A nail fungal infection, which is known medically as onychomycosis (on-i-ko-mi-KO-sis), seems to arrive unannounced. At first you may only notice a small white or yellow spot on your nail. Then, months later, your whole nail may be consumed by the fungi. Soon, the nail may turn yellow, gray, black, or brown. As the infection advances, the nail becomes brittle and can crack, sometimes breaking away totally from the nail bed.
Such infections are quite common, affecting between 10 to 12 million Americans of all ages, genders, and races. They primarily affect toenails, but sometimes fingernails, though rarely both at the same time. In most cases the infections are a nuisance that may cause embarrassment over the unsightly nails. In a few cases the infection is severe enough that walking can be difficult.
Symptoms of Toenail Fungus
- Dry, thickened, or discolored nail that turns white or yellow
- Scaliness on the skin surrounding the nail
- Pain while standing, walking, or running, which may be accompanied by blistering or swelling around the nail.
- Nail that has detached from the nail bed (rare)
What Causes Toenail Fungus?
Fungal molds called dermatophytes are the cause of fungal nail infections. (Other types of dermatophytes are responsible for athlete’s foot and jock itch.) But how nail infections are transmitted isn’t well understood. They are more common in people who have infections of the skin adjoining the nail. While warm, moist environments such as gym locker rooms or shower stalls can encourage the spread of skin infections, it isn’t evident that these lead to nail infections.
Trauma to the nail appears to be a factor. Regular distance runners who inadvertently bump their toenails against the running shoe toe box on downhill runs—thereby damaging the nail in the process—are prone to the infection. In addition, people who remain on their feet for long periods of time while wearing tight-fitting shoes, such as waiters, policemen, and construction workers, are also more inclined to develop the ailment. And people with compromised immune systems—from HIV infection and chemotherapy—may be more susceptible.
Nail infections also tend to occur more frequently with increasing age.
What If You Do Nothing?
Fungal nail infections are generally harmless, so treatment isn't necessary unless you are bothered by pain or upset by the appearance of the nails. Because prescription medications can be expensive and may have side effects, many people choose to live with the condition.
Home Remedies for Toenail Fungus
Over-the counter antifungal medications do not work (the Food and Drug Administration no longer allows them to claim effectiveness), and topical home remedies—which include tea tree oil, vinegar, Campho-Phenique (containing camphor and phenol), saline solution, and chlorine bleach—haven’t been shown to work. Bleach can actually be harmful.
The best way to successfully treat a fungal nail infection is with prescription medications. The preventive suggestions that follow may help keep you from developing the infection in the first place.
- Keep your nails clipped. Cut the nails straight and make sure they do not extend beyond the tips of your toes (or your fingers). (If you have one or more infected nails, use a separate pair of clippers for infected nails and another for healthy nails. If you have diabetes, consult your physician before cutting your toenails.)
- Disinfect. After each use, disinfect any manicure and pedicure tools by wiping them with cotton balls saturated with alcohol. Let them air dry for 60 to 90 minutes before using them again.
- Be careful at the nail salon. Make sure the salon has an autoclave (a special heating device for disinfecting instruments) and that it is used after each treatment.
- Keep clean and dry. Wash your hands and feet daily with soap and water and dry them well. Be sure to dry between your toes.
- Use an antifungal foot powder. Avoid cornstarch because it encourages fungal growth.
- Make sure your footwear breathes. Choose leather shoes with plenty of toe room. Have more than one pair and alternate your shoes to make sure they air out at least 24 hours before they are worn again. Also, avoid socks made from nylon or polyester because they don’t absorb perspiration as well as cotton or wool. In warm weather, wearing sandals may help prevent infections.
Beyond Home Remedies: When To Call Your Doctor
Contact your physician if the infection is painful and makes it difficult for you to stand or walk, or if you want to improve the appearance of your nails through treatment.
If you have diabetes, talk to your doctor before trying any kind of foot treatment.
What Your Doctor Will Do
Your doctor will take scrapings from under the nail to discover what type of infection is present. Once the condition is diagnosed, your doctor may prescribe one of the newer oral antifungal medication agents, itraconazole (Sporanox) or terbinafine (Lamisil). Cure rates range from 25 to 80 percent. These drugs occasionally cause skin rash, headache, and gastrointestinal symptoms, but side effects are less likely to occur than they do with earlier oral drugs. The new drugs may interact with other medications, such as some antihistamines and cholesterol-lowering “statin” drugs—so make sure your doctor is aware of any other medications you are taking.
Treatment is not cheap, but it has become less expensive. The usual three- to four-month course costs several hundred dollars, plus the price of blood tests to monitor for liver disease (a very rare complication). But new "pulsed" dosing for itraconazole—you take it daily for one week, then stop for three weeks—reduces the cost by up to 75 percent. (Even with treatment, however, there is a high rate of recurrence—50 percent or more.)
Another option is an FDA-approved topical medication, ciclopirox, sold under the name Penlac Nail Lacquer. You apply it daily to the affected nail and adjacent skin for up to 48 weeks and trim the nail weekly. It may cause skin irritation, but is otherwise safe; it costs less than the oral drugs.
In rare cases, if the infection is extremely painful, your physician may recommend removing the nail (though this alone will not resolve the infection).
The Complete Home Wellness Handbook
John Edward Swartzberg, M.D., F.A.C.P., Sheldon Margen, M.D., and the editors of the UC Berkeley Wellness Letter
Updated by Remedy Health Media