Toenail fungus, clinically known as onychomycosis (on·ih·koh·mai·kow·suhss) or tinea unguium (tin·ee·ah un·gwee·um), is a common and often embarrassing condition that affects millions of people worldwide. Its characteristic symptoms are white to yellow discolouration, thickening, and crumbling. Unfortunately, untreated toenail fungus is contagious, and can also lead to complications like painful ulcers and permanent damage to the affected nails. That's why it's important not to overlook this condition.
Black, brown, purple, green, and red discolouration are not fungal, but should not be ignored. See your primary care provider or foot care professional if you notice any of these colours in your nail.
In this post, we will explore toenail fungus in depth, examine available treatment options, and discuss the overall health impact of this condition to help you manage it better.
Understanding Toenail Fungus
Toenail fungus is primarily caused by fungi, with dermatophytes as the most common offenders. Think of this like mould in your nail. These microbes flourish in warm, moist environments and are opportunistic - meaning they will take advantage of a weakened immune system or other opportunity, such as injury, to take hold. The fungus then feeds on the healthy nail. Dead cells accumulate under the nail and lift it off the nail bed, making it thick and difficult to trim. The lifted nail may also dry out, curling downwards, which can cause painful ingrown nails. The most common cause of nail fungus is nail trauma; anything that allows the nail to lift up slightly from the nail bed can allow the fungus to get into the nail bed and take hold. Something as simple as stubbing your toe or aggressively cleaning under the edge of the nail can cause this.
Toenails are particularly vulnerable. Various factors increase the likelihood of developing this condition including nail injury, advanced age, history of athlete's foot, feet that sweat heavily, and certain medical conditions like diabetes, psoriasis, or decreased circulation. Once one nail is infected, it is assumed that the rest of the nails on the same foot will also develop the infection over time if it's not treated.
Toenail fungus is contagious to others. It can spread through direct contact with infected nails or contaminated surfaces such as improperly cleaned pedicure instruments, gym showers, swimming pools, and communal changing rooms. It can also be transmitted to anyone who lives in your home, generally through the shower or bath. Preventive measures can greatly reduce your risk, especially for those who frequent public spaces.
A more superficial type of fungus can grow on the nails if nail polish is left in place for too long. The polish may lift slightly, leaving a warm and moist environment between it and the nail plate, allowing fungal spores to thrive.
The data show that around 14% of the general population experiences toenail fungus, rising to 50% among people over 70. It is estimated that over 1 billion people worldwide are living with toenail fungus.
Types of Toenail Fungus
There are two main types of nail fungus: superficial white onychomycosis (SWO), and the more common subungual onycomycosis that affects the underside of the nail. The type of infection is usually dictated by the variety of fungus that causes it. Below are photos of some common types of fungal nail infections.
Diagnosis
Traditional laboratory diagnosis is done by taking clippings of the affected nail. These are examined under a microscope and most commonly tested with potassium hydroxide (KOH). Occasionally fungal cultures will be done, however these are more expensive and take several weeks. Unfortunately, for a variety of reasons, lab tests have a false negative rate of approximately 60%. That means that up to 60% of negative results are actually fungal! A toenail sample must be obtained under specific conditions. A Foot Care Nurse can help with obtaining an effective sample. The likelihood of diagnosis increases if the sample is professionally obtained.
The most common way to diagnose toenail fungus is clinical examination by an experienced practitioner. There are other nail conditions that can look like toenail fungus, so it's best to seek a professional opinion. Infections are classified as mild, moderate, or severe, using the Onychomycosis Severity Index.
The Complications of Untreated Toenail Fungus
Neglecting toenail fungus can lead to serious complications. Symptoms such as thickened, discoloured nails can cause pain and discomfort when wearing shoes. In some cases, the infection may extend to surrounding skin, resulting in athlete's foot. In severe cases, toenail fungus can cause painful ulcerations (wounds) under the nails that require medical intervention. Individuals with diabetes or weakened immune systems are particularly at risk. In the most severe case, an ulceration under the nail that is unable to heal can result in a blood infection (sepsis), and may require amputation of the affected toe.
The sooner your catch toenail fungus, the easier it is to treat. Untreated nail fungus can progress to a form called "total dystrophic onychomycosis" (TDO), in which the nail plate is completely destroyed and the nail becomes extremely thick, brittle, and crumbly (seen in the photo in the previous section on the far right). This form of nail fungus is very difficult to treat and has a high treatment failure rate, and a high rate of recurrence. In these cases the only option may be to permanently remove the nail.
Treatment Options
Traditional Treatment Methods
Standard methods of treating toenail fungus typically involve antifungal medications, either taken orally (by mouth) or applied topically. While toenail fungus can be difficult to treat, consistency in following treatment plans is crucial for a successful result. In all cases, nail polish must be avoided until the infection is cured.
Superficial white onychomycosis can easily be treated by a foot care professional by carefully filing down the affected nail area and then application of topical creams or lacquers. Subungual onychomycosis is more difficult to treat. Here are the most common medical treatments:
Oral medications, such as terbinafine and itraconazole, can eliminate the fungus from the inside out. Clinical studies reveal that these medications lead to positive outcomes in about 54-70% of cases. However, they carry risks and side effects, and may not be suitable for everyone. They also interact with many medications, and studies suggest they are less effective in people over the age of 65. These medications need to be taken 6-12 months, depending on the severity of infection, with frequent blood tests needed to make sure the medication is not too harsh on your liver. The total cost for treatment varies by pharmacy, but you can expect to pay around $200 for a 6-month course in Nakusp. These medications are covered by most extended healthcare plans.
Topical antifungal preparations, available by prescription, offer an alternative. These come in the form of either a cream or a lacquer. The build-up of cream or lacquer needs to be removed from the nail regularly, so the active ingredient is able to penetrate the infection. Studies indicate that topical treatments are effective in about 15-30% of cases. They need to be applied twice daily for 12 months, and are approximately $100-$140 per bottle or tube, which lasts 2-4 months depending on how many nails are affected. The total price for a year's treatment would range from $400-$600. These are covered by most extended healthcare plans.
Note: over the counter (OTC) topical antifungal remedies are less effective than prescription ones. Prescription strength topical preparations are proven to kill fungus and to contain a strong enough concentration of the active ingredient to do the job. Even if they contain the same active ingredient as prescription medications, the OTC preparations may not have it in sufficient strength to kill the strongest spores, leaving you with incomplete results and an infection that's now resistant to treatment. OTC preparations are best used for preventative maintenance, before infection can take hold.
Surgical removal of the affected nail may be suggested by your health care provider if the nail is severely infected or resistant to treatment. Nails will often regrow with some measure of deformity after this procedure, and opting for a permanent removal may still leave some small shards of nail that grow out and cause discomfort and embarrassment. This procedure is covered by the BC Medical Services Plan, at no cost to the patient. It will take 6-12 months for a new nail to grow in (in the case of the big toe), and the nail bed will be exposed and raw for a couple of weeks. Daily dressing changes are required until this heals.
Laser-based medical devices are not licensed to cure fungal nail infections in Canada. The way laser treatment works is poorly understood, with limited research done on it. Early results suggest that about 60% of people have improvement with the procedure. Depending on the type of laser used, some people find the procedure painful. Generally two treatments are required, 2-3 months apart, with the use of topical preparations in between. Prices vary by clinic, but the low end of the pricing is $800 for two treatments, and in many places are significantly higher. Before starting treatment, you should consult with a cosmetic dermatologist to make sure laser treatment is right for you. Laser treatments are not covered by extended healthcare plans.
No matter the treatment option chosen, filing down the affected nail(s) is the key to success. Skillful removal of infected areas significantly decreases the amount of fungus that the treatment needs to penetrate. If the most heavily infected areas are not removed, treatments may not be able to reach all of the fungal spores, and they may continue to reinfect the new, healthy areas.
The single most effective tool in treating toenail fungus is to regularly have the fungal areas removed by a foot care professional, such as a trained Foot Care Nurse, until the nail grows out healthy. This should be done every 2-8 weeks. Skillful removal of these areas increases the chance of treatment success by 77%! |
A New Option: Drug-Free Light Therapy
The ToeFX® system was developed by researchers at the University of Waterloo in Ontario. It is a safe and effective photo-disinfection system that uses LED lights and a proprietary nail paint to kill the fungus infecting the nail. The light waves interact with the topical application to create reactive oxygen and rupture the walls of the fungal cells, killing them.
ToeFX® is a Health Canada-approved technology. It boasts a 76% success rate for severe nail fungus, and even better success on mild-to-moderate infections. One significant advantage of this therapy is its infrequent application and hands-off approach for the patient, as the treatment is done at our clinic every two weeks with no at-home care required. It is also non-medicinal in nature, making it an attractive option for those wanting a drug-free approach. It is painless and has no reported side effects. Light therapy can produce results in as little as 12 weeks. It is safe for use in pregnancy, children, diabetes, and states of poor circulation.
Treatments are done in the clinic every 2 weeks for 8-12 treatments, depending on the severity of infection. Each treatment costs $90. The treatments include professional filing of the fungal areas at each visit, to ensure the best chances of success. Partial coverage of this therapy may be available through your extended healthcare plan as "medical foot care."
Seeing Results
Unfortunately, there is no quick way to get results when treating toenail fungus. The only way to know if the treatment is working is to wait for the healthy nail to grow in place of the infected nail. The extent of the infection dictates how quickly results are seen. For example, the nail of the big toe takes between 6-12 months to fully grow out; if half the nail is involved, that means it will take 3-6 months to see full results. If the full nail is involved all the way to the cuticle, then it may take a year before the whole nail is healthy again. The smaller nails will see results more quickly.
Here are some home-care tips to help reduce the risk of infecting household members, and to improve your chances of treatment success:
Wear shower sandals when bathing. Make sure these are dried and sanitized frequently.
Spray the shower/tub with a disinfecting cleaning product with the active ingredients pine oil, sodium hypochlorite, phenols, ethanol, or benzalkonium chloride after use. You can also use a dilute bleach solution, but you will need to clean the soap residue from the shower floor first.
Allow the shower/tub to dry completely before another person uses it.
Do not share a towel used to dry your feet with anyone.
Do not share nail care instruments, like clippers and files.
Keep your feet clean and dry, paying special attention to the area between the toes.
Wash socks and towels frequently in hot water. Dry at high heat, or hanging in the sun for 4+ hours. Change your socks daily, or more often if they are wet. Do not go barefoot in the home.
Disinfect your shoes daily with an antifungal spray or powder. Be sure to get all the way into the toe area of the shoe. Ideally you should replace your shoes once the infection is cleared, to reduce the risk of reinfection.
Do not go for a pedicure during the course of your treatment. Do not wear nail polish while treatment is ongoing.
What About Natural Remedies?
Fungal nail infections can be challenging to treat because the infection resides beneath the nail, making it difficult for topical remedies to reach the affected area. Popular natural remedies include mouthwash, apple cider vinegar, tea tree oil, garlic, oregano, baking soda, and Vicks VapoRub. While these all have antifungal properties, their effectiveness is limited due to their inability to penetrate deeply into the nail. There is some clinical evidence to support the use of Vicks VapoRub in the treatment of minor, early, surface infections, but it is similarly unable to penetrate down to the nail bed where the infection most often occurs. Again, the chances of success increase if a trained foot care professional carefully files down the infected portion of the nail so that these products can penetrate the infection.
If a fungal infection persists, it is advisable to consult a healthcare professional for appropriate diagnosis, and treatment options.
Tips to Prevent Toenail Fungus
Toenail fungus is a little bit like the common cold - just because you successfully treat it once, doesn't mean you won't get it again. In fact, the relapse rate is up to 50%! Taking preventive steps to reduce the amount of fungus in your environment can make a big difference. Here are some practical tips to lower your risk of developing toenail fungus, especially after a successful treatment:
Maintain Foot Hygiene: Wash your feet daily and dry them thoroughly, especially between the toes. If you have trouble reaching your feet, use a hair dryer to get between the toes. Be sure to change your socks daily, or more often if they get wet. Moisture-wicking socks such as wool are ideal.
Footwear: Opt for breathable shoe fabric. Avoid tight-fitting shoes, which can trap moisture and promote fungal growth. Disinfect your shoes regularly with an antifungal spray or powder. Allow your shoes to dry completely between wearings. A boot dryer may be needed if you have to wear the same work boots every day - and although it's more expensive, the ideal situation would be to have two pairs of work boots so they can dry completely between wearings.
Avoid Going Barefoot in Public Areas: Protect your feet in public showers and pools by wearing sandals to minimize fungal exposure.
Regular Nail Care: Keep your toenails trimmed and neat. Jagged edges can increase the risk of acquiring a toenail fungus. Those needing assistance with trimming their nails should seek out the services of a trained Foot Care Nurse, especially if you have medical conditions like diabetes or vascular disease, or are immune-compromised. Do not share nail clippers or files with other people.
Preventative Maintenance: Non-prescription antifungal nail preparations can help prevent fungus from taking hold if used routinely (2-3 times per week). We prefer professional products like PodoExpert's Healthy Nail Tincture, available at our clinic, but you can also use the home remedies listed earlier on this page, or any of the commercially-available products from your local pharmacy. Another alternative is to receive the ToeFX treatment every 8 weeks for 4-6 treatments. Studies have shown a reduced rate of reinfection by 86% at the 1-year mark.
Use Only Professional Nail Technicians: If you enjoy pedicures and manicures, make sure you only frequent establishments that follow strict hygiene practices. Do not be afraid to ask about their disinfection process, this is your health! Reusable foot instruments in nail salons must be soaked in a hospital-grade disinfectant (often referred to as "cold sterilizing") or by steam sterilizing; wiping/spraying with rubbing alcohol or a disinfectant is not sufficient. People with fungal nails should not seek pedicures until the nails are healthy again to reduce the risk of passing the infection to another salon client.
Treat Athlete's Foot Promptly: One of the most common sources of toenail fungus is cross-contamination from athlete's foot. Prompt treatment of this common skin infection can help prevent it from spreading to the nails. There are multiple OTC creams and spray available both at our clinic, and in your local pharmacy.
Final Thoughts
Toenail fungus is more than a cosmetic issue; it can trigger serious complications if ignored. Fortunately, various treatment options, from traditional antifungal medications to innovative light therapy, can help. Staying committed to your treatment plan is vital for overcoming this condition.
Additionally, preventive measures can minimize your infection risk, while professional insight can guide you through potential complications. By taking proactive steps, you can effectively manage toenail fungus and maintain healthy, beautiful feet.
Don't hesitate to discuss any concerns about toenail fungus with your Foot Care Nurse or other foot care professional. Taking action now can lead to healthier nails in the future!
