Staying one step ahead of toenail fungus

An established fungal infection is hard to eradicate, but you can stop its spread and improve your toenail's appearance.

Toenail fungus isn't a pressing health problem. Yet a fungal infection can ruin the appearance of your nails and cause pain as it lifts the nail away from the nail bed. And fungal infections are notoriously difficult to get rid of. "You may want to consider fungal toenail a condition to be managed rather than cured," says Dr. James P. Ioli, chief of the podiatry service at Harvard-affiliated Brigham and Women's Hospital.

How fungi infect the nail

Onchomycosis, or toenail fungal infection, is an invasion by a microscopic organism that thrives in warm, damp environments. Fungal spores are in the air, and they will grow if they land on a receptive surface like your toenail. They feed off the nail tissues, burrowing into the skin under the nail. Over time the nail thickens and may lift off the nail bed as fungal debris accumulates. Once your nail is raised off the nail bed, it won't reattach, and a new nail won't grow from that part of the nail bed. However, your nail will continue to grow from the root at the base.

Diagnosing toenail fungus

A number of conditions can masquerade as fungal infections. Age alone thickens and yellows the nail. Psoriasis can cause the nail and the surrounding skin to flake. Injuries can create bruising under the nail. Even the chemicals in nail polish can discolor the nail. "But you don't want to wait until your toenail is gnarly and raised off the nail bed," says Dr. Ioli. You should see a podiatrist as soon as you notice your nail changing, he advises.

Only a lab test on a scraping from your toenail can show for certain that fungus is responsible for your nail distortion. Misdiagnosing toenail fungus can cost you time and money trying over-the-counter products that won't have an effect.

Toenail fungus treatments

There are a myriad of treatments for fungal infections, which vary widely in cost and effectiveness. To be fully effective, the antifungal drug has to penetrate the nail and often the nail bed as well.

Over-the-counter products. Antifungal preparations that are applied on and under the nail with the same type of brush used for polish are widely available. They don't promise a cure but instead suggest that they can improve the appearance of fungal nails. There is no evidence that any one is particularly effective. "These are usually a waste of time and money," Dr. Ioli says.

Prescription topical treatments.  Effective products include efinaconazole (Jublia), tavaborole (Kerydin) and ciclopirox (Penlac). All require daily applications, and it may take as long as a year to see noticeable improvement. These products may work for early, superficial fungal infections because they kill fungi on the surface of the nail. Filing down the surface of the nail may enable them to penetrate more deeply into the nail or the nail bed. In studies, their cure rate averaged around 35%.

Oral medications. Itraconazole (Sporanox) and terbinafine (Lamisil) eliminated the fungus in 10 months for 55% to 70% of people in the studies required for FDA approval, but for 15% to 20% of users, the fungus returned within a few months. Either of these drugs can harm the liver, so your doctor will check your liver function at the beginning of treatment and again after six weeks. Itraconazole also interacts with a number of other drugs. If you take one of these drugs you'll also need to avoid drinking alcohol and stay out of the sun. "If you have diabetes, vasculitis, or another condition that could be worsened by fungus, these medications might be a good choice, but otherwise, the benefits may not be worth the risks," Dr. Ioli says.

Have realistic expectations

Don't expect any product to give you toenails like those in the advertisements. However, if you adopt a daily routine of washing and drying your feet thoroughly, filing down your nails if needed, and applying a topical antifungal remedy, you should see a distinct improvement.