Toenail Fungus (Onychomycosis)
Toenail fungus affects nearly 36 million people in the US and studies show that 15% of the population between the ages of 40 and 60 years old suffer with the condition. This number is much worse in Louisiana due to our muggy climate. Toenail fungus, or onychomycosis, thrives in a dark moist environment, so a closed-in, sweaty shoe is the perfect environment for it to thrive. Fungal toenails are caused by an organism called a dermatophyte. Believe it or not, it is the same organism that causes athlete’s foot. It is, however, much more difficult to treat in the toenails. The condition is considered a cosmetic issue by insurance companies and they use this as an excuse not to pay for treatment of fungal toenails. While the condition may seem trivial to someone who doesn’t have it, for those who do, it can have a huge negative impact on your self-esteem and confidence in social situations. While the fungal toenail itself is asymptomatic, a fungal toenail can cause secondary problems. Ingrown toenails and secondary bacterial infections are common in nails with a fungus infection. The good news is that the fungus responsible for fungal toenails only lives in dead tissue. So with the exception of immunocompromised patients, the fungus does not cause any major medical issues.
There are over the counter topical medications available for fungal toenails but they are rarely effective. The two most recent prescription topical medications are Jublia (efinaconazole) and Kerydin (tavaborole). Both of these are good options but even their success rate is questionable. The problem with topical medications is that they don’t penetrate the nail deep enough to kill the fungus. The active ingredients may be an excellent antifungal, but if it can’t get to the fungus it’s not going to be very effective.
Laser Treatment for Fungal Toenails
Laser treatment for fungal toenails is the latest advancement in treating toenail fungus. The laser works with the use of an FDA approved pulsed light wave that is transmitted through the nail. The patented technology ensures maximum uptake of the laser energy by the fungus and not the patient’s tissues. This laser energy essentially heats up the fungal particles and kills them. The procedure has no side effects and takes about 30 minutes.
Success of laser treatment for fungal toenails has a lot to do with who is using the laser. A very experienced podiatrist who knows how to cut back as much infected nail as possible beforehand and an experienced tech who knows how to use the laser system will make the difference between a successful outcome or not. It is also important to know that the toenails will not become instantly clear. It takes about 6-12 months for the previously infected nail to grow out and a new nail to form.
What are the signs of fungal toenails?
The appearance of a fungal toenail varies based on severity. It usually begins with mild yellowing of the nails. Gradually the nail will begin to thicken. As the nail thickens it becomes brittle and may appear to become laminated or layered with layers peeling off. As the condition worsens the nail may begin to separate from the nail bed. This process is called onycholysis. The lifting off of the nails usually begins at the tip of the nail and works its way back toward the cuticle. Patient’s often complain that their nails aren’t growing. The nails are indeed still growing but because they are so brittle they are chipping off as fast as they grow.
Thickening of the nails.
Yellow, white, or yellow-brown discoloration.
Distorted nail shape.
The nail becomes thickened with debris developing under the nail.
The nail may begin to separate off the underlying nail bed, called onycholysis.
Are fungal toenails painful?
Fungal toenails can become painful, but the pain is not directly related to the fungal infection. Pain is the result of the thickening of the nail. The thick nail creates pressure on the nail bed with can result in pain. Also, as the nail becomes more involved with fungus there is more likelihood of developing an ingrown toenail which can cause pain.
Will the fungus come back after we treat it?
The fungus can come back. A fungal infection is like any other infection; once you get rid of it you can always catch it again. As a result, it’s important to apply topical medication to the affected nails even after your treatment is done. Then, once your fungal infection is completely cured, you should save this medication in case symptoms return. The good news is that fungal infections in the toenails progress very slowly, so even if you catch it again it will likely take 3 to 5 years before the nails require re-treatment.
Does insurance pay for toenail fungus laser treatment?
While laser treatment for fungal toenails is FDA approved, private insurance and Medicare consider it a cosmetic issue and do not pay for it. However, you can use your HAS, Medical IRA, or Flexible Spending Account to pay for the procedure.
What is the cost of fungal toenail laser treatment?
Cost of the procedure has everything to do with the quality of the laser machine. Treatment with cheaper, less effective toenail laser machines, tend to cost less but are also less effective. Make sure you ask which laser machine your doctor will use. For a review of toenail laser machines click here.
Laser Toenail treatment, before and after pictures
These are not stock photos, they are actual pictures of our satisfied patients. Keep in mind that full clearing of the nails can take up to a year and many of these “after” photos were just several months after initial treatment.
Review of Toenail Fungus Laser Machines
PinPointe FootLaser was the first laser FDA for the treatment of fungal toenails. It is the tried and true model that has withstood the test of time. FDA approval was in 2010 and clinical trials extend back to 2007. Most studies involving toenail fungus involve this machine and more recent studies with newer machines compare themselves against the PinPointe FootLaser. The patented pulsed laser energy provides maximum absorption to the toenail fungus without heating up the surrounding tissues. This state of the art machine is top of the line and significantly more expensive to own than lesser brands. As a result, treatment with a PinPointe FootLaser can cost a little more than treatment with lesser machines. However, results are what count, and the PinPointe FootLaser is the most effective laser for the treatment of toenail fungus.
This laser was originally designed for Dermatologists and plastic surgeons for wrinkle reduction and acne scars. It was later modified to also treat toenail fungus and received FDA approval in 2011. The laser energy is not optimized to only be absorbed by the fungus and as a result, in spite of its name-CoolBreeze, heats up the surrounding tissues. As a result, the CoolBreeze laser can be painful as it tends to heat up the surrounding tissues. The machine actually sprays a cryogen (cooling spray) during treatment in an attempt to cool down the tissues.
Genesis Plus Laser
This laser is manufactured by Cutera and received FDA approval in 2012. This is one of the few lasers that does not have a standoff on the handpiece to control the distance the probe is held from the nail. Laser energy varies tremendously in a logarithmic fashion based on how far the probe is from the nail. If the probe is too far from the nail it won’t kill the fungus, if it’s too close it will burn the tissues.
Originally designed for dermatology procedures, this laser was modified for treatment of fungal toenails. This laser is a smaller, less expensive Nd-YAG laser. It is made by Light Age, Inc. The laser was approved for fungal toenails in 2011.
How did I catch a fungus in my toenails?
Toenail fungus has nothing to do with hygiene. It doesn’t matter how clean you are or how often you wash your feet. If you are destined to catch it, you’re going to catch it. It is the same fungus that causes athlete’s foot. As with athlete’s foot, some people are more susceptible than others to becoming infected. The fungus that causes the condition is everywhere. It’s in your shoes, it’s in your carpet. The fungal spores are floating in the air all around us. You don’t need close contact with someone else’s infected toenails to pick it up. Having said that, fungus does like a dark, warm, moist environment so a sweaty shoe is the perfect environment for fungus to grow.
How long will it take my toenails to clear up?
Toenails do not have a blood supply so even if the fungus is killed the nails will not change in appearance until a new nail grows in behind it. Think of it like when you dye your hair. The colored hair will be there until it grows out and you cut it off. The process of growing out a new toenail takes about a year to a year and a half. Patients find this aspect of treating their fungal toenails very frustrating because in today’s society we are all looking for instant gratification. This year of waiting for the fungal nail to grow out is true regardless of type of treatment.
Topical treatments for fungal toenails
Treating fungal toenails with topical medication can be challenging. Topical medications have trouble penetrating the nail to access the fungus, and if they can’t get to the fungus they can’t kill it. There are dozens of medications on the market today for fungal toenails. Two of the more recent brands that show promise are Jublia and Kerydin.
These medications are competing prescription medications commonly recommended by podiatrists. Interestingly, the big selling point of these medications is not the actual antifungal, but their “delivery mechanism”. As previously mentioned, the problem with treating fungal toenails is getting the medication through the nail. They are both applied once a day.
When using topical antifungal medications, it is very important to thin out the toenails as much as possible. Thinning out the nails give the medication a better chance of accessing the fungus. Thinning out of the nail is done with a Dremel and takes a skilled hand to perform properly. A properly thinned out toenail will greatly increase the chances of success for the medication and also improve the appearance of the nail.
Can I paint my toenails while I am treating them with topical antifungal medication?
Ideally no, however, Kerydin has several studies showing its effectiveness even over toenail polish. If you are the type of person that likes to show off their toes, there are two reasonable options. There is a product on the market called Dr.’s Remedy Enriched Nail Polish. This brand of toenail polish contains antifungal chemicals including Tea Tree Oil. While it is not as effective as Jublia or Kerydin, it is a reasonable alternative if painting your toenails is a must. A second option, we recommend going ahead and painting your toenails for a special occasion but removing the polish after several days. This way the polish is not on long enough to cause problems. It’s only when polish is left on for weeks or months that it becomes a major contributor to fungal toenail infections.
What about home remedies for fungal toenails?
There are many home remedies for treating fungal toenails. However, podiatrists do not typically recommend home remedies, as they are both off label and have adverse effects. For the sake of completions, the following are some of the most common treatment options.
While off label, there have been reports of anecdotal success with twice daily applications of Vicks VapoRub. The active ingredients in Vicks include: Camphor, Menthol, and Eucalipus oil. These ingredients have been shown in some studies to be effective against certain types of fungus. In spite of the lack of scientific evidence as to its effectiveness, we have many patients in our office that claim they have had great success with daily application of Vicks VapoRub.
Vinegar has been a long time home remedy for fungal toenails. Vinegar is acidic and toenail fungus does not like an acidic environment. While any type of vinegar will do, apple cider vinegar is most often discussed as it is thought to also have anti-inflammatory properties. The regimen is to soak your feet twice a day is 50% vinegar 50% water for 15 minutes.
While most of us know Listerine as a mouth was, it was originally developed in the 1800’s as an antiseptic. It was found to drastically decrease battlefield wartime infections. With the development of antibiotics, Listerine fell out of favor as a wound dressing and was rebranded as a mouthwash. Having said that it does seem logical that Listerine might make an effective treatment against fungus. Its active ingredients include Thymol, which is an effective fungicide and Eucalyptus oil which has antimicrobial properties.
Tea Tree oil
Tea tree oil comes from the extract of the melaleuca alternifolia tree native to Australia. It is known to have strong anti-bacterial and anti-fungal properties. t can be applied directly to the nails with a cotton swab or added to foot soaks. Tea tree oil is well known for its antifungal properties and is the active ingredient in several FDA approved topical antifungal medications.
There is also evidence that soaking your feet in dilute bleach (1 tablespoon per gallon of water) will eliminate toenail fungus. The general recommendation is a 30 minute soak. Some experts suggest that this merely bleaches the yellow color out of the nails but doesn’t actually kill the fungus.
Does toenail polish cause yellowing of the nails?
Yes, toenail polish can cause your nails to turn yellow. Toenails are composed of the same material as your skin, keratin. Like your skin, nails can absorb water and other compounds including pigments. Nail polish reacts with your nails and turns them a yellow color. The reaction is hard to predict because it sometimes takes days to occur and sometimes weeks, and sometimes not at all. It also has a lot to do with the color and brand of nail polish you choose. Generally speaking, darker colors, particularly reds and burgundies cause more of a reaction. Although the discoloration is unsightly, it is not in anyway harmful to your nails.
What can I do if my nails turn yellow from toenail polish?
To remove the yellow staining caused by nail polish begin by buffing the top of the nail. Next soak the nails in hydrogen peroxide for 15 minutes. As an alternative to hydrogen peroxide lemon juice may be effective. Soak once or twice a day until the nails clear.
Is there anything I can do to prevent toenail yellowing from toenail polish?
To prevent yellowing of the nails from nail polish follow these general guidelines:
Use a protective base coat.
Give your nails a break of several days to weeks between polish applications.
Experiment with different colors and brands to find ones that don’t cause the problem.
Try to select lighter colors of polish.
Don’t leave nail polish on for extended periods of time.
How do I know if my yellow nails are from nail polish or fungus?
Distinguishing a fungal toenail from a yellow toenail caused by nail polish is difficult. You will probably have to visit the podiatrist to make this determination. A trained eye can distinguish the difference right away, but the difference is subtle. Generally speaking, a toenail that is yellowed by toenail polish will have an even yellow tint throughout the nail with no other changes. Fungal nails are also yellow but usually show other telltale signs of fungus such as thickening and brittleness. The nail may also be lifting off the nail bed, especially at the tip. Also, a nail that is yellow from polish usually has more of a uniform clear yellow tint. Fungal yellowing is usually not evenly distributed over the toenail and has a more cloudy yellowing appearance. For confirmation your podiatrist may order a fungal culture. This is a painless procedure where a small piece of nail is clipped off and sent to the lab.
Can I catch a fungus from a nail salon?
In Louisiana, pedicurists are required to hold a license with the Louisiana State Board of Cosmetology. This licensing process requires extensive training in, amongst other things, hygiene and proper cleaning of instruments. Many salons in town are more high-end, meaning you pay more for their services. There are also low-end salons. Just because they are cheaper doesn’t mean they are bad, but cheaper salons are more likely to take short cuts.
Whether this is true or not, there are certain precautions one can take when having a pedicure. Certain salons have specific instruments for individual patients. That means the instruments are only used on you and no one else.
Another common way that the fungus is passed from one client to another is through the toenail polish itself. After painting one client’s toenails the brush is put back in the bottle of toenail polish and stored until someone else chooses that color. Tests have shown that the fungus can live in the bottle of polish for years. We advise bringing in your own polish or purchasing a new bottle at the salon when getting a pedicure.
What about oral medications for Fungal toenails?
Oral antifungals are an effective option for fungal toenails but they have their own drawbacks, most notably, potential liver damage and drug interactions. In years past, Ketoconazole (Nizoral) and Griseofulvin (GrisPeg) were the two main oral medications for toenail fungus. These medications were effective but came with a higher risk of liver and kidney damage. In addition, these medications had to be taken for up to a year.
Ketoconazole and Griseofulvin have largely been replaced by triazole and allylamine antifungals for treating onychomycosis. These newer medications offer fewer side effects, shorter treatment courses, and higher cure rates. Of these newer drugs, Terbinafine (Lamisil) and itraconazole (Sporanox) are the most widely used.
Terbinafine is an allylamine antifungal that is very effective against fungal toenail. It is broad spectrum and is effective against mostorganisms responsible for fungal toenails. Lamisil is less effective against non-dermatophytes such as Candida and molds. Lamisil dosage is 250mg tablet once a day for 3 months. Due to its safety and effectiveness, Lamisil is the most widely prescribed oral medication for fungal toenails. The company has done a very good job of advertising. Everyone knows Digger!!
Sporanox is an azole antifungal medication. Sporanox is has a broader antifungal spectrum than Lamisil that included many nondermatophytic molds and Candida species. This wider antifungal spectrum comes at a price. Along with the same liver concerns that the other antifungals have, Sporanox also has an FDA black box warning for patients with evidence of ventricular dysfunction such as congestive heart failure(CHF).
Dosing for toenail fungus is 200mg/day for 3 months. There is also a “pulsed” dosing available where the pill is taken for 1 week out of the month for 3 months. This dosage is 200mg twice daily for 7 days, repeat monthly for a total of 3 months. Sporanox should be taken after a meal, preferably a fatty meal, to ensure maximal absorption.
Can oral antifungals damage my liver?
Most medications are filtered through the liver and oral antifungals are no different. Antifungals, however, are more taxing on the liver than other medications and can cause damage to the liver. Before your podiatrist prescribes an oral antifungal they may require blood work. The blood work is a liver profile to make sure your liver is healthy enough for the medication. Patients with known liver problems such as Hepatitis or cirrhosis should not take oral antifungals.
How is nail fungus diagnosed?
Fungal toenails are largely diagnosed clinically based on their classic presentation which is easily determined by a podiatrist. There are also more objective diagnostic tests available. KOH Preparation and PAS (Periodic Acid Schiff) test use staining techniques to identify fungus and there is also a fungal culture medium available. Unfortunately, these tests are notoriously inaccurate. Specifically, they are often false negative, meaning that the test result shows no fungus when in fact there is fungus.
There is also newer diagnostic technology available for diagnosing toenail fungus called a PCR (Polymerase Chain Reaction). This machine has been around for many years but has more recently become an important tool for diagnosing toenail fungus. A PCR, sometimes called a “molecular photocopying”, literally copies small fragments of DNA and amplifies a small portion of DNA which can then be used to diagnose a genus and species of organism. Once amplified the machine compares the strands of DNA with known fungal types and can give a very accurate diagnosis of not only a fungal toenail but the exact type of fungus in the toenail. The technique is not yet FDA approved so many insurance companies do not cover it. However, it is inevitable that it will get FDA approval and most probably will become the standard diagnosing technique for not only fungal toenails but for all types of infections.
Specific types of toenail fungus
Distal subungual onychomycosis
This is the most common type of toenail fungus. The condition starts at the tip of the nail, usually in the corner, and progresses back towards the cuticle. As the condition progress, the entire nails will become involved. The condition is usually caused by Trichophyton rubrum and invades the nail bed and underside of the nail plate.
White superficial onychomycosis
This type of fungal toenail accounts for about 10% of onychomycosis cases. This type of fungal toenail is caused by Trichophyton mentagrophytes. It invades the superficial layers of the nail plate causing the nail to take on a bright white chalky appearance. Because this type of fungus is found superficially on the nail plate it is easier to treat. In fact, your podiatrist should be able to sand away the top layers of the nail revealing a completely normal looking nail underneath. While you may walk out of the podiatrist’s office with a completely normal looking nail it is important to treat the nail with antifungal medication or it will come right back.
Another plus about this type of fungus is that topical medications are usually very effective because the medication can easily get to the fungus.
Proximal subungual onychomycosis
This is the least common form of onychomycosis. The infection begins at the cuticle and progresses toward the tip of the nail. The most common infectious organism is Trichophyton rubrum but can also be caused by Candida. This form of toenail fungus usually occurs in immunocompromised patients and may be associated with HIV. It can also occur secondary to local trauma or in patients with poor blood flow.