure that the nail salons, parlors, and spas you are visiting use disinfected equipment and new towels as nail fungi can be transmitted through these tools.

Living with someone who has nail fungus

Fungi is contagious and can be picked up through skin-to-skin contact. Living with a fungi-infected individual can put you at risk, especially if you are sharing items with that person.

 

III. Nail Fungus Signs and Symptoms

Nail fungus may affect a nail fully or partially, and may spread to other fingernails and toenails. In more severe cases, it may also affect the skin around your nails.

A. Early Signs and Symptoms

As the condition is generally not painful, paying attention to any change in appearance and texture on your nail may help you detect the problem early on.

Nail discoloration

Changes in the nail’s color might be the first sign of the presence of fungus on your nail.

White, yellow, or dark-colored spots may appear on or under your nail (proximal onychomycosis); or you might notice flaking white areas on the nail’s surface. In other cases, white, yellow, or brown streaks or lines may occur on the nail (lateral onychomycosis) or the whole nail turns white, yellow, brown, green, or black.

Change in nail’s texture/shape

Changes in the nail’s texture may include pitting of the nails, characterized by depressions on the nail’s surface and scaling under the nail (subungual hyperkeratosis).

The nail may curve in on the sides, take on an unusual shape, and become thickened at the center — making it difficult to trim.

Brittleness

The corner or tip of the nail may crumble (distal onychomycosis), making pieces break off easily.  

Pictures

 

 

B. Severe Signs and Symptoms

As the infection progresses, other symptoms may start manifesting, such as:

Unpleasant odor:

a foul odor emanates from the affected nail.

Chipping off:

the tips of the nail might break or chip off, causing jagged edges. Upper layers of the nail might start peeling off.

Loss of nails:

in more severe cases, a condition called onycholysis occurs, wherein the infected nail disengages from the nail bed and leads to the partial or total loss of the nail.  

Decayed / diseased nails:

the infection promotes the decay of the nail.

Pictures

 

 

IV. Nail Fungus Classification

A. Nail Fungus Gallery: What Does Nail Fungus Look Like

B. Distal Subungual Onychomycosis (DSO)

This is the most common type of fungal nail infection, and it is usually caused by trichophyton rubrum, a dermatophytic fungus. DSO starts on the end of the nail bed and the underside of the nail plate. It may be difficult to treat this completely, and can become a lifelong condition.

In some instances, DSO may be caused by wearing closed shoes that fit too tightly for prolonged periods of time. Once the infection starts, wearing closed shoes might become uncomfortable and make the infection worse.

The progression of DSO includes:

• The nail often turns yellow or white partially or completely
• Pieces of debris made up of skin and nail fragments begin to build up under the nail
• The nail may eventually crumble, split and disengage from the nail bed
• Thickened nail

C. White Superficial Onychomycosis (WSO)

This condition makes up 10 percent of nail fungal infection cases and is most commonly caused by Trichophyton mentagrophyte, another type of dermatophytic fungus.

It occurs on the uppermost layer of the nail plate and usually affects the toenails. WSO can be treated quickly.

The signs associated with WSO include:

• Opaque white spots or ‘islands’ on the nail’s surface
• The whole nail might eventually turn white, soft and crumbly

D. Proximal Subungual Onychomycosis (PSO)

Proximal Subungual Onychomycosis is another type of nail fungus which is also caused by dermatophytes, usually trichophyton rubrum in particular. PSO occurs on the proximal nail fold (skin at the nail fold) and may penetrate the nail plate.

This condition may affect the fingernails and toenails in equal frequency. It commonly occurs in people with compromised immune systems and is considered one of the symptoms of human immunodeficiency virus (HIV) infection. It may also develop due to nail trauma.

PSO may appear in the following ways:

• Thickened skin at the nail fold, which may cause the skin to separate from the nail
• The nail color may become opaque white

E. Candida Infections of the Nail

Otherwise known as yeast infection of the nail, this condition is less common and may also affect the skin around the nail. It occurs more frequently on the fingernails than the toenails, and may invade nails weakened by previous infection or trauma. People who habitually immerse their hands in water are at high risk of developing this type of nail fungus infection.

Candida onychomycosis is usually characterized by:

• Separation of the nail from the nail bed (onycholysis)
• Discoloration of the nail- color might turn to white, green or brown
• Abnormality of the nail shape
• Thickened nail
• The skin around the nail (nail fold) may become swollen and tender
• The site of the infection may become painful

F. Total Dystrophic Onychomycosis

This condition refers to the complete destruction of the nail plate and may be the end result of any of the four types of nail fungus infection above.

 

V. Test and Diagnosis of Nail Fungus

A. Nail Clinical Examination

In order to ensure that your nail abnormalities are caused by fungal infections and not by other conditions that share symptoms with onychomycosis, a doctor’s diagnosis is required. This is vital in making sure that the recommended treatment will be effective for that specific case of onychomycosis.

Before giving their diagnosis, doctors conduct careful physical examination of your infected nails and surrounding skin, as well as an interview about the symptoms you’re experiencing and your medical history. These are beneficial in differentiating fungal from non fungal causes of your nail abnormalities.

Common clinical characteristics of onychomycosis-affected nails are white/yellow or orange/brown streaks in the nail plate. However, nonspecific findings include: nail thickening, onycholysis (which is the separation of the nail from its nail bed), and subungual hyperkeratosis (which is the excessive build up of the nail bed and the hyponychium).

Specialists also look for a match of your conditions and the physical characteristics of the five classifications of onychomycosis as discussed in the previous section.

Aside from examining the physical appearance of your nails, predisposing factors for onychomycosis are also considered. These are: older age, immunodeficiency, poor circulation, diabetes, and others which are also further discussed in Section 2. The existence of these factors and characteristics raises the clinical suspicion of onychomycosis.

It should also be noted that before undergoing laboratory tests, these considerations must be acknowledged:

• Nail material should be sent for microscopy if treatment will be given. Even though there is a 30% to 40% false negative rate, positive results should be carefully interpreted as it cannot be automatically considered as an invasive infection.
• Nail sample culturing may take several weeks but should be undertaken to determine the species that cause your nail abnormalities.
• Nail histology is not usually required, except for cases where another cause of nail changes is suspected.

Only about one half of nail dystrophies are caused by fungus, so in order to ensure correct diagnosis, laboratory testing may still be required.

B. Collecting Nail Specimen

In order to run laboratory tests to confirm diagnosis, samples should be collected from the infected nails. The sample collection process begins with thorough cleansing of the infected nail area and surrounding skin with 70% alcohol to eliminate other contaminants.

Obtaining optimal nail specimens depends on the presumptive diagnosis and site of the infection. The following approaches are recommended:

For Distal Subungual Onychomycosis (DSO)

The nail should be clipped short with sterilized nail clippers. The infected nail bed area is where the specimen can be scraped off. This is where the existence of fungi is most present for patients with suspected DSO.

The extraction should be done closest to the non living epidermis that surrounds the edges of the nail plate (also known as the cuticle). Specimens should also be collected from the nail plate’s underside that is closest to the cuticle. This area has less contaminants that can affect the result of the test.

For Proximal Subungual Onychomycosis

In this classification, the proximal nail bed is the infected area. However, fungi invade the area under the cuticle before it settles in the proximal nail bed.

This is the reason why the uninfected nail plate should be gently trimmed with a number 15 scalpel blade. Debris can also be removed, using a clean and sharp curette, from the infected proximal nail bed as near as the lunula as possible. You can also obtain material from the proximal nail fold.

For Candida Onychomycosis

Samples must be obtained from the lateral, as well as the proximal nail fold of the eponychium. Material from the lifted nail bed should be extracted if Candida Onycholysis is also suspected. Debris can also be collected from the undersurface of the nail if there is deficient scrapings collected from the nail bed.

For White Superficial Onychomycosis

A disinfected and sharp number 15 scalpel blade or curette may be used to scrape off the white area of the nail plate where the infection occurs. Then, the debris of the infected area will be removed.

C.   Laboratory Test

After collecting infected nail samples and skin scrapings, specimen analysis and antifungal susceptibility tests are conducted. First, the laboratory experts will examine the nail and skin scrapings to identify the type of organism that causes your infection. Below is a thorough discussion of these examinations.

Microscopy, staining, and culturing procedures may take up to six weeks before results can be received. Another generic test called the polymerase chain reaction (PCR), a method of detecting dermatophytes, delivers results within hours. The main approaches of laboratory confirmation of the diagnosis are the following:

• Potassium hydroxide smear
• Culture
• Histology

These comprises of the microscopic examination and culture of the obtained nail and skin debris. In identifying nondermatophyte molds, collecting several samples may be required. Results from these tests will strengthen the diagnosis and are also vital to formulating the proper treatment plan.

1. Specimen Analysis

In order to identify the exact microorganisms that cause your nail changes, both direct microscopy and laboratory culture of the extracted nail specimens are required.

a. Direct Microscopy

Direct microscopy is a tedious test due the nail debris’ thickness and coarseness, as well as the fungi’s short presence. There is also a possibility of a high false-negative result rate as mentioned earlier.

Understanding the limitations of direct microscopy in diagnosing the cause of your onychomycosis is essential. This type of test only serves as an examination to confirm the presence or absence of fungi in your infected nails and does not yield results that determine the exact infective agent found in the collected and tested nail debris .

To rule out the presence of fungi, a 20% preparation of potassium hydroxide or KOH, in dimethyl sulfoxide may be used. When testing a KOH preparation, the examiner should closely observe the hyphae, which is the long branching thread-like structure of a fungus. This is to determine if they are dermatophytes or non dermatophytes such as yeasts or molds.

Even though direct microscopy is considered as the most efficient screening method, meticulous matching of both microscopy and culture test results are required to derive to an accurate diagnosis.

b. Culture

A fungal culture is required as it is the only method that can identify the specific microorganism and pathogen. There are two different growth media types for non dermatophytes and dermatophytes. These are the following:

• Cycloheximide media, which consists of Sabouraud peptone-glucose agar and dermatophyte test medium (or DTM), that hinders the growth of non dermatophytes
• Cycloheximide-free media, which consists of inhibitory mold agar or Sabouraud glucose agar and Littman oxgall medium, that allows growth of yeasts and molds

Growth on both types of media suggests that the infective organisms are probably dermatophytes. However, growth on cycloheximide-free medium demonstrates that the infective organism may be a nondermatophyte such as Scytalidium dimidiatum, Scytalidium hyalinum, or Scopulariopsis brevicaulis.

Nevertheless, the growth of a nondermatophyte from a specimen alone does not strongly conclude that the organism that infected your nail is a non dermatophyte.

Non dermatophytic fungi that are often associated with onychomycosis are the following:

• Members of Scopulariopsis (particularly S. brevicaulis)
• Members of Scytalidium
• Members of Alternaria
• Members of Aspergillus
• Members of Acremonium
• Members of Fusarium
• Onychocola canadensis
• Pyrenochaeta unguis-hominis
• Botryodiplodia theobromae

Summerbell, a dermatologist, suggested that in order to increase the predictive power of a non dermatophytic nail invasion diagnosis, non dermatophytes identified in the nail material may be categorized as one of the following:

• Contaminant — are the species that grow in culture from the dormant propagules that are preset on the nails
• Normal mammalian surface commensal organism
• Transient saprobic colonizer — or noninvasive colonizer of accessible surface molecules; persistent secondary colonizer or colonizer of material that is infected by a dermatophyte but is incapable of remaining after the dermatophyte is successfully removed
• Successional invader — are species that can cause infection after penetrating a nail through the disruption caused by another principal pathogen
• Primary invader — which are able to infect and cause nail fungal infections in a healthy nail

Another additional technique to confirm the non dermatophytic nail invasion may require the organism’s isolation from successive specimens from the infected area. If the pathogen that causes your infection is a dermatophyte, succeeding cultures will most likely grow out the infective dermatophyte itself, a second contaminant that is unrelated to the first, or completely zero growth at all.

2. Antifungal Susceptibility Testing

Antifungal susceptibility testing is beneficial to the diagnosis and treatment strategy. This is one of the current major focus of the the Subcommittee for Antifungal Susceptibility Testing, which was founded by the National Committee for Clinical Laboratory Standards in 1982.

The Subcommittee started their testing methods with Cryptococcus and Candida species. After years of thorough examinations, they developed a broth-based procedure for yeast susceptibility testing that produces an interlaboratory reproducibility level practically identical to that acquired for antibacterial specialist testing.

By utilizing these susceptibility testing strategies, efforts were made to build up interpretative breakpoints which a given minimum inhibitory concentration (MIC) is related to a recognized and unsatisfactory possibility of candidal infection treatment failure.

MIC is the lowest concentration of antifungal, bacteriostatic, antibiotic, or any antimicrobial drug that interferes a microorganism’s growth after overnight incubation.

The tentative breakpoints that were previously created are presently under review. These are breakpoints for fluconazole, excluding therapy for C. krusei, and itraconazole, which are recommended for mucosal candidal infections only.

The National Committee for Clinical Laboratory Standards is working on their progress for the development of susceptibility testing methods for antifungal agents in dermatophyte-caused infections.

Susceptibility in infections, such as those caused by nail fungus, are becoming more clinically significant. Susceptibility testing helps in recognizing relapse, which is the reinfection by the same agent. In addition, it also presents evidence if the fungus itself is the origin of the failure of treatment.

VI. Treatment of Finger and Toenail Fungus

A. Treatment Selection

As mentioned in an earlier section, a dermatologist (skin doctor) or a podiatrist (foot doctor) will start with a physical examination of the infected toenail or fingernail. Debris under the nail, a portion of the nail, or affected skin tissues may be collected for further microscopic testing and culture. The test will be able to determine the cause of the infection: fungus, yeast, or molds.

1. Classifying Severity of Nail Fungus

Your doctor will determine the severity of the condition based on the symptoms present.

As discussed in the “Nails Fungus Signs and Symptoms” section, signs such as nail discoloration and change in the nail’s shape and texture may indicate that the infection is on its early stages and may be considered as mild.

Other symptoms, such as an unpleasant odor, chipping off of the nail, loss of nails, and a decayed appearance of the nail, may signal that the infection has progressed to moderate or severe level.

An infection that affects more than 50% of the nail is considered a severe form of nail fungus infection.

2. Disease (Nail Fungus)-Oriented

As discussed in the “Nail Fungus Classification” section above, there are five major types of nail fungus infection, and it is important to identify which specific condition an affected person actually has. Determining the type of onychomycosis one has is key to getting the right treatment and help for the infection. As dermatophytes are responsible for the majority of nail fungus infections, most treatments are formulated to fight against that organism. However, antifungal agents that work actively versus dermatophytes, such as terbinafine, are shown to be less effective against non-dermatophytes, such as organisms belonging to the Candida species and molds.

3. Patient-oriented

Treatments may vary, depending on the patient’s medical background and history.

Pregnant and breastfeeding women

FDA pregnancy categories must be duly noted before prescribing medication to a pregnant woman. Most nail fungus oral medications belong to Category B (considered safe based on animal studies, but not yet studied on humans) or Category C (animal studies show possible adverse effect on babies; use with caution). Particularly, oral antifungal medications containing griseofulvin, should be avoided as they can cause birth defects when taken during the first trimester. Fluconazole increases the risk of miscarriage and larger doses are also associated with birth defects.

It is advisable for pregnant women to opt for topical solutions or alternative home remedies in treating nail fungus infection. However, it should also be noted that the use of essential oils during pregnancy is still a controversial topic and should be administered with extreme caution.

Diabetics

60% Sixty percent of lower leg amputation is done on people with diabetes, and a toenail fungus infection can increase the risk of amputation for diabetics. See a doctor immediately if you are diabetic and suffering from the condition, as the infection needs to be taken seriously and treated immediately.

Toenail fungus infection may also lead to a secondary infection and cause sores that will not heal. A doctor should be extra aggressive and aim to eradicate the infection as soon as possible for patients with diabetes.

Children

Nail fungus infection is rare in children, with an occurrence rate of less than 0.5% worldwide. Currently, griseolfulvin is the only oral medication licensed for use in treating pediatric nail fungus infection.

Clinical studies show the efficacy of these three drugs in treating the condition in children: terbinafine, itraconazole and fluconazole. Data demonstrates high cure rates and pediatric tolerance for these medications. These three drugs are being proposed for use in the treatment of pediatric nail fungus infections.

People with liver issues

They are generally advised to avoid taking terbinafine (Lamisil) for the treatment of nail fungus infection. The drug may elevate serum levels of aminotransferases (liver enzymes), and lead to liver damage. FDA issued a warning about the use of terbinafine (Lamisil) and itraconazole (Sporanox), as they have been associated with serious liver damage, which may lead to liver failure or even death.

4. How to Know What Type of Treatment Would Work Best for You?

In the recent years, there has been a more optimistic outlook on the treatment outcome of patients with nail fungus due to the introduction of promising new options, such as itraconazole, terbinafine and fluconazole. A personalized treatment plan that factors in a patient’s profile, symptoms, infection type, drug toxicities and interactions, is shown to result to improved success rates.

Below, we explore more details about the available treatment options.

B. Types of Treatment

Over The Counter (OTC) Topical Treatments

Over the counter / non-prescription topical solutions may be used for the treatment of mild nail fungus infection.

As these therapies usually contain natural ingredients, they are safe to use with minimal contraindications, so you can use two or more remedies together. They are relatively inexpensive but may take several months to fully take effect.

These topical remedies penetrate deeper into the layers of the nail when the nail is clean, trimmed and thinned. To clean the nail, soak it daily in a baking soda, hydrogen peroxide and water mixture.

These over the counter treatments have not been comprehensively evaluated in clinical studies. The limited trials done involved only a small number of patients.

Common ingredients used in non-prescription topical agents include:

Undecylenic acid

There have been two studies (1965 and 2008) done on the effectiveness of undecylenic acid versus nail fungus infection. The 2008 trial involved 154 patients and established a 50% to 65% mycotic cure rate for mild to moderate cases, and 35% for severe cases–  after three months. However, undecylenic acid was combined with two other ingredients cyanoacrylate and hydroquinone in a solution called Renewed Nail. Thus, the effectiveness of undecylenic acid on its own cannot be clearly concluded.

How to use: In the trial study, the affected nail was trimmed and debrided, and the solution was applied every 2 weeks for three to four visits. The solution can be applied once or twice a week at home.

Tea tree oil (melaleuca alternifolia)

Two small studies have been done on this ingredient as a cure for onychomycosis. The combination of the two studies did not suggest significant benefit with the tea tree oil treatment. The more recent study showed a 20% cure rate and 67% improvement in nail appearance with 100% concentrations of the oil. Tea tree oil is relatively inexpensive with a 0.05 ounce bottle costing less than 10 dollars.

How to use: Apply 100% undiluted tea tree oil straight to the affected nail. Soak for 10 minutes and then gently scrub the nail using a soft bristle toothbrush. Do this therapy twice daily until a new healthy nail grows back. Continuous application may prevent the recurrence of the fungus.

Sunflower seed oil (ozonized)

One study examined the effectiveness of a product called Oleozon, which contains ozonized sunflower oil. The results were remarkable, at 90.5% cure rate for the patients. Among those who used Oleozon, only 2.8% had a relapse after 1 year.

How to use: Rub a small amount directly to the affected nail twice daily.

Snakeroot extract (ageratina pichinchensis)

This is a natural antifungal substance that is derived from the sunflower plant family. In a randomized trial where 96 patients were given either snakeroot extract or ciclopirox for six months, the snakeroot extract group reported a 59% mycotic cure rate and 71% clinical cure rate. Furthermore, results from the two groups did not show significant difference.

How to use: Apply once every three days for one month, twice a week for the second month, and then once a week for the third month onwards.

Coconut oil

This is a generally safe and effective antifungal agent, except if you are allergic to coconuts. Caprylic acid (one of the medium-chain fatty acids) may break through the protective coating of the fungi and cause the fungus cells to liquify, eliminating the infection.

How to use: Can be applied directly to the nail as often as needed.

Lavender oil

A natural antiviral, antifungal, anti-inflammatory, antiseptic agent that may be effective in treating mild nail fungus. It is a highly-potent oil known to help promote blood circulation and strengthen the immune system.  

Lavender oil may work by destroying the cell membrane of fungal cells. Make sure that you are using only pure lavender oil, as some solutions may be combined with other kinds of oil.

How to use:

• Apply one drop of pure lavender oil to the affected nail twice daily.
• Soak nail in a mixture of warm water, 5 drops of lavender essential oil and a few tablespoons of Epsom salt- for 20 minutes daily.
• Combine one drop of lavender oil with one drop of tea tree oil and rub directly on affected nail twice daily.

Garlic

An old-time folk remedy for various ailments, garlic contains a compound called allicin to help fungal infections. Several scientific research have shown the effectiveness of allicin in combating fungal infections, on top of other skin-related problems, such as acne, boils, and eczema.

How to use: To make garlic oil, crush two cloves of garlic and combine with two tablespoons of olive oil. Apply the solution directly to the affected nail and cover with a bandage and leave on for 24 hours.

Garlic oil may also be combined with vinegar, as vinegar also contains antifungal properties that can shorten the healing time.

Tolnaftate

A synthetic biocarbamate that is also known as an antifungal remedy.

It is marketed as treatment for athlete’s foot, ringworm and other skin infections. However, the molecules may be too big to penetrate the nail and may be ineffective versus nail fungus.

How to use: topical agents containing tolnaftate are available without a prescription. They come in ointment, spray, cream, lotion, gel, powder or solution form. Follow dosage guidelines.

Some individuals opt for over the counter topical creams and prepared solutions, as they are more convenient to use. These well-known topical solutions already contain one or a combination of the active ingredients above:

EmoniNail

The blend lists FDA-approved undecylenic acid, as well as natural healing oils, such as tea tree oil and sunflower seed oil as its active ingredients.

The product has an 89.4% success rate (based on aggregated reviews) within one to two months. Users report good results with the use of EmoniNail, including being free from the infection after decades of dealing with it and healthy-looking nails.

They offer a 100% money back guarantee if results are not seen within 60 days.

A 0.8 ounce bottle can be bought online from their website or other online retailers for $59.95 per bottle, good for one month use.

How to use: the solution comes with a brush for easier application and recommended for use twice daily.

Funginix (Fungisil)

Comes in a creamy texture for better absorption and contains undecylenic acid as its main active ingredient. Also includes herbal extracts and essential oils like camphor, menthol, tea tree oil, lavender oil, sweet almond oil, etc.

The product has an 83.2% success rate (based on aggregated reviews) within two to four months.  

Funginix suggests a treatment period of 6 months to kill all the fungus in the affected nail. They also offer a 100% money back guarantee within 60 days from date of purchase.

A 0.8 ounce bottle is available online via their website or through other online retailers for $49.95 per bottle, good for one month use.

How to use: the product comes with an applicator brush and recommended for use twice daily.

ZetaClear

The topical nail solution contains natural oils such as almond oil, jojoba oil, tea tree oil, Vitamin E oil, lemongrass oil, clove oil, and also undecylenic acid.

The product is given a 76.1% success rate (based on aggregated reviews), within two to four months.

ZetaClear may work in removing fungal infection traces by penetrating deep into the skin. It takes one to two weeks for it to work.

It can be bought online through their website or other online retailers for $59.95 for a 3-month set.

How to use: the topical solution comes with a brush and recommended for use at least 3 times daily at 3 brush strokes each time.

Naturasil (formerly Dermisil)

Combines a homeopathic ingredient, thuja, with essential oils, such as cymbopogon citratus leaf oil, eucalyptus leaf oil, jojoba seed oil, lavender oil, etc.

It has a 71.1% success rate (based on aggregated reviews), within two to four months.

Naturasil may work by penetrating the nail and the surrounding skin and treating the source of the infection. They offer a 90-day money-back guarantee.

A 15ml bottle costs $29.95 and can be bought through their website or through other online retailers. It may last for 1 month.

How to use: Use the included brush to apply on the affected nail three times daily. Manufacturer noted that burning sensation may occur.

Pedifix Fungasoap (Tea Tree Ultimates Fungasoap)

Contains tea tree oil and other natural ingredients, such as olive oil, coconut oil, jojoba oil,  menthol, aloe, etc.

The product is given a 68% success rate (based on aggregated reviews), but can take as long as twelve months to treat the infection.

Tea tree oil in Pedifix Fungasoap can work as an antifungal agent; however, when used as a body cleanser, the ability of the ingredient to reach the fungus in the nail bed cannot be established.

It comes in three sizes: 2 ounce trial bottle ($4.95), 6 ounce bottle ($11.95) and 13.5 ounce bottle ($19.95). These are available online through their website or other online retailers.

How to use: Use as a body wash twice daily and rinse thoroughly after use.

OPI Fungus Fix

Contains natural ingredients, such as ethoxydiglycol, propylene glycol (moisturizing), undecylenoyl glycine (antibacterial), and usnic acid (antifungal).

It has a 67% success rating (based on aggregated reviews).

Currently, OPI no longer produces OPI Fungus Fix in the US, but the 30ml container is still available in the UK for 19.70GBP via their website.

How to use: Use the brush to apply one to two drops between the nail and the nail bed twice daily.

Omega Labs Fungus Treatment

Indicates undecylenic acid as its main ingredient.

It has a 65% success rating (based on aggregated reviews). Based on the company website, it can restore healthy nails in 12 weeks.

Omega Labs Fungus Treatment can be bought online from their website or through other online retailers for $9.50 per 15ml container.  

How to use: Apply to the affected nail two to three times daily.

Fungi-Nail Brand

The topical solution contains 25% undecylenic acid- the maximum dosage allowed without a prescription.

It is given a 56.4% success rating (based on aggregated reviews). According to their website, you can start to see results within four weeks.

When applied, Fungi-Nail may form a clear, water-resistant barrier to lock in the solution and prevent it from wearing off.

They offer a 100% money-back return policy.

It is available through various online stores and pharmacies, such as Amazon, Myotcstore, Walmart, etc. It comes in two sizes: 30ml economy-sized bottle and 1.7ml pen brush applicator.

How to use: Apply the solution twice daily under the nail and around the cuticle.

Excilor

Ingredients include glycerol, nail care lipids, biotin, ethyllactate, acetic acid, etc.

It has a 52% success rating (based on aggregated reviews). According to their website, results will be visible as the nail starts to grow back, which is around 1 month.  

Excilor is made with a TransActive technology that may work in penetrating the nail without the need to file it beforehand.

The applicator pen is available online in Amazon for $29.99.

How to use: Apply twice daily (morning and evening).

RX/Prescription Medication

Topical Antifungal Medications

Prescription topical solutions are also available for the treatment of nail fungus. Treatment with topical agents alone are generally shown to be insufficient, due to lack of penetration through the nail bed.

Topical agents have few contraindications and drug interaction. However, they may result to adverse effects, such as redness, stinging and itching on the application site.

Nail debridement and trimming may be done beforehand by your doctor to help the agent penetrate the nail more efficiently. A lotion containing urea as the active ingredient can also work in thinning the nail. Nail avulsion (a surgical procedure involving the removal of the nail plate from its attachments and the nail bed) combined with topical therapy has yielded more positive results. However, this method is painful and recovery from the surgery might take a long time.

A combination of prescription oral medication and topical antifungal preparations may be recommended for moderate to severe cases of nail fungus infection.

Topical therapy may be continued after the course of oral prescription medicine to help prevent the recurrence of the infection.   

The most widely-used prescription topical medications currently available in the market are:

Tavaborole (Brand Name: Kerydin):

an oxaborole (boron-containing compound) antifungal agent that is prescribed for the treatment of nail fungus infection caused by Trichophyton rubrum or Trichophyton mentagrophytes. As mentioned in the section above, nail fungus infections due to these kinds of fungi are classified as: Distal Subungual Onychomycosis, White Superficial Onychomycosis, or Proximal Subungual Onychomycosis.

Tavaborole works in inhibiting protein synthesis, which leads to cell death and eventually eliminates the nail fungus infection. When combined with a 1:1 mixture of ethyl acetate and propylene glycol, it has been shown to fully penetrate through the nail plate.

Two randomized trials showed the following results: complete cure rate in 6.5% and 9.1% of patients after 48 weeks of treatment; mycotic cure rate in 31.1% and 35.9% of participants.

These side effects occurred in less than 5% of the patients: exfoliation, rash and irritation on the application site. Patients are advised to seek immediate medical attention should the following severe side effects occur: severe allergic reactions, such as rashes, hives, itching, difficulty breathing, tightness in the chest, swelling of the mouth, face, lips, or tongue; ingrown toenail; severe or persistent irritation.

A full course of treatment requires 48 weeks of daily application. The price of a 10ml bottle of 5% Kerydin topical solution starts at $1,393.54 in this website.

How to use: Apply the solution over the entire surface and under the tip of the infected nail, once daily.

Efinaconazole (Brand Name: Jublia):

is a triazole topical antifungal specifically developed for the treatment of distal and lateral subungual onychomycosis (DLSO). The 10% solution, under the Jublia brand name, received FDA approval in June 2014.

This relatively new treatment is a broad-spectrum antifungal showing promising results against dermatophytes, non-dermatophytes and yeast. Efinaconazole penetrates the nail unit more efficiently, due to its lower keratin binding and faster keratin bound drug release compared to other topical antifungal agents.

Research has shown efinaconazole as being more potent than other nail fungus treatment options- terbinafine, ciclopirox, itraconazole and amorolfine, versus Trichophyton rubrum, Trichophyton mentagrophytes, Candida albicans and Epidermophyton floccosum. Two clinical trials, which involved 48 weeks of daily efinaconazole application and no nail debridement, reported 17.8% and 15.2% complete cure rates. 53.4% to 55.2% mycotic cure rates were also demonstrated after 52 weeks of treatment. These results are comparable to a 12-week treatment course with oral itraconazole.

Around 2% of patients in the clinical trials experienced these side effects: ingrown toenail, redness, itching, swelling, burning or stinging, blisters, and pain. Users are advised to seek immediate medical attention if the following conditions are observed: severe allergic reactions (rash, hives, itching, difficulty breathing, tightness in the chest, swelling of the mouth, face, lips, or tongue); ingrown toenail, and severe or persistent irritation at the application site.

The duration of a full treatment course is 48 weeks. The price of a 4ml bottle of 10% Jublia solution starts at $557.37 in this website.

How to use: Apply to clean, dry nails (wait at least 10 minutes after showering or bathing), once a day.

Ciclopirox (Brand name: Penlac):

is a synthetic hydroxypyridine antifungal indicated for the treatment of nail fungus infection and athlete’s foot caused by the dermatophytes Trichophyton rubrum, Trichophyton mentagrophytes and Epidermophyton floccosum; as well as seborrheic dermatitis.

Ciclopirox in cream or lotion form is not recommended as treatment for nail fungus infection, as the thick texture cannot penetrate the nail unit. An 8% ciclopirox solution in nail lacquer / nail polish form, under the brand name Penlac, has been specifically developed for nail fungus infections and has demonstrated better penetration levels.

However, results of two clinical trials done reported low success rates: 6% to 9% complete cure rates, 29% to 36% mycotic cure rates, and 77% mycotic cure rate with regular nail debridement. Treatment failure rate is at 61% to 64% after 48 weeks of use.

Ciclopirox is shown to work synergistically with oral antifungal drug terbinafine — the combination resulted in a 68% complete cure rate and 88% mycotic cure rate; compared to 50% complete cure rate and 65% mycotic cure rate when terbinafine is used alone.

Side effects experienced by patients in the clinical trial include: periungual erythema, erythema of the proximal nail fold, burning sensation on the application site, changes in nail shape and color, and ingrown toenails. User are advised to seek immediate medical attention if the following adverse reactions are observed: severe itching and skin irritation (redness, burning, dryness) or nail changes.

The full course of ciclopirox treatment takes 48 weeks. Price of a 6.6ml bottle of Penlac nail lacquer, containing 8% ciclopirox solution, starts at $9.99 in this website.

How to use: Apply over the entire nail plate, once daily; preferably at bedtime or 8 hours before washing.

Oral Antifungal Medications

Oral antifungal agents may be used for the treatment of moderate to severe nail fungus infection. Oral medications under the azoles and allylamines drug classes are most commonly prescribed.

Azole antifungals work by inhibiting the cytochrome P450 dependent enzyme lanosterol 14-alpha-demethylase. This action depletes ergosterol, which leads to the cell death of fungal cells. Itraconazole and fluconazole belong to the azole family.

Allylamine antifungal agents also hinder the synthesis of ergosterol, by inhibiting the enzyme squalene epoxidase. Terbinafine is under the allylamine medication class.

These drugs are typically taken for a period of six to twelve weeks. However, you need to wait for the healthy nail to grow back completely before you will see the end result.

Clinical studies show that the combination of oral and topical antifungal therapies is more effective, compared to treatments using a single approach. (See above for data on lower cure rates of terbinafine solo treatment versus terbinafine-ciclopirox combination)

Possible adverse effects of these oral antifungal medications include headaches, gastrointestinal problems, and skin rashes. Serious medical conditions associated with the use of these drugs are Stevens-Johnson syndrome (a life-threatening skin disease),  Long QT syndrome (a heart rhythm condition), ventricular dysfunction and liver damage.  Patients with renal, heart or liver issues are discouraged from taking oral antifungal agents. Blood tests to check the liver function are usually done before beginning oral therapy and after every 6 weeks of treatment.

More detailed information on the uses, clinical studies results, contraindications, and side effects of the top oral antifungal agents for the treatment of nail fungus infection are given below:

Griseofulvin (Brand names: Fulcin, Grisovin, Grisactin, Gris-PEG): used to treat dermatophytes infection on the scalp, fingernails and toenails.

Studies show griseofulvin has lower efficacy compared to terbinafine and itraconazole, with only 30% to 40% mycotic cure rate for toenail fungal infections. Treatment duration can take up to 6 to 9 months for fingernail infection, and 12 to 18 months for toenail infection. Due to the availability of newer and more effective (based on clinical studies) antifungal agents, griseofulvin is no longer a priority choice in the treatment of nail fungus infection.

The following should not use griseofulvin:

• Pregnant women or those who might become pregnant during and six months after the treatment period, as it can cause fetal harm.
• People with liver problems
• Those with porphyria (a genetic enzyme problem)
• Males who might father children in the next six months, as it can damage sperm cells
• Nursing mothers, as it not known whether the drug passes into the breast milk.
• Children younger than 2 years of age, or weighs less than 35 pounds

Before starting on griseofulvin medication, tell your doctor if you have any of the following conditions:

• Liver issues
• Lupus (a chronic, autoimmune disease that can affect the skin, joints and organs)
• An allergy to penicillin

Let your doctor know of any medications (blood-thinner such as warfarin; hormone pills), vitamins and supplements (including natural ones) that you are taking, as other drugs may interact with griseofulvin.

Other possible interactions include:

• Skin sensitivity to sunlight, that may cause you to sunburn more easily.
• Increased side effects when taken with alcohol: increased heart rate, excessive sweating, flushing and redness.

Common side effects include:

• Nausea and skin rashes (experienced by 8 to 15% of patients)
• Gastrointestinal problems: diarrhea and upset stomach
• Headache and vomiting
• Skin itching
• Sleep problems: insomnia

Call your doctor immediately if you experience any of these severe adverse reactions:

• Fever, flu or chills
• White patches or sores inside the mouth or on the lips
• Confusion or inability to perform everyday activities
• Symptoms that may signify liver problems: severe nausea, loss of appetite and upper stomach pain, dark-colored urine, clay-colored stools, jaundice (yellow skin or eyes), intense itching, and loss of energy
• Signs of an allergic reaction: hives, difficulty breathing, swelling of your face, throat, tongue or lips.
• Lupus-like symptoms: fever, swollen joints and glands, muscle aches, chest pain, and patchy skin color
• Other skin reaction: painful skin, red or purple rashes that spread and lead to blistering and peeling.

How to take: The recommended dose for adults is 500 to 1,000 mg/day — follow your doctor’s advice on the recommended dosage for your condition. Use the medicine only for the duration prescribed by your doctor and do not exceed or shorten length of treatment. Griseofulvin is best taken with fatty food to help absorption.

It is the only oral antifungal agent licensed for the treatment of pediatric nail fungus infection, with the recommended dose of 10 mg per day for the age group 1 month and up.

Terbinafine (Brand name: Lamisil):

an antifungal agent under the allylamine family of medications, and indicated for the treatment of ringworm, tinea versicolor and nail fungus infection.

The agent is shown to have potent antifungal properties against dermatophytes, particularly T. rubrum and T. mentagrophytes, but has lower efficacy versus the Candida species compared to oral azoles.

Based on the results of clinical studies, terbinafine is currently the most effective oral antifungal agent against nail fungus infections. Daily oral terbinafine (250g, once a day, for a period of 6 weeks for fingernail fungus and 12 weeks for toenail fungus) rendered a 66% clinical cure rate and 76% mycotic cure rate. The study also showed relatively low clinical relapse rate of 21% after treatment with terbinafine.

Terbinafine has a strong tendency to dissolve in lipids or fats (lipophilic), and distributes well in the skin and nails. It can be detected in the nail within one week of treatment and for six months after terbinafine therapy. It has higher tolerability compared to other oral antifungals used for the treatment of nail fungus.

Terbinafine is not recommended for individuals with the following conditions:

• Active or chronic liver disease– as it is associated with hepatic toxicity, which may result in cholestatic hepatitis, liver failure or even death
• Neutropenia (abnormally low levels of neutrophils)- as it may lead to the severity of the condition
• Depression
• Immunodeficiency/immunosuppression (inability of the immune system to fight diseases)- as the treatment can lower lymphocyte count (white blood cells) in the blood
• Lupus
• Renal dysfunction– as terbinafine metabolites are excreted through the kidney. There are inadequate studies on the effect of terbinafine on patients with renal impairment

The most common side effects associated with the drug intake include: gastrointestinal upsets such as diarrhea or taste disturbance (4.9%), dermatological issues such as skin rashes, pruritis, urticaria or eczema (2.3%) and headaches. Serious adverse reactions such as Steven-Johnson syndrome, toxic epidermal necrolysis, hepatic toxicity occurred in 0.04% of the patients.

Users are advised to seek immediate medical attention if the following symptoms develop:

• Severe allergic reactions, such as hives, mouth sores, swelling of the face, lips, tongue or throat, skin blistering and peeling, problems swallowing and breathing.
• Signs of liver issues, such as nausea, vomiting, right upper abdominal pain, jaundice (yellowing of skin and eyes), loss of energy, dark-colored urine and pale-colored stools.
• Taste and smell disturbance
• Signs of depression
• Fever
• Skin eruption, loss of pigment (skin loses its natural color), skin reddening (erythema), scaling or unusual sensitivity to sunlight
• Lymph node enlargement

How to take: 250 mg oral terbinafine once a day for adults — 6 weeks for fingernail fungus infection and 12 weeks for toenail fungus infection. Always follow doctor’s advice on the duration and dosage- do not exceed or shorten treatment.

For pediatric onychomycosis, some experts recommend: 5mg/kg of oral terbinafine daily. However, take note that oral terbinafine is not licensed for use for the treatment of nail fungus infection in children.

Itraconazole (Brand name: Sporonox):  

a triazole antifungal that works against a broad spectrum of fungi, including yeasts, dermatophytes and some nondermatophyte moulds. It is indicated for the treatment of fungal infections.

Clinical trials show a 70% cure rate, and mycotic cure rates of 63% (based on pulse dosing) and 69% (based on continuous dosing).

Like terbinafine, it is highly lipophilic- it penetrate the nails quickly and can be detected as early as one week from start of the treatment and persists for up to 6 to 9 months after the end of the therapy. Due to this long-lasting effect, intermittent pulse dosing with itraconazole shows an efficacy level that is comparable to daily continuous dosing.

Intake of this drug is not recommended for the following people:

• Pregnant women
• Breastfeeding mothers- it passes to the breastmilk and can harm a nursing baby
• Individuals who have suffered from congestive heart failure
• People with allergy to itraconazole or other similar drugs such as fluconazole or ketoconazole

Itraconazole has a high drug-to-drug interaction and can cause life-threatening adverse effects when taken together with certain medications. Inform your doctor of any medicines you are taking, especially the following:

• Sedatives or anti-psychotic medicines, such as Valium or Xanax
• HIV / AIDS medications
• Antibiotics, particularly erythromycin, ciprofloxacin, and clarithromycin
• Blood thinners such as warfarin
• High cholesterol medications
• Cancer medications, such as dasatinib and nilotinib
• Blood pressure medications, such as digoxin, verapamil, aliskiren, and diltiazem
• Immunosuppressants, such as dexamethasone and everolimus
• Urinary problems medications, such as Flomax, Vesicare and Detrol
• Seizure medications, such as carbamazepine
• Narcotics, such as oxycodone and fentanyl
• Medicines taken during organ transplants, such as sirolimus and cyclosporine
• Migraine medications, such as eletriptan

Avoid taking antacids within 1 hour before and 2 hours after taking itraconazole, as it may affect your body’s ability to absorb this drug.

Itraconazole can also interact with vitamins and herbal supplements, so give your doctor the complete list of all drugs (prescription and over-the-counter) and supplements you are taking or have recently stopped (within the last six months).

Common potential side effects include:

• Nausea, headaches and vomiting
• Gastrointestinal issues such as constipation
• Hypokalemia (drop in potassium level)
• Fever, muscle and joint aches and pain
• Hormonal problems, such as changes in menstrual cycles, impotence and erection problems
• Falling hair
• Unusual taste in the mouth
• Elevated liver transaminase level
• High triglyceride level

Contact your health care provider immediately if you encounter any of the following adverse effects:

• Severe allergic reactions, such as hives, swelling of the tongue, throat, face or mouth, severe skin rashes and difficulty breathing
• Elevated heart rate
• Confusion or a light-headed feeling
• Hearing problems and ringing in your ears
• Urinating problems, such as urinating incontinence, absent or little urination, and painful urination
• Vision problems, such as blurred vision or double vision
• Numbness or tingly feeling
• Intense pain from the upper stomach to the back
• Liver issue symptoms, such as nausea, itching, fatigue, jaundice (yellowing of the skin or eyes), upper stomach pain, dark-colored urine, and light-colored stools
• Congestive heart failure symptoms, such as gasping for breath, irregular heart rate, coughing with mucus, weight gain, sleep problems, and swelling

How to take: The presence of nail fungus infection must be confirmed before starting with itraconazole therapy. For adults, the recommended dosage is 200 mg once daily, for a period of 12 weeks, for the treatment of toenail fungus infection. For fingernail fungus infection, the recommendation is 200 mg twice a day, for a period of 1 week.

Clinical trials show that the efficacy of pulse dosing is comparable to continuous dosing: 200 mg twice daily for one week every month for a period of two months for fingernail fungus infection, and three months for toenail fungus infection.

Fluconazole (Brand name: Diflucan):

an antifungal agent used to treat a range of fungal infections, such as oral and throat thrush, and yeast infections. It is currently not licensed for use against nail fungus infection, though seven studies have examined fluconazole for the treatment of the condition.

Fluconazole functions by preventing the fungus from creating a form of plant-based cholesterol that it needs to survive. It is used to target dermatophytes and most Candida species (except Candida krusei and Candida glabrata).

For the treatment of nail fungus infections, the studies report a range of 28% to 36% clinical cure rate for toenail infections and 76% to 90% for fingernail infections. Mycotic cure rates are 47% to 62% for the toenails and 89% to 100% for the fingernails. A higher dose of 450 mg and longer treatment period (9 to 12 months) resulted to higher cure rates.

Because of its pharmacokinetic property (time course of drug absorption and distribution in the body), fluconazole can be administered once-a-week in a 450 mg dosage — leading to better user compliance and reduced treatment costs.

The following people should avoid taking this medication:

• Those with kidney problems, as fluconazole is excreted through the kidneys and your body may not be able to eliminate the drug efficiently
• Individuals who are allergic to azole antifungal agents
• People with intolerance to certain sugars or milk (glucose-galactose, lapp lactase, or sucrose), as Diflucan (fluconazole brand) capsules contain lactose
• Pregnant and breastfeeding women

Before starting on any course of treatment, it is important to let your doctor know of any medications (prescription and non-prescription), vitamins and supplements, that you are currently or have recently taken, to avoid possible drug interactions.

Fluconazole may increase the levels of certain drugs in the body, which can result to dangerous adverse effects. The following drugs should not be taken with fluconazole:

• Heart (irregular heartbeat) medications, such as Covert (ibutilide), Norpace (disopyramide), Promestyl, Procan, or Procanbid (procainamide), Pacerone, Cordarone, or Nexterone (amiodarone), Betapace/Betapace AF (sotalol), Tikosyn (dofetilde), or Multaq (dronedarone)
• Antibiotics like erythromycin (all drugs containing erythromycin case, ethylsuccinate, lactobionate or stearate), Biaxin (clarithromycin), Avelox (moxifloxacin), and Zithromax (azithromycin)
• Birth control pills or hormone replacement therapy drugs containing estrogen
• Depression/mood medications, such as Pamelor (nortriptyline), Prozac (fluoxetine), Buspar (buspirone), Celexa (citalopram), and Abilify (aripiprazole)
• Psychiatric drugs, such as Haldol (haloperidol) and Geodon (ziprasidone)
• Specific medications for cancer, such as Doxil/Adriamycin (doxorubicin), Cometriq (cabozantinib), Inlyta (axitinib), Bosulif (bosutinib), and Votrient (pazopanib)
• Blood thinners, such as Coumadin (warfarin)
• Cholesterol drugs, such as Lipitor (atorvastatin), Zocor (simvastatin), and Mevacor (lovastatin)
• Hismanal (astemizole)
• Norpace (disopyramide)
• Lozol (indapamide)
• Juxtapid (lomitapide)
• Nebupent (pentamidine)
• Orap (pimozide)
• Quinidine
• Foradil or Perforomist (formoterol)
• Epinephrine
• Coreg (carvedilol)
• Migergot/Cafergot (ergotamine) and Migranal (dihydroergotamine)

Drinking alcohol while on fluconazole therapy may worsen certain side effects (headaches, stomach upsets) of the medicine. Do not consume grapefruit juice on the entire duration of the treatment, as the juice slows down the pace at which the body breaks down fluconazole, causing the drug’s level in the blood to rise.

Common side effects associated with fluconazole include:

• Headaches, nausea and vomiting
• Stomach pain and diarrhea
• Skin rash
• Sleep problems such as insomnia

The more serious adverse effects include:

• Irregular heart rate or change in the heart’s electrical activity
• Breathing problems
• Seizures
• Signs of liver failure and inflammation, such as jaundice (yellowing of the skin, nails and eyes), and increase in liver enzyme levels
• Low levels in white blood cell and platelet count
• Angioedema (swelling of the mouth, lips, and tongue)
• Elevated triglycerides level
• Drop in potassium level
• Steven-Johnson syndrome or toxic epidermal necrolysis (TENs)

How to take: 100 mg to 300 mg once per week for 3 to 6 months (fingernail fungus infection) or 6 to 12 months (toenail fungus infection). Higher dose of 450 mg per week may also be given for higher efficacy. Follow your doctor’s advice and do not underdose or overdose.

Nail Removal

Though rarely necessary, your podiatrist, dermatologist or general surgeon may suggest nail avulsion or removal for severe or recurrent nail fungus infection — especially when a large portion of the nail is diseased, the nail is extensively thickened or the condition is painful. Nail removal is an outpatient procedure done in your doctor’s clinic or office.

Nail removal makes it possible to apply topical antifungal solutions directly to your nail bed, improving the absorption of the agent and increasing the chance of curing severe nail infections.

The procedure must be accompanied by topical or oral antifungal therapy to kill the fungi and other organisms. Otherwise, the infection can affect the new nail that grows. It may take 6 months for the new fingernail and 12 to 18 months for the new toenail to grow back.  

Nail avulsion can be done chemically or surgically; it can be partial (only damaged portion of the nail) or total (whole nail), depending on the extent of the infection.

After the nail is removed, it is important to keep the area clean as the open wound has a big chance of becoming infected. Follow your doctor’s step-by-step care guide to ensure successful results. A highly absorbent dressing and an elastoplast or a paper tape are typically used to cover the operated area and to keep the dressing in place. The dressing may be removed after 24 hours and it is advised to soak the area in warm water or saline solution twice a day. A povidone-iodine solution may also be applied to help quicken the healing process.

The operated limb must be frequently elevated to minimize pain and swelling and it is best to keep it well-rested for at least 2 weeks. Handling the nail matrix and nail folds gently is crucial to avoid complications after the procedure.  

In some cases, the patient may opt to permanently prevent a new nail from growing back. The doctor will then surgically, chemically or electrically destroy the nail matrix (matricectomy) so that the nail plate cannot be regenerated.

Chemical nail removal / avulsion

This non-surgical technique is generally painless and usually involves partial nail removal.

The steps for chemical nail removal include:

• A cloth adhesive tape is placed on the skin around the nail that is to be removed. This is to prevent the solution from getting into and irritating the soft skin tissue.

• In cases when there is gross thickening of the nail, superficial nail abrasion may be done first to improve the solution’s penetration into the nail.

• A 40% to 50% urea ointment/solution (with 5% white beeswax or paraffin, 20% anhydrous lanolin and 35% white petrolatum) is applied directly on the nail surface and covered with plastic and hypoallergenic tape. The nail and dressing must always be kept dry as water may counteract the efficacy of the solution.

• The urea ointment/solution softens the nail within the following one week to 10 days.

• After the nail has softened, it will be removed either by detaching the nail plate from the nail bed (total removal) or by trimming out only the diseased portion of the nail (partial removal).

• The area must always be kept clean. You may cover it with a nonstick bandage. It would take around 2 weeks to heal.

• Continue with your oral or topical nail fungus medications, as advised by your doctor.

Other formulations that showed positive results in softening the nail are: 20% urea and 10% salicylic acid ointment; and 1% fluconazole and 20% urea mixed with ethanol and water (applied once daily in the evening).  

Chemical nail avulsion is the preferred nail removal method for patients with diabetes, heart problems or immunosuppression.

The advantages of this method compared to surgical nail avulsion include: minimal pain during and after the procedure (no need for anesthesia), low infection and hemorrhage risk, and shorter downtime.

Disadvantages include: length of application duration (one to two weeks), and possible irritation due to the acidity of the urea solution.

Surgical nail avulsion

The steps involved in performing surgical nail avulsion include:

• Certain medications, especially those that thin the blood and may promote bleeding (warfarin, coumadin) must not be taken for several days before the operation.

• A local anesthesia is injected to the finger or nail to prevent pain during the procedure.

• The doctor uses a blunt instrument, such as a nail elevator device (Freer septum elevator), a mosquito hemostat or a dental spatula, to separate the nail plate from its attachments.

The two common approaches in surgical nail avulsion are: distal avulsion and proximal avulsion.

In distal nail avulsion, the instrument is inserted under the distal free edge (tip) of the nail plate to disengage it from the nail bed hyponychium.

Proximal avulsion may be done when the distal (tip) of the nail plate is damaged (distal nail dystrophy) and may not be accessible. The nail elevator is then introduced beneath the cuticle in the proximal groove (the skin folded over the part where the nail plate is attached to the finger or toe) to separate the proximal nail fold from the nail plate.   

• The nail plate is then loosened from its attachments. This step must be done gently and carefully to avoid trauma to the adjacent, unaffected tissue. In partial nail avulsion, only the diseased portion is removed.

• The doctor then applies an ointment to the wound and covers it with gauze and tape.

• Follow your doctor’s instructions on how to care for the wound to avoid infection or other complications. Use clean water to wash around the area twice a day; do not use hydrogen peroxide or alcohol as these can irritate the open skin and slow down healing. The wound should heal in a few weeks.

• Continue with your oral or topical nail fungus medications, as advised by your doctor.

After the nail removal procedure, your doctor might prescribe matricectomy to prevent an infected or disfigured nail from growing back. Matricectomy involves destroying the nail matrix to permanently prevent a new nail plate from growing back.

This may be a good option for chronic and recurring nail fungus infection that is unresponsive to aggressive antifungal therapy.

Matricectomy can be partial or total; It can be achieved chemically, surgically or electrically.

Laser Treatment

Laser therapy is a relatively new option for the treatment of stubborn nail fungus infection.

Some experts see laser as the answer to the challenges of penetrating the hard surface of the nail plate using topical antifungal agents, the potential serious adverse effects of oral antifungal therapy, as well as the pain and risks associated with nail removal.  

Lasers utilize light energy with the right strength and wavelength to target infected tissues. High doses of light energy can penetrate into the specified area and destroy the fungus and other harmful organisms.

Laser treatment do not minimize the risk of nail fungus infection recurrence, and it is recommended that nail care techniques are implemented afterwards.  

Initial research pointed to the effectiveness of this method in treating nail fungus infection, but there is still inadequate evidence to fully support laser therapy as a routine treatment for the condition.

The downside of laser treatment is the high cost associated with it, which is typically not covered by health insurance- as it is considered an aesthetic/cosmetic procedure.

The current top FDA-cleared brands of laser machines for the treatment of nail fungus infection are:

Pinpointe FootLaser

The first FDA cleared laser for the temporary increase of clear, healthy nail in patients with nail fungus infection.

It works by emitting laser light that passes through the nail without causing damage to the nail unit or the surrounding skin. Results are not instantaneous though, as it takes time for the affected nail to grow out.

Clinical studies show that  with only a single session, more than 70% of patients reported sustained improvement in nail appearance. This outpatient procedure takes around 30 minutes to complete, is virtually painless (some patients may experience a warming or a slight pinprick sensation) and requires no recovery period.

A Pinpointe Footlaser procedure typically costs around $1,000.

Noveon laser by Nomir Medical Technologies

Designed to specifically treat toenail fungus infection, it uses a technique called photo-inactivation– to prevent discomfort due to heat build-up during administration.

It boasts of a dual wavelength system, which may be more effective in killing fungi and bacteria, compared to a single wavelength laser treatment. Visible improvement may be seen in one to two months as damaged nail surfaces begin to be replaced with healthy new nail surfaces.

A 2010 clinical study showed clear linear nail improvement among 85% of the patients after 180 days;  with 35% of these patients achieving further improvement after 270 days.

A typical session takes less than 30 minutes (each session can treat four toenails at the same time), is generally painless and requires no downtime. Patients may need two to four sessions, depending on the condition and recommendation of the doctor.

Treatment costs are not indicated on their website.

Erchonia Lunula Laser

Utilizes cold laser treatment for toenail fungus infection; it uses low-level laser light and combines the power of two wavelengths (635 nm for regenerative outcomes and 405 nm for antifungal effects).

According to the website, the use of cold laser therapy prevents the risk of burns, pain and foul-smelling plumes associated with heat-based lasers. They list among Lunula Laser advantages: no pain, no downtime, no risk; and requires little time (12 minutes per session, each session can treat all 5 toenails at the same time- all 10 toenails can be treated in 24 minutes total), and minimal setup.  

The clinical trial established that after four sessions, nail fungus was destroyed for 99% of the participants. After 48 weeks, only 4 out of the 323 patients suffered recurrence of the infection. They prescribe  S a four treatment sessions, at weekly intervals, for best results.  

Treatment cost not specified on the website.

Hyperion HyperBlue 1530 Laser

A portable multi-use diode laser apparatus used for the treatment of nail fungus infection, as well as warts, matrixectomies, and neuromas.

It emits energy in the infrared and visible spectrum and only targets the infection, leaving the surrounding area unharmed. Each treatment session takes 15 minutes, done 30 days apart; and it is 98% effective, according to this website.

The portable design of Hyperion HyperBlue 1530 Laser allows service providers to treat patients from the comfort of their own home.

Treatment cost not specified.

Cutera GenesisPlus Laser

Indicated for the treatment of nail fungus infection and several skin conditions, such as warts, scars (hypertrophic and keloid), large pores and uneven texture, wrinkles, rosacea, etc.

For the treatment of nail fungus infection, the company reported a 70% improvement rate, based on 7 participants who received 2 sessions of laser therapy each. Visible results may be seen after 3 months.

Treatment cost not specified.

Home Remedies

Without treatment, nail fungus infection may persist indefinitely. For individuals who want to treat their condition without the use of harsh chemicals and ingredients that may lead to adverse side effects, there are several home remedies that might do the trick.

These options might work best on mild nail fungus infection or one that is on its early stages. Home remedies are rarely studied in clinical trials, so scientific research to measure their efficacy are usually not available.

As these home remedies are applied topically, it is always best to trim your fingernails or toenails as close to the nail bed as possible to provide easier access and penetration to the source of the infection

These natural treatment options may have been passed down across several generations, through word of mouth. Some people swear by these home remedies for the treatment of nail fungus infection:

Vicks VapoRub

This is one of the most popular home remedies for nail fungus infection. Vicks VapoRub may be applied directly to the affected nail, twice daily.

Vicks VapoRub as treatment for nail fungus has been studied in a clinical trial involving 18 participants.

The study yielded good results and feedback: positive effect occurred on 83% of the participants; mycotic and clinical cure rates were at 27.8% after 48 weeks; 55.6% of the participants achieved partial clearance, while 16.7% showed no change. Overall, 50% of the participants rated their response to the end results as “satisfied”, and the other 50% gave a rating of “very satisfied” at the end of the 48-week treatment.

Another study evaluated the efficacy of another brand of medicated chest rub against the nail fungus infection. The results demonstrated that the ingredients camphor, eucalyptus oil, thymol and menthol, which are also active ingredients found in Vicks VapoRub, have the potential to be effective in controlling nail fungus infection in concentrations of 5 mg/mL for each one. These ingredients are known to have strong antifungal properties.

Vicks VapoRub should not be used on babies less than 2 years old. According to their website, topical application of Vicks  VapoRub should not exceed four times daily. Vicks Vaporub should never be ingested as camphor can lead to poisoning when taken internally.

Overuse of this ointment may result to negative side effects, such as:

• Severe nausea and vomiting
• Blurred vision
• Shakiness
• Unsteady walk or shaking
• Confusion
• Urination difficulty
• Drowsiness
• Mood swings
• Slowed breathing
  

Bleach

The household cleaner, also known as sodium hypochlorite, is advertised to kill 99.9% of fungus, germs and bacteria in your home and may actually also work in destroying the fungus in your nail.

Though there are no scientific studies to support it, some people have found success in treating their nail fungus infection through a bleach bath/soak:

• Put one tablespoon of bleach to a basin with a gallon of warm water.
• Soak the affected nail for 3 to 20 minutes, twice per day- once in the morning and once in the evening. Try to dip only the finger or toe with the affected nail to minimize possible side effects.
• You may add some drops of tea tree oil, oregano oil or pieces of oregano leaves to the bath to increase its antifungal properties.
• Dry hands or feet thoroughly after each soak.

It may take at least two months of daily soaking before you will see results with the bleach therapy. Never soak in the same mixture more than once, as the water gets contaminated after you have soaked your infected nail in it.

Carefully monitor your skin’s reaction. Stop immediately if you notice undesirable side effects, such as irritation on the skin surrounding the nail.

Bleach is a corrosive chemical and should never be used undiluted. Always use it in a well-ventilated place- open the window to get rid of the strong chlorine smell.

Possible adverse reactions include skin irritation and redness, itching and pain. Direct contact with undiluted bleach can damage the eyes, skin and mucous tissues.

Vinegar

White vinegar or apple cider vinegar is another well-known and affordable home remedy for nail fungus infection. You may use other kinds of vinegars, as well.

Vinegar is a natural antifungal and antibacterial, it has been used for various therapeutic purposes since the ancient times. In China, people have been using it to prevent the spread of viruses since the 1200 BC. In Ancient Greece (400 BC), Hippocrates, the father of modern medicine, prescribed apple cider vinegar as treatment for coughs, colds and other illnesses.

Vinegar is a natural all-purpose cleaner and disinfectant and may take the place of household chemical cleaners in keeping your surroundings sanitized.

Fungus grows in an alkaline environment. The acidity of the vinegar relieves itching, balances the body’s PH level, and provides a hostile environment for different kinds of fungus and bacteria.

For the treatment of nail fungus infection, vinegar can be used in the following ways:

Vinegar soak:

Dip your toe or finger in a 50% vinegar and 50% water solution for 30 minutes, 3 times daily. It is recommended to alternate the use of warm water and cold water for soaking. Make sure to completely dry your feet and hands afterwards.

Do not use the same solution for multiple soaking, as the water gets contaminated once you soak your infected nail in it.

Oral consumption:

Apple cider vinegar is the type of vinegar prescribed for oral intake- it builds your immune system and helps you fight infections from within.

Add two tablespoons of apple cider vinegar to 16 oz of clean water and drink the solution all throughout the day. You may add honey to make the taste more pleasant.

Avoid drinking undiluted apple cider vinegar as it can destroy your tooth enamel and burn your throat.

Direct application:

Pour a few drops of vinegar directly into the infected nail. Let it dry and repeat at least twice daily.

Consistent application is key to better cure rates.

Vinegar may also be combined with other home remedies for stronger antifungal benefits:

• Vinegar and rice flour paste
• Baking soda soak after the vinegar soak to inhibit further growth of fungi
• Vinegar and Epsom salt soak
• Vinegar and mouthwash (Listerine) soak
• Topical application of vinegar and hydrogen peroxide solution
• Vinegar and copper sulfate spray
• Vinegar, borax, and hydrogen peroxide soak

Remember that anything taken in excess can be detrimental to our health, even for natural products. These are the negative side effects associated with too much apple cider vinegar, or any other kind of vinegar:

• May slow down digestion (when taken internally)- which may worsen symptoms of gastroparesis (a condition wherein food stays in stomach for too long — common in people with Type 1 diabetes)
• Skin burns (when applied topically)
• Weakened tooth enamel leading to tooth decay and loss of minerals (as it frequently passes through the mouth, especially if undiluted)- this can be prevented by sipping the drink through a straw
• Throat burns caused by the acetic acid in vinegar (when taken internally)- which may lead to painful throat and difficulty swallowing
• Indigestion (when taken internally)- as it suppresses appetite and provides a feeling of fullness
• Low potassium levels and other abnormalities in the blood chemistry (when taken internally)
• Osteoporosis (when taken internally)- minerals leach from the bones to counter the acidity in the blood and may affect bone density and lead to brittle bones and/or bone loss

Consumption of vinegar may interact with the following drugs:

• Insulin or insulin-stimulating medications– may cause potassium levels or blood sugar to get too low
• Digoxin (Lanoxin)– this drug already lowers potassium levels, taking it with vinegar can lead to dangerously low potassium levels
• Certain diuretic medications– may also cause potassium levels to drop
• Laxatives

Mouthwash

Mouthwash, particularly Listerine, has been used to treat nail fungus infections for many years. Listerine is an oral disinfectant and has the following ingredients to help fight fungal infection:

• Thymol– an oil derived from thyme (an evergreen herb), it is a fungicide and commonly used to target fungi, bacteria and viruses
• Eucalyptol oil– an essential oil made up of 90% eucalyptus oil, it has anti-inflammatory, antibacterial and antiseptic properties
• Salicylate– a non-steroidal anti-inflammatory compound, it gets rid of dead skin cells and allows healthy new cells to grow

Many people find mouthwash soak effective for the treatment of nail fungus infection in its early stages. It may instantly prevent the spread of the infection; however, it may take several months before visible results on the existing condition can be seen.

How to do a mouthwash soak:

• Make a solution composed of 50% mouthwash and 50% warm water.
• Soak your feet or hands for 20 to 30 minutes, once per day.
• After soaking, gently remove the dead skin cells from the affected nail (or all nails, if you want), using a soft-bristled brush. This step allows your skin and nail to breath and encourages healthy cells to start growing back.

Mouthwash can also be combined with vinegar in a 50-50 topical solution or spray — for use three to four times daily.

Do not ever drink mouthwash or Listerine. Side effects with the topical use of Listerine are very rare. There is also no known contraindications.

Hydrogen Peroxide

Hydrogen Peroxide (H2O2) has strong oxidizing properties, and can also be used as a bleaching and antifungal agent, disinfectant and antiseptic.

The method of using hydrogen peroxide to treat nail fungus infection is called oxidative therapy. Soaking the affected nail in a 3% hydrogen peroxide solution  and water/vinegar mixture may destroy the fungus due to the high level of oxygen.

How to do it:

• Combine a 3% hydrogen peroxide solution with an equal volume of water or vinegar.
• Soak the finger or toe with the infected nail for 20 to 30 minutes daily.

It may take at least a month to see visible results with the oxidative therapy for nail fungus infection.

Make sure that the hydrogen peroxide solution is not more than 3%, as more concentrated solutions can cause skin irritations. Observe your skin’s reaction and stop therapy if skin redness, stinging, irritation, blisters or signs of allergic reaction occur. Excessive use may lead to skin damage.

Do not ingest non-food grade hydrogen peroxide. There is no known contraindications with the use of 3% hydrogen peroxide solution topically.

VII. Complications of Nail Fungus if Left Untreated

Compared to other acute and chronic medical conditions, nail fungus infection might not seem like a highly threatening or dangerous disease. Since the infection is not particularly painful, affected individuals might consider it as a purely cosmetic concern and delay seeking advice from their health providers.

However, the longer you wait before treating your condition, the harder it will be to heal successfully. Ignoring a nail fungus infection can lead to serious consequences as the fungus progresses and may cause negative symptoms beyond the aesthetics:

Deformed nails/ Destruction of nails

As the infection grows from the tip towards the cuticle, the nail becomes thickened, discolored, brittle, and eventually appears deformed or misshapen. When this happens, it might lead to discomfort and pain when walking and putting on closed shoes.

Onycholysis– a condition characterized by the separation of the nail plate from the nail bed can also occur. The loose portion or the entire nail may then either fall off on its own or will have to be removed in an avulsion procedure (discussed in detail in the Treatments section). This might lead to the permanent loss of the nail or in more severe cases, several toenails or fingernails.

Spread of infection to other nails

Fungal infections are highly contagious and can easily spread to the skin surrounding the affected nail and to the other nails as well. The skin might become inflamed, itchy, dry, and cracked — and lead to athlete’s foot or tinea pedis. Athlete’s foot causes skin peeling, stinging, blisters, and sores.  

Wearing socks and closed shoes for prolonged periods of time can cause the infection to spread quickly, once one of the toenails has been affected.

Spread of fungus around the body

Keeping a harmful organism alive in your nail can cause the infection to migrate to other parts of the body, such as hands, back, and legs. It can also spread to the genitals, inner thighs and buttocks — in a condition called jock itch. Jock itch is characterized by a red, itchy, and usually ring-shaped rash.

One in every two dozen cases of nail fungus infections results to the spread of the infection to other parts of the body. Older people or those with weakened immune systems are especially susceptible to this.

Paronychia

The fungus can create cracks, chips, and openings in the nail and skin, where bacteria can get in and cause a condition called paronychia (whitlow). It usually enters through a break in the skin between the nail fold (cuticle) and the nail plate.

Paronychia can either be acute or chronic: Acute paronychia develops quickly and is usually caused by the Staphylococcus bacteria, while chronic paronychia occurs slowly and is commonly caused by more than one infecting agent, typically Candida yeast and a bacteria.

Symptoms include:

• Red and tender skin around the nail
• Abnormalities in skin shape, color, or texture
• Blisters
• Detachment of the nail plate from the nail bed

Acute paronychia may be treated using home remedies, and oral or topical antibiotics; while chronic paronychia is harder to treat and may require antifungal medication or even nail removal, in very severe cases.

Cellulitis

Bacteria that entered through the cracks and openings in the nail and skin can cause widespread infection in the body. This may lead to cellulitis — a bacterial skin infection that is potentially serious, even deadly, when it spreads into the underlying tissues, lymph nodes, and the bloodstream.

Symptoms of cellulitis include:

• Swollen, inflamed area in the skin that tends to expand or change rapidly
• The area feels warm and tender to the touch
• Fever
• Blisters
• Can spread quickly on different parts of the body
• Usually appears on one side of the body

Cellulitis can have especially serious consequences for people with diabetes, nerve damage, circulation problems, or weakened immune system. It is associated with increased risk of diabetic amputation.

It is strongly recommended that individuals seek immediate medical attention on the first sign of cellulitis, as the infection can cause rapid widespread infection and lead to serious internal damage or even fatality.

Section VIII: Nail Fungus Prevention

Given the stubborn nature of nail fungus infection, it is best to take a proactive approach to minimize the chance of its occurrence.

As discussed in the above section (Section II: Nail Fungus Cases — Risk Factors), certain people, such as swimmers and those who have diabetes, have a higher likelihood of contracting the infection. People who have suffered from it before are also at high risk of getting it again — as recurrence rate is at 10% to 50%, despite treatment.

It would be wise, especially for these individuals, to take extra precaution to avoid the hassle, costs, and worries of having to deal with nail fungus infection.

A. Food and Supplements

The adage that whatever you put inside your body manifests on the appearance of your hair, skin, and nails is true.

An antifungal diet gets rid of food ingredients that fungal parasites can feed on and in the process, reduces inflammation inside the body. Eliminating sugar and conventional grain products from your diet means starving the parasites and can lead to their death.

These are the inflammatory food you should avoid:

• Sugar is the primary food that fungi crave. These are not just limited to sweets — such as candies, cookies, chocolate bars, doughnuts and baked goods — but also sugar from carbohydrates, dairy, and fruits (see below).

• Conventional grain products — especially those that contain gluten, such as wheat, rye, barley, and oatmeal. White rice and corn are gluten free, but contain a good amount of starch that converts to sugar (glucose).

• Some dairy products such as cow’s milk, cream, and cheese (lactose is also a form of sugar)

• Processed oil products such as corn oil, canola oil, palm oil, vegetable oil, peanut oil, soybean oil, margarine, and shortening

• Processed, cured, and smoked meat and other food products

• Sweet fruits that contain a high amount of fructose must also be limited, including all kinds of dried fruits, banana, grapes, melon, pear, mango, figs, papaya, peach, etc. Fruit juice must be avoided due to its high sugar content

• Certain vegetables — such as potatoes (due to high starch content) and mushrooms (fungal food)

• Alcohol, coffee, fruit juices, carbonated drinks

• Junk food

Pay special attention if you have specific food allergies, as they can cause inflammation and adverse reactions (such as fungal and yeast growth) inside your body. The list of the most allergenic food includes: dairy, eggs, peanuts, and tree nuts (cashew, walnuts), seafood, wheat (gluten), and soy.

Consume more of the following:

• High-fiber food to help rid your stomach of toxins, waste, fat, and cholesterol particles: legumes (split peas, black beans, lentils, lima beans, peas), vegetables (artichokes, broccoli, brussel sprouts, leafy greens), vegetable/green juice, and fruits (berries, avocado)

• Probiotic food to replenish good bacteria and to support your gut health: yogurt (aim for plain yogurt and not those that contain sugar), fermented food such as cultured vegetables (kimchi, sauerkraut), kombucha, and kefir beverages

• High quality protein sourced from hormone-free, grass-fed, pasture-raised, cage-free, and wild-caught chicken, beef, eggs, and fish

• Good fats, such as coconut oil, olive oil, flax seeds, and chia seeds

• Antibacterial and antifungal food ingredients, such as garlic, ginger/turmeric, cinnamon, onion, oregano, seaweed, cayenne pepper, etc.

Though not yet backed by medical research, many individuals report good results from taking probiotic supplements. The good, beneficial bacteria provided by probiotics may strengthen the antifungal properties of good bacteria that we already have on our skin and help prevent fungal infection from occurring. A weakened immune system is more susceptible to fungal infections, so make sure that you get the right nutrients everyday. You might want to take a good quality multivitamin that contains Vitamin A, Vitamin C, Vitamin D, zinc, and other essential vitamins and minerals.

B. Lifestyle and Environment

Good hygiene is key to preventing nail fungus infection, so it is important to always keep your feet and hands clean and dry.

Here are some other simple practices you can adapt to minimize the risk of contracting nail fungus infection:  

Trim your nails correctly and keep them short:

Use sanitized tools and clip your nails straight across. Gently file down thickened areas and sharp edges. Do not trim (or pick at) the skin around your nails.

Proper cleaning and drying:

Using soap and water, wash your hands regularly and your feet at least once a day. Dry thoroughly, including between your fingers and toes.

Wear clean, moisture-wicking socks:

Change your socks everyday, or as often as needed, especially when your feet sweat excessively. Consider copper sole socks, as they have antifungal properties.

Invest in the right footwear:

If you need to wear closed shoes, opt for those made with breathable materials, such as canvas or leather. Wear shoes with a wide toe box to avoid cramping your toes, and choose the correct fit: not too small or too big, and make sure your toes are not touching the end of your shoes. Allow your shoes to dry in between uses.

Sprinkle antifungal foot powder:

Do this all over your feet before putting on your socks and shoes, to make sure that they remain dry all throughout the day. This can be used on the inside of your shoes as well.

Do not walk barefoot around warm and moist public areas:

This includes communal locker rooms, swimming pool decks, public shower areas, gyms, sauna. Wear flip flop slippers or shower sandals.

Disinfect regularly:

Sanitize your own bathroom floor and shower head, and wash your socks with warm water, detergent, and bleach. Use antibacterial spray on your shoes and expose them to sunlight (not recommended for leather shoes).

Avoid skin-to-skin contact with people with any kind of skin or nail fungal infection:

Fungus can be passed on through skin-to-skin contact, so ask family members and people you interact with regularly to treat their condition ASAP, to avoid the spread of the infection. Do not share footwear and nail tools with other people. Wash your hands thoroughly if you touch infected skin or nails.

Do not smoke:

Smoking increases the chance of getting nail fungus infection.

 

C. Preventing Reinfection

It is frustrating to have to deal with recurrent cases of fungal nail infection. Apart from the tips given above, you can add the following practices to avoid reinfection:

• Use the medications (oral or topical) completely and correctly as prescribed by your healthcare provider. Be consistent, as the fungus may still be present, even if outward symptoms are no longer visible.

• Watch out for the early signs of the infection: By now, you might already be familiar with the first signs of nail fungus infection (see Nail Fungus Signs and Symptoms section). Visit your doctor immediately once you start noticing nail changes to avoid the infection from progressing further.

• Replace all footwear that have come into contact with the fungus: The harmful organisms may persist inside your shoes, socks, and other footwear for many months, and can easily cause another round of infection. In case you do not want to get rid of your shoes, make sure to sanitize and disinfect them properly. You may also consider investing in a UV sterilizer.

• Soak your hands and feet in an antifungal bath regularly: This provides a hostile environment for the fungus and prevents it from growing. A vinegar-water solution (one part vinegar and five parts water) can kill any existing fungus, as the organism cannot survive in an acidic setting. You can also try a saline solution soak (two teaspoons of salt for every pint of warm water).  

D. Nail care routines and hygienic practice you can do at home

Bad news for those who love to get their nails done in salons: it can put you at increased risk of getting nail fungus infection. The fungus can spread through the following ways:

• Direct contact between clients
• When the nail technician does not sanitize her hands between servicing different customers
• It can be passed on through the shared nail tools, especially if they are not properly sanitized between uses.

The good news is: it is easy to do your own manicure and pedicure at home. You can avoid the hazards associated with getting your nails done in public salons/spa, and this will help you to save on costs too.

1. Manicure and Pedicure Procedures

Before you start your manicure or pedicure, make sure that you do not have any skin injuries, cuts, or abrasions around the nail area. Wait at least 24 hours after you wax or shave your hands and feet, before applying any form of nail polish.

Always maintain proper hygiene and good sanitation practices when doing your nails at home.

Here are the steps of doing your own manicure/pedicure safely at home:

• Wash your hands and feet and use a sanitizer containing at least 70% alcohol.

• Prepare your tools: a sanitized set of nail instruments (see below). Some tools that cannot be disinfected, such as nail files or pumice stones, must never be shared and should be discarded if they were used on infected nails before.

• Use a nail polish remover to get rid of leftover nail polish or nail color. Non-acetone nail polish remover is gentler on the skin but works more slowly compared to acetone-based nail polish remover. To avoid the unpleasant smell and chemicals, some people opt for DIY chemical-free nail polish removers.

• Clip and file your nails to your desired length and shape. Get rid of sharp edges. Avoid metal or coarse nail files as they may cause splintering on the nails.

• Clean the surface and bottom of your nails, using a nail brush and orangewood stick.

• To help minimize the risk of getting nail fungus infection, it is recommended that you skip the cuticle-pushing and cutting step. Cuticles are necessary, as they prevent bacteria and fungus from entering your nails.

• Time to paint your nails: Start with a base coat to strengthen weak and brittle nails, apply your colored nail polish in layers, and then end with a clear top coat. Allow each layer to dry before applying the next one.

• Dry your polish and apply moisturizer to your hands and feet.

2. Essential Nail Tools

A complete manicure/pedicure tool kit includes the following:

• Nail-polish remover and cotton swabs or pads
• Nail clippers
• Emery board and nail buffer
• Nail brush and orangewood sticks
• Hand/nail moisturizer
• Base coat
• Nail polish
• Clear topcoat

3. How to sanitize and clean your nail tools

Even if your nail instruments and tools are for your own exclusive use, you still need to sanitize them to prevent the growth of germs and bacteria. Sterilizing should be done after every use.

Here are the steps on how to do it:

• Wash your tools with antibacterial soap and warm water.

• Place them in a heatproof bowl and let them submerge in boiling water for 15 to 20 minutes.

• Wipe them with cotton balls drenched in alcohol.

• Let them dry thoroughly before storing in a clean, dry container.

4. Recommendations on using nail polish

Check the ingredients of your nail polish and make sure that it does not contain these toxic chemicals:

• dibutyl phthalates (DBP)
• toluene
• formaldehyde
• oxybenzone

Apply nail polish in well-ventilated areas to minimize your exposure to the chemical vapors — inhaling the fumes can cause headaches, dizziness, and irritated eyes.

It is best to remove nail polish after a couple of weeks, and go at least one week without it. This will allow your nails time to breath. Keeping the polish on for too long may cause nail discoloration and worse, lead the pigments to permeate through your nail plate and dry out your nails. This can cause yeast, bacteria, mold or mildew to develop underneath the nail plate, which can then lead to nail fungus infection or other long-term problems.

Do not use non-medicated nail polish when you are suffering from nail fungus infection, as it can make the condition worse. It will make it harder for topical antifungal solutions to penetrate through your nail plate and the colored polish will create a dark condition that fungus needs to thrive.

There are certain medicated nail polish products that claim to treat nail fungus infection, while providing coverage for your unsightly nails; however, their effectiveness have not yet been proven.

Remember that it is always best to treat a nail fungus infection immediately, rather than covering it, to improve your chances of getting rid of it successfully.

 

Section IX: Frequently Asked Questions on Nail Fungus

A. Are fingernail fungus just as common as toenail fungus?

No, nail fungus infections occur mainly on the toenails, and less frequently on the fingernails, due to the following reasons:

• Fungi live in warm, moist, and dark places, and when your feet are confined inside your socks or closed shoes for prolonged periods of time — that provides a friendly environment for the fungi to thrive in. Whereas your hands are usually exposed to air and light, which minimizes the risk of fungal infection affecting the fingernails.

• Healthy blood circulation strengthens the immune system, as it allows your antibodies to detect and fight infections more rapidly. Your lower extremities have less blood flow than your arms and hands, making it more difficult for your immune system to identify and stop toenail infections from progressing.

 

B. I’ve been treating my nail fungus for months but haven’t found cure. Is my treatment really working?

Treating a stubborn nail fungus infection requires a lot of time and patience. Oral antifungal agents are commonly taken for six weeks for fingernail fungus infection, and three months for toenail infection. Topical solutions may need to be consistently applied for up to one year.

Your treatment duration and the length of time it takes for your nail fungus infection to clear up depend on the severity of your condition. Also, you might not be able to see the end result until a healthy new nail grows in place of the diseased one.

Fingernails may take 4 to 6 months to fully grow out, while toenails usually take 12 to 18 months.

However, there are small signs that will show if your nail fungus infection is starting to heal –– your affected nail will become less brittle, the discoloration will disappear, and the odor (if any) will go away. You may also observe the appearance of the nail near the proximal nail fold (cuticle) to see if the new growth is clear and healthy-looking.

Even if you notice these positive changes, you should still continue with your treatment to fully eradicate the infection, unless otherwise advised by your podiatrist or dermatologist.

In case you do not notice any improvement in your condition after one month of treatment, please consult with your doctor immediately.

C. Can I still get nail fungus even if I wear nail polishes often?

Nail polish is not protection against nail fungus infection. On the contrary, it might even make you more susceptible to contracting the condition.

Covering your nails with colored polish will create a dark environment that is a perfect breeding ground for fungus to grow.

Nail polish is a ‘sealant’ — it protects the nails and seals in moisture. Unfortunately, this seal hinders the nail bed from breathing and leads to a dark and moist environment that encourages the fungus to spread.

Covering your nails with polish might also prevent you from observing any changes on your nails’ texture and appearance — which might delay the diagnosis and treatment of nail fungus infection.

As discussed in the section above (Section 8: Nail Fungus Prevention, Recommendations on Using Nail Polish), keeping the polish on for too long may cause the pigments to permeate through your nail plate and dry out your nails. This can cause yeast, bacteria, mold or mildew to develop underneath the nail plate, which can then lead to nail fungus infection.

Using fake nails is also not recommended for the same reasons given above.

D. Can you use topical treatment and nail polish?

This is not advisable, as the nail polish may inhibit the solution’s ability to penetrate through the nail plate and render the treatment ineffective.

A medicated nail lacquer/polish containing an 8% ciclopirox solution (Penlac brand name) has been specifically developed for nail fungus infections. More details about this prescription topical antifungal agent are discussed under Section 6: Treatment of Fingernail and Toenail Fungus.

Certain brands of over-the-counter medicated nail polish, such as Dr.’s Remedy Enriched Nail Care and DaniPro AntiFungal Infused Nail Polish, are also available. However, their effectiveness have not been fully established.

 

Section X: Best Resources on Nail Fungus

It helps to be armed with the right information in your battle against the stubborn nail fungus infection.

Based on our intensive research, these are the most helpful online resources on the condition:

A. Mayo Clinic

Mayo Clinic provides comprehensive information about nail fungus broken down into several sections, making it easy for readers to head straight to the specific answer they are looking for:

• Definition
• Symptoms
• Causes
• Risk factors
• Complications
• Preparing for your appointment
• Tests and diagnosis
• Treatments and drugs
• Lifestyle and home remedies
• Alternative medicine
• Prevention

The ‘preparing for your appointment’ section is particularly unique and useful — it tackles what you should do and the questions you can ask to make sure that all your concerns will be addressed by your healthcare provider.

Additional pages are included:

• Expert Answers
• Expert Blog
• Multimedia — also includes a slideshow on how to trim thickened toenails

Pages are written in an organized, easy-to-understand manner.

B. WebMD

The topic overview on fungal nail infection provides all the basic information you need in one page. Links to slideshows and pictures are also included in the main article, in case you need more details about a specific aspect.

More resources are available when you click on the other links provided: medical reference, video, slideshow and images, quizzes (test how much you know about nail fungus infection), and news archive.

However, you would need to sort through the list as it combines all pieces related to different kinds of fungal infections. It might be more efficient for the reader if all information related to nail fungus infection were summarized in one place.

Nonetheless, you would definitely learn a lot about the condition from WebMD, if you know where to look.

C. NHS Choices

NHS Choices covers the overview, symptoms, causes, treatments, and prevention of fungal nail infection in one long page. They provide jump links to each section for easier browsing. They also have a separate, more detailed take on the treatment options.

It is good that the website shows the date when their pages were last reviewed and when they are due for the next one. This helps ensure readers that all data provided are regularly updated.

D. Wikipedia

Wikipedia packs a lot of information in their onychomycosis page. Subpoints are broken down into signs and symptoms, causes, diagnosis, treatment, prognosis, epidemiology, and research.

However, it might be a bit too scientific for individuals who do not have a medical background. This is a great resource if you want to know the technical terms related to the condition.

E. Global Nail Fungus Organization

As the Global Nail Fungus Organization site is solely dedicated to nail fungus infection, it is indeed a rich resource for everything you need and want to know about the condition.

The medication comparison page is remarkably useful as it summarizes the brand names, costs, cure rates, benefits and side effects of available treatments. Detailed reviews are also available for the top over-the-counter topical treatments.

The use of numerous videos, pictures, and slideshows help provide a clear and complete picture of the condition.

Though it is managed by a team of medical practitioners, well-researched information is presented in simple, everyday terms that can be easily understood by anyone.

Overall, the whole site is very credible and organized and can definitely be considered as the online authority on fungal nail infections.

F. Nail Fungus in the Press

Currently, laser treatment options for nail fungus infection are being studied by doctors everywhere. Initial findings show promising results, with minimal side effects. However, laser therapies are costly and are usually not covered by health insurance.

Here, Dr. Jeff Lamour talks about the toenail fungus laser removal available in Austin, Texas now.

https://youtu.be/iYOEr938cVs

Section XI: Conclusion

Summary of:

Nail Fungus Definition

Nail fungus infection, also known as onychomycosis or Tinea Unguium, is a very common condition that is characterized by changes in the nail’s color and texture.

Nail fungus is commonly caused by microscopic fungi (called dermatophytes) that enter your toenails, fingernails, and even the skin under your nail (called the nail bed) through small cuts and cracks in the nail or on the surrounding skin. Nail fungus infection happens when there is an overgrowth of these dermatophytes.

When diagnosing a fungal nail infection, a medical specialist (such as a dermatologist or a podiatrist) would have to rule out other related conditions, such as nail injury, psoriasis, and melanoma because of some similarities in their symptoms.

These three conditions typically bear a resemblance to nail fungal infections, but one of the most identifiable difference of onychomycosis from these other nail conditions is the nail’s emission of a foul odor. This can be a symptom more connected to the presence of a nail fungus condition.

According to an analysis from NC State University, there are an estimated 2%-18% of people who are affected by nail fungal infections worldwide. Another study reported that onychomycosis has an international prevalence range of 3-26% worldwide.

A research report also demonstrated that toenail onychomycosis is the most difficult fungal infection to cure.

Nail Fungus Causes

An overgrowth of pathogens in your nail area causes nail fungus. As fungus (a kind of pathogen) thrive in warm and moist environments, the feet are more prone to getting in contact with fungus (i.e. by wearing sweaty socks in tight shoes for a long time or by walking barefoot on wet and humid places like the public sauna, spas, community pools, etc.).

The toes also have less blood flow than the fingers, which makes it harder for the body’s immune system to detect and block the infection. Thus, toenail fungal infection is more common, and it typically occurs in about 10% of the adult population.

However, the occurrence of fingernail fungal infection is still possible if fingers are constantly kept wet or damp and if they are exposed to dermatophytes.

Pathogens typically infect a nail by penetrating it through small cuts in the skin surrounding your nail, a crack in your nail, or any separation between your nails and fingers or toes.

One or a combination of the three types of pathogens can cause nail fungal infections. These pathogens are dermatophytes, candida, and non-dermatophytes.

Dermatophytes (usually trichophyton rubrum) are the most common cause of onychomycosis. They can spread through direct skin-to-skin contact with infected people, animals, soils, and objects.

Candida (a type of yeast) and molds cause 8% and 2% of fungal nail infections, respectively. Yeast overgrowth — caused by illness, birth control or antibiotic pill intake, and immune system problems — may lead to infection.

Non-dermatophytic molds (NDMs) are among the types of fungi that grow in soil, skin, and nails. These do not typically spread through person-to-person contamination.

There are different modifiable and non-modifiable factors that affect your susceptibility to fungal infections. This includes your overall health, your environment’s humidity and heat levels, and the condition of the nail(s) infected, among others.  

Non-modifiable factors that increase your risk of nail fungus infection development are:

• Age (individuals older than 60 are more prone to nail fungal infections)
• Gender (males are reported to be up to three times more likely to acquire nail fungal infections than women)
• Existing health condition (having a nail injury, skin condition like psoriasis, as well as other diseases such as diabetes, peripheral arterial disease, HIV, and cancer increases the susceptibility to fungal nail infections)

• Medications and other major medical procedures (TNF inhibitors, corticosteroids, chemotherapy, and having major operations and prolonged hospitalization can escalate to more health problems such as infections from nail fungi)

Modifiable factors that can lead to nail fungal infections include:

• Walking barefoot in moist and warm public places (such as shower rooms, community pools, locker rooms, and spas)

• Certain working conditions (such as wearing heavy footwear that hinder proper ventilation throughout the feet and working with abrasive chemicals)

• Sharing nail care tools with other people

• Injuring your nails

• Going to unhygienic/unregulated nail salons/spas
• Living with someone who has nail fungus

Nail Fungus Signs and Symptoms

Nail fungus may affect a nail fully or partially and may spread to other fingernails and toenails. In more severe cases, it may also affect the skin around your nails.

As the condition is generally not painful, paying attention to any change in appearance and texture on your nail may help you detect the early signs and symptoms:

• Nail discoloration (white, yellow, or dark-colored spots; flaking white areas on the nail’s surface; white, yellow, or brown streaks; whole nail turns white, yellow, brown, green, or black)

• Change in nail’s texture/shape (pitting of the nails, curving in on the sides, nail becomes thickened at the center)

• Brittleness (crumbling)

As the infection progresses, more severe signs and symptoms may start manifesting, such as:

• Unpleasant/foul odor

• Chipping off

• Loss of nails

• Decayed / diseased nails

Nail Fungus Classification

There are five major types of nail fungus infection:

• Distal Subungual Onychomycosis (DSO): the most common type of fungal nail infection, and usually caused by trichophyton rubrum, a dermatophytic fungus. DSO starts on the end of the nail bed and the underside of the nail plate.

• White Superficial Onychomycosis (WSO): most commonly caused by Trichophyton mentagrophyte, another type of dermatophytic fungus. It occurs on the uppermost layer of the nail plate and usually affects the toenails.

• Proximal Subungual Onychomycosis (PSO): also caused by dermatophytes, it occurs on the proximal nail fold (skin at the nail fold) and may penetrate the nail plate. PSO may affect the fingernails and toenails in equal frequency.

• Candida Onychomycosis (yeast infection of the nail): this condition is less common and may also affect the skin around the nail. It occurs more frequently on the fingernails than the toenails and may invade nails weakened by previous infection or trauma.

• Total Dystrophic Onychomycosis: refers to the complete destruction of the nail plate and may be the end result of any of the four types of nail fungus infection above.

Test and Diagnosis of Nail Fungus

In order to ensure that your nail abnormalities are caused by fungal infections and not by other conditions that share symptoms with onychomycosis, a doctor’s diagnosis is required. This is vital in making sure that the recommended treatment will be effective for that specific case of onychomycosis.

These are the steps undertaken to properly diagnose and confirm the presence and type of nail fungus infection:

• Nail Clinical Examination: doctors conduct careful physical examination of your infected nails and surrounding skin, as well as an interview about the symptoms you’re experiencing and your medical history. These are beneficial in differentiating fungal from non fungal causes of your nail abnormalities.

• Collecting Nail Specimen: the sample collection process begins with thorough cleansing of the infected nail area and surrounding skin with 70% alcohol to eliminate other contaminants. Obtaining optimal nail specimens depends on the presumptive diagnosis and site of the infection.

• Laboratory Test: after collecting infected nail samples and skin scrapings, specimen analysis (includes direct microscopy and laboratory culture) and antifungal susceptibility tests are conducted. Microscopy, staining, and culturing procedures may take up to six weeks before results can be received.

Treatment of Finger and Toenail Fungus

A personalized treatment plan that factors in a patient’s profile, symptoms, infection type, drug toxicities and interactions is shown to result to improved success rates. Other things that need to be considered are the severity of the nail fungus, as well as the existing physical condition of the patient, specifically if the individual is pregnant or breastfeeding, diabetic, has liver issues, or a child.

The types of treatments currently available are:

Over The Counter (OTC) Topical Treatments

Over the counter/non-prescription topical solutions may be used for the treatment of mild nail fungus infection.

They are generally safe to use with minimal contraindications, so you can use two or more remedies together. They are relatively inexpensive, but may take several months to fully take effect.

Common ingredients used in non-prescription topical agents are:

• Undecylenic acid

• Tea tree oil (melaleuca alternufolia)

• Sunflower seed oil (ozonized)

• Snakeroot extract (ageratina pichinchensis)

• Coconut oil

• Lavender oil

• Garlic

• Tolnaftate

These top over-the-counter antifungal topical solution brands for the treatment of nail fungus infection already contain one or more of the above ingredients:

• EmoniNail

• Funginix (Fungisil)
• ZetaClear
• Naturasil (formerly Dermisil)
• Pedifix Fungasoap (Tea Tree Ultimates Fungasoap)
• OPI Fungus Fix
• Omega Labs Fungus Treatment
• Fungi-Nail Brand
• Excilor

RX/Prescription Medication

Prescription topical antifungal medications are also available for the treatment of nail fungus. Treatment with topical agents alone are generally shown to be insufficient due to the lack of penetration through the nail bed.

The most widely-used prescription topical solutions currently available in the market are:

• Tavaborole (Brand Name: Kerydin)

• Efinaconazole (Brand Name: Jublia)

• Ciclopirox (Brand Name: Penlac)

Oral antifungal medications may be used for the treatment of moderate to severe nail fungus infection. Oral medications under the azoles and allylamines drug classes are most commonly prescribed.

Clinical studies show that the combination of oral and topical antifungal therapies is more effective, compared to treatments using a single approach.

Top oral antifungal agents for the treatment of nail fungus infection are:

• Griseofulvin (Brand names: Fulcin, Grisovin, Grisactin, Gris-PEG)

• Terbinafine (Brand name: Lamisil)

• Itraconazole (Brand name: Sporonox)

• Fluconazole (Brand name: Diflucan)

Nail Removal

Though rarely necessary, your podiatrist, dermatologist, or general surgeon may suggest nail avulsion or removal for severe or recurrent nail fungus infection — especially when a large portion of the nail is diseased, the nail is extensively thickened or the condition is painful. Nail removal is an outpatient procedure done in your doctor’s clinic or office.

The procedure must be accompanied by topical or oral antifungal therapy to kill the fungi and other organisms. Otherwise, the infection can affect the new nail that grows.

Nail avulsion can be done chemically or surgically (distal avulsion and proximal avulsion); it can be partial (only damaged portion of the nail) or total (whole nail), depending on the extent of the infection.

After the nail removal procedure, your doctor might prescribe matricectomy to prevent an infected or disfigured nail from growing back. Matricectomy involves destroying the nail matrix to permanently prevent a new nail plate from growing back.

Matricectomy can be partial or total; It can be achieved chemically, surgically, or electrically.

Laser Treatment

Some experts see laser as the answer to the challenges of penetrating the hard surface of the nail plate using topical antifungal agents, the potential serious adverse effects of oral antifungal therapy, as well as the pain and risks associated with nail removal.  

Lasers utilize light energy with the right strength and wavelength to target infected tissues. High doses of light energy can penetrate into the specified area and destroy the fungus and other harmful organisms.

The current top FDA-cleared brands of laser machines for the treatment of nail fungus infection are:

• Pinpointe FootLaser
• Noveon laser by Nomir Medical Technologies
• Erchonia Lunula Laser
• Hyperion HyperBlue 1530 Laser
• Cutera GenesisPlus Laser

Home Remedies

For individuals who want to treat their condition without the use of harsh chemicals and ingredients that may lead to adverse side effects, there are several home remedies that might do the trick.

These options might work best on mild nail fungus infection or one that is on its early stages. Home remedies are rarely studied in clinical trials, so scientific research to measure their efficacy are usually not available.

Some people swear by these home remedies for the treatment of nail fungus infection:

• Vicks VapoRub

• Bleach

• Vinegar

• Mouthwash

• Hydrogen Peroxide

Complications of Nail Fungus If Left Untreated

The longer you wait before treating your condition, the harder it will be to heal successfully. Ignoring a nail fungus infection can lead to serious consequences as the fungus progresses and may cause negative, and even deadly, symptoms beyond the aesthetics:

• Deformed nails/ Destruction of nail

• Spread of infection to other nails

• Spread of fungus around the body

• Paronychia

• Cellulitis

Nail Fungus Prevention

Given the stubborn nature of nail fungus infection, it is best to take a proactive approach to minimize the chance of its occurrence.

Food and Supplements. An antifungal diet gets rid of food ingredients that fungal parasites can feed on and, in the process, reduces inflammation inside the body. Eliminating these food items means starving the parasites and can lead to their death: sugar, conventional grain products, some dairy products, processed oil, processed and cured food products, sweet fruits high in fructose,  alcohol, caffeine, carbonated drinks, and junk food.

To strengthen your immune system versus infections, consume more of the following: high-fiber food, probiotics, high quality protein, good fats, antibacterial and antifungal food ingredients.

Lifestyle and Environment. Good hygiene is key to preventing nail fungus infection, so it is important to always keep your feet and hands clean and dry.

Here are some other simple practices you can adapt to minimize the risk of contracting nail fungus infection:

• Trim your nails correctly and keep them short

• Clean and dry them properly

• Wear clean, moisture-wicking socks

• Invest in the right footwear

• Sprinkle antifungal foot powder

• Do not walk barefoot around warm and moist public areas

• Disinfect regularly

• Avoid skin-to-skin contact with people with any kind of skin or nail fungal infection

• Do not smoke

Preventing Reinfection. Apart from the tips given above, you can add the following practices to avoid reinfection:

• Use the medications (oral or topical) completely and correctly

• Watch out for the early signs of the infection

• Replace all footwear that have come into contact with the fungus

• Soak your hands and feet in an antifungal bath regularly

Implement proper nail care routines and hygienic practices at home, instead of having your nails done in salons. Know the right manicure and pedicure procedures, invest and sanitize your essential nail tools, and use nail polish correctly.

Frequently Asked Questions on Nail Fungus

A. Are fingernail fungus just as common as toenail fungus?

No, nail fungus infections occur mainly on the toenails and less frequently on the fingernails.

B. I’ve been treating my nail fungus for months but haven’t found cure. Is my treatment really working?

Treating a stubborn nail fungus infection requires a lot of time and patience. Oral antifungal agents are commonly taken for six weeks for fingernail fungus infection, and three months for toenail infection. Topical solutions may need to be consistently applied for up to one year.

Your treatment duration and the length of time it takes for your nail fungus infection to clear up depend on the severity of your condition. Also, you might not be able to see the end result until a healthy new nail grows in place of the diseased one.

C. Can I still get nail fungus even if I wear nail polishes often?

Nail polish is not protection against nail fungus infection. On the contrary, it might even make you more susceptible to contracting the condition.

Covering your nails with colored polish will create a dark environment that is a perfect breeding ground for fungus to grow.

D. Can you use topical treatment and nail polish?

This is not advisable, as the nail polish may inhibit the solution’s ability to penetrate through the nail plate and render the treatment ineffective.

Best Resources on Nail Fungus

Based on our intensive research, these are the most helpful online resources on the condition:

Mayo Clinic

Mayo Clinic provides comprehensive information about nail fungus broken down into several sections, making it easy for readers to head straight to the specific answer they are looking for

WebMD

The topic overview on fungal nail infection provides all the basic information you need in one page. Links to slideshows and pictures are also included in the main article, in case you need more details about a specific aspect.

NHS Choices

NHS Choices covers the overview, symptoms, causes, treatments, and prevention of fungal nail infection in one long page. They provide jump links to each section for easier browsing. They also have a separate, more detailed take on the treatment options.

Wikipedia

Wikipedia packs a lot of information in their onychomycosis page. Subpoints are broken down into: signs and symptoms, causes, diagnosis, treatment, prognosis, epidemiology, and research.

Global Nail Fungus Organization

As the Global Nail Fungus Organization site is solely dedicated to nail fungus infection, it is indeed a rich resource for everything you need and want to know about the condition.

The medication comparison page is remarkably useful as it summarizes the brand names, costs, cure rates, benefits and side effects of available treatments. Detailed reviews are also available for the top over-the-counter topical treatments.

Nail Fungus in the Press

Currently, laser treatment options for nail fungus infection are being studied by doctors everywhere. Initial findings show promising results, with minimal side effects. However, laser therapies are costly and are usually not covered by health insurance.

Here, Dr. Jeff Lamour talks about the toenail fungus laser removal available in Austin, Texas now.

https://youtu.be/iYOEr938cVs