Discolored, thick, yellow, unsightly and painful toenails are one of the most common foot complaints. The most common cause of these changes to the toenails is an infection of the toenails by a fungus. The most common fungus is called trychophyton ruburm and it is the cause of athlete’s feet as well as “ringworm” and “jock itch”. Simply put, this fungus targets skin and thrives in a damp and dark environment. When t. rubrum, as it is known, infects the skin, treatments are often simple: apply an appropriate anti-fungal skin cream and eradicate the fungus organism.

When t. rubrum infects the toenails, however, killing the fungus organism and restoring the nails to their former appearance is difficult and in some cases impossible. The toenails as well as the fingernails are complex. The nails grow from what is called the nail matrix which is located under the fold of skin at the base of the nails. The nail matrix extends along the entire base of the nail and is several millimeters thick. It can be mechanically damaged by stubbing the toe or dropping a heavy object on the toenail. It can be infected by irritating the cuticle which protects the nail matrix. Pushing back, lifting or cutting the cuticle during a pedicure and manicure can allow fungus organisms to infect the nail.

A nail fungus will affect the appearance of the nail as the fungus organisms create a thick mat under the nail on the nail bed. Indeed, the root of the fungus infection often is found in the nail matrix. This explains why many topical treatments are ineffective or only minimally effective, although a topical solution called Jublia may be helpful for some cases of mild  onychomycosis.

The most effective treatment continues to be oral medication which can kill the fungus organisms within the skin around the nail,  the matrix or nail root and in the nail bed where the fungus lives.

I prescribe one of two oral medications. In most cases I prescribe Lamisil tablets (terbinafine) to be taken in a pulsed-dose regimen. I instruct patients to take one pill a day for seven days and then repeat that regimen every three months over the course of one year. I will debride, or, mechanically remove, the fungal nail material as the new  healthy nail grows. In some cases I will prescribe Diflucan (fluconazole) to be taken once a week for 12 weeks at a time and repeated up to two more times. In either case, I test a sample of the nail first to verify that the nail is in fact infected with a fungus and I screen some blood tests before initiating this treatment as well. With the pulsed dosing method of using  Lamisil I have not had one patient experience any complications.

My success rate using the above methods has been good with almost all patients treated seeing a noted improvement in the appearance of their nails.

Please understand, however, that the nail matrix or nail bed may have sustained permanent damage and even after treatment the new nail will not return to its former uninfected appearance. In addition, the nail or nails may be permanently damaged from other causes such as psoriasis or other skin conditions.

A number of podiatrists adverise laser treatments for nail fungus. I am well aware of these treatments. To date there is not substantial evidence to justify the expense of the treatment. In fact some podiatrists are charging patients upwards of $1000. And, even if the laser treatment does work, the new nail that grows may still not resemble the appearance of the former healthy nail.  And even a laser treatment can not guarantee that the nails will not become re-infected and need another treatment. If this treatment becomes validated in controlled studies I will consider incorporating it into my practice. But, the treatment would have to be affordable.

I have a thorough discussion with my patients about all available options. I am not against topical treatments that are frequently discussed such as the use of tea tree oil if patients want to try them. Many of those treatments have favorable anecdotal reports but not controlled studies supporting them. Interestingly, an article recently appeared in a Family Practice medical journal touting the effectiveness of Vicks Vapor Rub!

For more information, read this article from the Wall Street Journal about laser treatments for nail fungus.