Nail fungus! What can be done these days?

August 19, 2019 / Duncan Fisher
A lot, luckily.

Fungal infection in the nails is very common. It’s spoken of as ‘onychomycosis’. It looks like nail thickening and discoloration, and nails sometimes separate from their nail beds. It's unsightly, and it can also hurt a little bit. Onychomycosis is what’s wrong in about 90% of all toenail infections.

The cause is usually one of the Trichophyton molds. Sometimes the nail problem starts as an infection in surrounding skin, like athlete’s foot. It’s most likely to occur where there is high humidity, where feet are damp all the time, or where there is nail damage. There may be a genetic predisposition to onychomycosis, too. We also know that diabetic patients, the elderly, people with poor blood circulation, and people who are immunosuppressed have a higher than normal tendency to develop it.

Onychomycosis doesn’t cause really big problems, but it is unpleasant. It can also take time to cure. Luckily, management is getting better.

A lot can be done.

Topical treatments

Your dermatologist can offer a number of topical agents, to put directly onto the nails. They’re all relatively safe to use, and there is no worry of possible drug interactions. They vary in effectiveness because they work in different ways. The challenge is to get the drug through the nail, to the infection. That’s not easy, because of the chemical structure of the nail. Its function is to protect you from outside invasion, after all. There have been significant advances in topical treatment in the last few years. You might ask your doctor about tavaborole, efinaconazole, luliconazole, and, in Europe, ciclopirox.

There are very recent investigations of several new treatments, as well. These are not in clinical use yet, but they may be soon. It’s good news!

Oral medication

There are oral therapeutics for onychomycosis. Doctors like to avoid them if they can, because of possible safety issues and potential drug interactions. But they do work, and better overall than the topical treatments do.

There are at least two experimental agents now in testing, and they look to be very effective. Safety trials are next. With luck, these will turn out to be easy on patients, and adaptable to clinical use.

Non-drug treatments

There is a novel non-drug treatment under investigation, using short electrical pulses to ionize air molecules around Trichophyton growths, and inhibit them. This idea is only in its infancy, still in the laboratory phase, but eventually this ‘thermal plasma’ strategy may possibly have something to offer.

Another strategy under investigation is laser treatment, sometimes coupled with a nano-preparation of a drug called tioconazole. There is only limited evidence that laser treatments eradicate fungal growth. Meaningful studies are still lacking. But there are reports that laser treatments at least improve cosmetic appearance, and they may therefore be used eventually as concomitant treatment with other therapies. Laser treatments for onychomycosis do no harm, in any case, and they are FDA-approved for this purpose in the United States.

What you can do yourself

When you go to the doctor for help with your onychomycosis, do stay on the treatment program carefully. (Don’t expect slow-growing nails to look different instantly; don’t stop treating the infection just because it starts to look better.)

To help things along, you can disinfect your shoes and socks often. You can keep your feet as cool and dry as possible. You can avoid walking barefoot out in public. And you can treat promptly any sign of fungal infection, even if it’s only athlete’s foot, in any member of your family. Fungal infections are very contagious.

Gupta AK and Stec N. Recent advances in therapies for onychomycosis and its management [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):968 (https://doi.org/10.12688/f1000research.18646.1)

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