Treatment Options For Toenail Fungus

Toenail fungus (medically known as tinea unguium or onychomysis) affects nearly 10 percent of the world’s population and up to 32 million people in the United States alone.   Historically, treatment of toenail fungus has been disappointing for both doctors and patients who suffer from it due to poor cure rates and high reoccurrence rates.  Recently, the FDA approved some new topical treatments for toenail fungus.  Here is a list of current treatments for toenail fungus and how they stack up. 

Oral Antifungals
Oral antifungals are still the gold standard of treatment for toenail fungus.  Oral antifungals yield perhaps the best cure rates of any toenail fungus treatment.   However, all of the oral antifungals have potential to cause liver damage and can interact with other medications.   Many patients when informed of these potential side effects opt out of this treatment.   Studies show that actual problems are rare.  These medications depend upon a “reservoir” effect in which the medication becomes concentrated in the nail itself.  The reservoir effect allows these oral medications to be taken for only a few months, but they continue to work until the nail grows out, usually up to a year or more.  Current oral medications on the market include terbinafine (Lamisil) and itraconazole (Onmel).  Cure rates with oral antifungals approach 40 percent which is the highest of all toenail fungus treatments.

Topical Antifungals
There are numerous topical antifungals on the market, both over the counter and prescription.  Some alternative health care specialists advocate using tea tree oil and some patients feel that this works.  Other over the counter topical toenail medications are available as well.  While some may show some success, there are really no scientific studies to evaluate their effectiveness.   Cicloprox (Penlac) is a prescription topical antifungal that has been around for many years.  It is available as a nail lacquer that is painted on like a toenail polish.  However to be effective, it has to be removed once a week.  Also, wearing of toenail polish which is popular with women cannot be done while using cicloprox.  Two new topical toenail fungus medications have been introduced to the market.   Efinaconazole (Jublia) and tavaborole (Kerydin) are newly FDA approved topical medications for the treatment of toenail fungus The advantage of both over cicloprox is better penetration into the nail, and they do not have to be removed weekly.  The cure rates of these topicals approach 18 percent for efinaconazole (Jublia), nine percent for tavaborole (Kerydin) and six percent for cicloprox (Penlac).

Laser Treatment
A relatively new and technologically attractive treatment for toenail fungus is a laser.  Many podiatrists now offer laser treatment of toenail fungus.   Recent studies have not been able to show that laser treatment for toenail fungus actually works at all even after multiple treatments.  In addition, insurance companies do not cover this expensive procedure.  Patients who have been treated with lasers for toenail fungus however, report some improvement in appearance.

Surgical Removal
While aggressive, surgically removing the infected toenails can be performed.   This radical treatment is very painful to undergo, and takes weeks if not months of recovery time to grow a new toenail.  However, if the nail disease is severe enough to cause nail deformities so severe that topical medications will not penetrate effectively enough, and oral medications are contraindicated, then there may be no other option.

Photodynamic Therapy
Photodynamic therapy is a process where a chemical is applied to the nail and later a light source is applied to the nail to eradicate the fungus.   Photodynamic therapy has shown good results in other areas such as skin cancer and precancerous conditions.   For toenail fungus, it may be a treatment of the future.

There are a number of ways to treat toenail fungus.  The cure rates of even the newest treatments are poor.  The best cure rate is oral therapy, but it has issues with liver damage and medication interaction.  Topical treatments show promise, but require ongoing treatment for a year or more.   Lasers, while technologically attractive, have not shown any long term benefit.  Photodynamic therapy may be a treatment option in the future.