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Medical Author:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Medications

In the past, medicines used to treat onychomycosis (OM) were not very effective. OM is difficult to treat because nails grow slowly and receive very little blood supply. However, recent advances in treatment options, including oral (taken by mouth) and topical (applied on the skin or nail surface) medications, have been made. Newer oral medicines have revolutionized treatment of onychomycosis. However, the rate of recurrence is high, even with newer medicines. Treatment is expensive, has certain risks, and recurrence is possible.

• Topical antifungals are medicines applied to the skin and nail area that kill fungi and some other pathogens.
• These topical agents should only be used if less than half the nail is involved or if the person with onychomycosis cannot take the oral medicines. Medicines include amorolfine (approved for use outside the United States), ciclopirox olamine (Penlac, which is applied like nail polish), sodium pyrithione, bifonazole/urea (available outside the United States), propylene glycol-urea-lactic acid, imidazoles, such as ketoconazole (Nizoral Cream), and allylamines, such as terbinafine (Lamisil Cream).
• Topical treatments are limited because they cannot penetrate the nail deeply enough, so they are generally unable to cure onychomycosis. Topical medicines may be useful as additional therapy in combination with oral medicines. This results in treatment medicine concentrations that come from two directions, topically and from within the body via oral medicine.
• Newer oral medicines are available. These antifungal medicines are more effective because they go through the body to penetrate the nail plate within days of starting therapy.
• Newer oral antifungal drugs terbinafine (Lamisil Tablets) and itraconazole (Sporanox Capsules) have replaced older therapies, such as griseofulvin, in the treatment of onychomycosis. They offer shorter treatment periods (oral antifungal medications usually are administered over a three-month period), higher cure rates, and fewer side effects. These medications are fairly safe, with few contraindications (conditions that make taking the medicine inadvisable), but they should not be taken by patients with liver disease or heart failure. Before prescribing one of these medications, doctors often order a blood test to make sure the liver is functioning properly. Common side effects include nausea and stomach pain.
• Fluconazole (Diflucan) is not approved by the Food and Drug Administration (FDA) for treatment of onychomycosis, but it may be used by some clinicians as an alternative to itraconazole and terbinafine.
• To decrease the side effects and duration of oral therapy, topical and surgical treatments (see below) may be combined with oral antifungal management.

Surgery

Surgical approaches to onychomycosis treatment include surgically or chemically removing the nail (nail avulsion or matrixectomy).

• Thick nails may be chemically removed by using a urea compound. This technique usually should be deferred to a surgeon or dermatologist.
• Surgically removing the nail plate (fingernail or toenail) is not effective treatment of onychomycosis without additional therapy. This procedure should be considered an adjunctive (additional) treatment combined with oral medical therapy.
• A combination of oral, topical, and surgical therapy may increase the effectiveness of treatment and reduce the cost of ongoing treatments.

Laser Treatment

One of the newest treatments to kill pathogens infecting the nails is laser therapy. The laser beam can penetrate the nail tissue and disrupt fungal and other pathogens enough to kill them. Some patients may experience some mild discomfort during the procedure. Reports suggest that laser therapy is about as effective as medical therapy. Some patients may require more than one treatment. This treatment can be very expensive.

Alternative Treatments

There are many claims made that home remedies can be used to treat a fungal nail infection. Products such as Listerine, VapoRub, beer soaks, peroxide, and others are purported to be effective. Unfortunately, there is little or no data to support these claims; some of the commercially available products do not promote their use for nail infections although some individuals may use them for alternative treatments.

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