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Fretting About Foot Fungus: Tips for Toenail Treatment
By Christine Dobrowolski, DPM

The medical term for toenail fungus is "onychomycosis," pronounced on * EE * ko * my * ko * sis, and represents both the fungal and yeast elements that can affect the toenail. Six to nine million Americans are affected with toenail fungus and athletes tend to be affected at a higher rate. In a recent study of NBA and WNBA players, 89% of players had onychomycosis at some time during their career. It is of no surprise that athletes are more susceptible to developing toenail fungus. The combination of a closed-in shoe and increased warmth and moisture from sweating create a perfect environment for fungus to grow.

There are a number of treatments for onychomycosis. The most aggressive and effective treatments are with oral anti-fungal medications. The most common oral anti-fungal medications are Itraconazole (Sporonox ®) and Terbinafine (Lamisil ®). Both medications are taken once daily for 3 months, although they continue working for up to 9 months. The effectiveness of the medications ranges from 60 to 80%, with a recurrence rate of 15%. Lamisil® appears to be more effective and has fewer drug interactions than Sporonox®, but both medications are equally expensive. With both medications there is a long list of benign side effects including nausea, vomiting, abdominal pain, diarrhea, rash, headache, taste disturbances and dizziness. Serious adverse effects are very rare, less than 0.5%, but do include hepatitis and acute hepatic necrosis.

Luckily, there are many other options besides oral anti-fungal medications. Unfortunately, they are not very effective. The most effective topical medication is Ciclopirox (Penlac ®) lacquer. Some studies have shown cure rates up to 60%, but in my experience the effectiveness is about 10-15%. Side effects occur in less than 2% of patients and include burning and redness around the nail. This medication is only available by prescription and is also expensive. Another prescription topical is a urea based medication called Carmol® 40. This medication helps to decrease thickness of fungal nails.

Home remedies that can be used include bleach, tea tree oil, grapeseed extract, Vics VapoRub® and others. With any home remedy or non-prescription topical, you must understand that the effectiveness of the treatment is fairly low, less than 10%. If you do try one of these therapies make sure to use it every day. File the top of the nail down to roughen up the surface and apply the medication with a q-tip. Bleach can cause skin irritation and some individuals have had skin reactions to the Vics VapoRub®. In most cases the few side effects that have occurred with these topicals are minimal and they are considered very safe.

To increase the effectiveness of the treatment, I recommend combination therapy. If you choose to take an oral medication, make sure you use a topical anti-fungal agent as well. Nail removal is also an option. Once the nail is removed, the topicals can reach the nail bed and become more effective. The nail will grow back in over a period of 8-10 months. Permanent nail removal is reserved for those with chronic ingrown nails, ulceration under the nails or pain from the fungal nails.

The best form of treatment is prevention and preventing the fungus from spreading to other toenails may be the best treatment option. I recommend choosing a topical that you feel comfortable with and use it once a week. No matter which treatment option you choose, you should take the following steps to avoid re-infection.

  1. Make sure you rotate your shoes often and keep them in a cool dry place.
  2. Change your insoles frequently, and make sure they dry out between use.
  3. Place an anti-fungal powder or spray in the shoes to help fight off the fungus.
  4. Bleach out the shower on a weekly basis and wash your shower mat regularly in hot water.
  5. Make sure your athletic shoes fit well to prevent jamming at the toes. Jamming at the toes leads to microtrauma at the nails and increases the chance for fungal infection.
  6. If you belong to a gym or health club, wear sandals in the locker room and don't walk around barefoot.
  7. Don't keep your shoes in the gym locker where they cannot dry out.
  8. If your feet sweat excessively, try using an antiperspirant spray on your feet before your workout.

The bottom line is that treating onychomycosis is very difficult. If you have fungal toenails that cause pressure, pain or infection, consider talking to your doctor about prescription medications or nail removal. Make sure you take precautions to prevent re-infection and take multiple approaches to eradicate the problem. If your fungal toenails are only unsightly and don't cause any discomfort, try a weekly application of an over the counter topical along with methods to prevent re-infection.

Christine Dobrowolski is a podiatrist, runner, and author of "Those Aching Feet: Your Guide To Diagnosis and Treatment of Common Foot Problems," available via her publisher, SKI Publishing, and at Barnes & Noble and

Articles by Dr. Christine Dobrowolski, DPM