The toes of summer
by David Dunaief
Aug 12, 2020 | 2505 views | 0 0 comments | 236 236 recommendations | email to a friend | print
Dr. David Dunaief is located in Downtown Brooklyn and focuses on the integration of medicine, nutrition, fitness and stress management.
Dr. David Dunaief is located in Downtown Brooklyn and focuses on the integration of medicine, nutrition, fitness and stress management.

As we begin venturing into summer public spaces, we are also beginning to expose our toes at the beach and in sandals. Some are more self-conscious about it because of onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails but can also affect fingernails. It turns nails yellow, can make them brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including nail pain and increased potential risk for infections like cellulitis in those with compromised immune systems.

Different organisms can affect the nail. The most common class is dermatophytes, but others are yeast and nondermatophytes. Some medications work better on one type than another. Also, yellow nails can be a sign of psoriasis, instead.

Onychomycosis is not easy to treat. The risk factors are unclear but may relate to family history, athlete’s foot, older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected.

The bad news is that no treatments are foolproof, and the highest “cure” rate is around two-thirds. Treatments can take from around three months to one year, and the recurrence rate of fungal infection is approximately 20 to 50 percent with patients who have been “cured.”

Oral treatments

Oral antifungal options include Lamisil, Diflucan and itraconazole. These tend to have the greatest success rate, but they have side effects.

In a small, randomized controlled trial (RCT), terbinafine was shown to work better in a head-to-head trial than fluconazole. Of those treated, 67 percent of patients experienced toenail fungus clearing with terbinafine, compared to 21 and 32 percent with fluconazole, depending on duration.

Patients in the terbinafine group were treated with 250 mg of the drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of the drug for either 12 or 24 weeks, with the 24-week group experiencing better results.

The disadvantage of terbinafine is the low risk of liver damage and failure. Liver enzymes need to be checked regularly during treatment.

Topical options

A common topical medication is ciclopirox. The advantage of this lacquer is that potential side effects are minor. However, it takes approximately a year of daily use, and its efficacy is lower than oral antifungals.

In two RCTs, ciclopirox showed a seven percent “cure” rate in patients, compared to 0.4 percent in the placebo groups. In one trial, ciclopirox had to be applied daily for 48 weeks in patients with mild to moderate levels of fungus.

Laser therapy

Unfortunately, there are very few trials showing significant benefit with this relatively expensive approach. However, side effects are mild. A study with one type of laser treatment did not show a significant difference after five sessions.

In a small study of 56 patients comparing laser only with laser plus topical antifungals, the best complete “cure” rates were achieved with the combination therapy, 21 percent versus 11 percent with laser only.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or five of the patients experienced complete “cure” of their nail fungus. Partial improvement occurred in 10 patients’ toenails when the gel was applied daily for 48 weeks.

No treatments are perfect. Oral medications tend to be the most effective, but also have the most side effects. If treating for medical reasons, such as diabetes, then oral may be the best option.

If you decide on this approach, discuss it with your doctor and comply with regular precautionary tests, such as liver enzyme monitoring. However, if treating for cosmetic reasons, then topical medications or alternative approaches may be a better choice.

No matter what, have patience. The process may take a while; nails, especially in toes, grow very slowly.
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