Here’s How You Should Treat Toenail Fungus, According to a Podiatrist

Toenail fungus treatments include the simple, the weird and wacky, and the high tech. See what a podiatrist recommends.

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What is toenail fungus?

Toenail fungus (onychomycosis) is caused by a group of fungi known as dermophytes. This group thrives on skin and on keratin, the main component of hair and nails. The fungus gets under the nail and begins to grow, damaging the nail so it discolors, becoming white, brown or yellow. Eventually, the nail might thicken, harden, become brittle and even fall off.

According to the American Podiatrist Medical Association, nail fungus is easy to pick it up from showers, locker rooms, and swimming pools, because fungi thrive in the damp, humid conditions. People with underlying health conditions like diabetes, circulatory issues, or immune-deficiency conditions are especially vulnerable.

This condition can be very difficult to cure. Toenail fungus treatment often lasts for several weeks or months, but podiatrists have a clear strategy for treatment.

Take a full medical history

The first step is to take a history of the problem,” said Mark Hinkes, DPM, CEO of HappyFeet LLC, and a podiatrist with 40 years experience. “In other words, I want to know how long have you had this and what previous treatment you’ve had.” A podiatrist needs to understand the extent of the problem, and also any other medical factors which may influence their choice of treatment.

A full medical history is also important because the first line of defense is usually oral medication, but this treatment can have side effects for people with underlying health issues. Make sure you reveal everything—here are 14 things to never lie to your doctor about.

Physical exam

Once he’s got a medical history, Dr. Hinkes moves on to a physical exam.

“A physical exam determines the quality,” he explained. “What does it look like? Is it thick? Does it smell? What color is it? Is it flaky? Is it on the tip of the nail? Is it at the base of the nail? And what color is it? Is it white? Is it superficial? Is it yellow, green black?”

Here are 10 subtle signs of disease that your feet can reveal.

Lab analysis

“We really cannot make a diagnosis by looking at the toenail,” Dr. Hinkes said. “It’s difficult to know whether it’s an infection of fungus, mold, or yeast. You must harvest a sample of the nail and send it to pathology.”

That’s the only way to ascertain exactly what the problem is so the podiatrist can prescribe the best course of action. Once the exact cause of the problem is identified, the podiatrist can then move on to giving precise treatment.

“We really cannot make a diagnosis by looking at the toenail,” Dr. Hinkes said. “It’s difficult to know whether it’s an infection of fungus, mould or yeast. You must harvest a sample of the nail and send it to pathology.” That’s the only way to ascertain exactly what the problem is so the podiatrist can prescribe the best treatment.

Oral treatments

Oral anti-fungal treatments such as Lamisil (terbinafine), Diflucan (fluconazole) or Sporanox (itraconazole) are an effective alternative and take around three months to work.

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However, they can have unpleasant side effects, including stomach upset, dizziness, skin problems, and liver damage leading to jaundice. This is why taking a full medical history is essential. Here’s some advice from doctors and nurses on coming clean.

“The medications we use to treat this are expensive and they are not benign,” cautioned Dr. Hinkes. “Lamisil is so powerful it stays in your body six months after you stop using it, and that’s one of the reasons why it works so well. So when we use these medicines, we have to be conscious that we may be affecting a person’s liver, because the liver is the organ that helps to detoxify the body and excretes that medicine.”

People with liver problems or raised liver function can’t tolerate oral medication, and some patients don’t respond to oral medication, so topical treatments are an alternative.

Topical treatments

Topical treatments are applied directly to the infected nail but may take a long time to work. For example, the relatively new treatment Kerydin can take up to 12 months to clear the condition. But they’re much more suitable for those with liver problems or who’ve not responded to oral treatments.

“Not every medicine works great for every person,” Dr. Hinkes stated. “If someone was treated with the oral medicine and it didn’t have a success, there’s an alternative. We have good topical medicines that work great.”

Laser treatment

Laser treatment for this condition is a relatively new approach, but one offered by many podiatrists as it’s non-invasive and works quite quickly. The laser can attack the fungus beneath the nail, killing it off without damaging the nail itself.

Many podiatrists now consider this an effective treatment, but because it’s new, there’s not enough concrete data to compare with other treatments. Dr. Hinkes raises another concern: “A clinical cure and a mycological cure are two different things. With the clinical cure, you look at the nail and it looks fine. It’s pink and shiny and smooth and it looks great. But if you sample the nail, you might find that there’s mold or fungus there, so it does not have what we call a mycological cure—mycology is the study of fungi.

“What I’m led to believe,” he continued, “is that the laser treatment will give you a good clinical cure, but not mycological cure. So in other words, there may still be fungus, mold, or yeast on the nail at the end of the treatment.” This makes it more likely that the infection will return.

Surgical treatments

Modern treatments made surgery a last resort. “Before we had these 21st century medications, we didn’t have a good choice in how to deal with toenail fungus,” said Dr. Hinkes. “Oftentimes patients would come in, and out of frustration and lack of any real significant clinical cure with medication, they would ask for their nails to be permanently removed.”

Sometimes the whole nail can be removed and a healthy nail can grow in its place. But if the infection has got into the nail matrix, where the new nail is formed, the new nail will also be infected. In cases like this, it may be necessary to remove the matrix. This can be done with chemicals such as phenol or sodium hydroxide.

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“Application of those chemicals would destroy the matrix cells,” explained Dr. Hinkes, “So that after the patient recovered from the trauma of the surgery no toenail would grow there.

“The other method,” he went on, “which is also very frequently used, is to surgically, sharply, cut out the matrix cells. And when that happens, you get a couple of stitches to the base of the area and that’s the end of it.”

Home remedies

Since the treatment for this condition doesn’t always work and can cause side effects, many people look to home remedies as a first step.

Essential oils and ozonized oils

Several essential oils have been shown to be effective against nail fungus.

“Research by our group and others has shown that essential oils may be cheap, efficient alternatives that have minimal side effects,” Professor Lígia Salgueiro and Professor Eugénia Pinto (University of Coimbra, Portugal) told Science Daily. Lavender oil “shows wide-spectrum anti-fungal activity and is highly potent.”

Tea tree oil also has anti-fungal and antiseptic properties. The National Center for Complementary and Integrative Health cites some small-scale clinical studies suggesting that tea tree oil might be an effective home remedy. (Essential oils can also combat foot odor.)

Oils such as olive oil and sunflower oil contain ozone gas. A 2011 study published in the Brazilian Journal of Microbiology, showed that small doses of this kind of ozone, applied over a short period, can eliminate fungus. A different study, conducted at the National Center for Scientific Research, Cuba, found that sunflower oil was more effective than the prescription drug Xolegel (ketoconazole).

Plant extracts

Olive leaf extract contains oleuropein, which is known to have anti-fungal properties. You can apply olive leaf extract as a topical treatment, or take it in the form of capsules. A review published in The Pharma Journal showed that the supplement was more effective than a topical treatment.

Snake root extract comes from a plant in the sunflower family. A 2008 study conducted by the Centro de Investigación Biomédica del Sur and published in Planta Med, found that applying the extract to the affected nail over three months was more effective than treatment with the prescription anti-fungal Penlac (ciclopirox). Like natural remedies? Here are some more options.

Nail polish

In a recent study published in the Journal of Industrial & Engineering Chemical Research, researchers added silver nanoparticles to store-bought clear nail polish. They found that it was effective at tackling toenail fungus.

Weird and wacky

Most people have heard of using Vicks VapoRub for a cold, but the camphor and eucalyptus oil in the rub are also effective anti-fungals. A 2011 study published in the Journal of the American Board of Family Medicine showed that applying Vicks VapoRub regularly could be effective in getting rid of nail fungus.

Another popular home treatment is to use Listerine mouthwash on its own or mixed with an equal amount of white vinegar. Mouthwash happens to have many surprising alternative uses.

The podiatrist’s take on home remedies

While home remedies are unlikely to cause any harm in themselves, Dr. Hinkes urges caution when using them.

“Resorting to folk remedies can be dangerous because it could keep the patient from getting a legitimate diagnosis and treatment. Now in some people, this could be a critical thing, because it can be contagious—you can pass it to other people and you can pass it to other parts of your body. So it’s really not something you want to fool with.”

Dr. Hinkes’ advice is clear: “I would suggest a visit to a foot care specialist.” This could be a podiatrist, but foot care nurses also offer an excellent and affordable service as an alternative. And if neither of those is available, try a dermatologist.

Left untreated, this condition won’t go away on its own and can cause serious pain, deformity and even lead to further complications. Podiatrists recommend seeking expert help—you’re better safe than sorry.

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