Unlike the internet and social media ads , I hate to say it , it is not quick and easy.

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Thick yellow white crumbly toenails are a common problem . There are many conditions which cause nail deformity but I will just be discussing the most common cause, fungus. We podiatrists call this onychomycosis. Due to the thickness of the nail, this can cause soreness as well. Nail fungus can cause ingrown nails over time and can cause the nail to get loose. The nail fungus also involves the nail bed and this can get hypertrophied and sore too.

How did this happen?:

It doesn’t matter how clean you are or how clean your feet are. Unlike athlete’s foot you cannot contract it from using the same shower or your foot touching someone else’s foot that has fungal nails. The fungus is everywhere and thrives in a dark moist environment like your shoes. Even though you come in contact with fungus doesn’t mean that you will get fungal toenails.

Genetic predisposition: Some people are genetically predisposed to getting toenail fungus which likely is related to skin chemistry and amount of sweating in the feet/ creation of moist environment. But, there has to be a traumatic incident to introduce the fungus into the nail.

Trauma even very minor to the toenail: There has to be a traumatic incident like stubbing your toe or having something fall on it, having you toenail fall off . The trauma can be quite minor. The fungus is then introduced to it’s new home, your toenail, and starts to feast on the keratin protein in your nail and all that crumbly debris is the aftereffect. So, it lives under the nail in the nail bed and nail root. Because of this, topical antifungals are not effective if the entire nail has fungus. There are very few medications on the market that can treat onychomycosis.

The type of fungus that typically grows in the toenail is called a dermatophyte meaning skin loving. In my experience, on a rare occasion mold can grow on the nail but more often than not it is a dermatophyte. But, there has been a recent study published in 2023 showing that molds are more common in fungal cultures than dermatophytes. A confounder in the study cited less than ideal sampling rates and disinfection prior to sampling as a possible explanation. https://pubmed.ncbi.nlm.nih.gov/37274390/ So true infection is difficult to parse out versus contamination or colonization. The importance of proper sampling cannot be overstated as described below.

How is it diagnosed?:

Clinical appearance: Normally, it is a clinical diagnosis ( how the nail appears and history), however, there are other nail conditions that may resemble a fungal toenail infection. Therefore, prior to initiating topical or oral treatment, a test may be done to confirm the diagnosis.

Special stains and cultures: This is done by taking a sample of the nail, preferably on the undersurface of the nail plate as far back as possible taking soft crumbly debris close to the nail bed. There are different types of stains taken of the material that show fungal elements of present. KOH (potassium hydroxide ) stains for fungal elements and is shown to have a sensitivity rate of 55.9%-80% . Periodic acid Schiff Stain or PAS has a 83% sensitivity. (Frazier WT, Santiago-Delgado ZM, Stupka KC 2nd. Onychomycosis: Rapid Evidence Review. Am Fam Physician. 2021 Oct 1;104(4):359-367. PMID: 34652111).  Neither of which though identify the specific organism.

These tests unfortunately can be negative but if a good sample is taken as described above , then it is more likely to be more accurate. Fungal cultures are typically done with the stains but these take 4weeks to result and are only positive 56% of the time and false negatives are common. .² From the literature I have read, one of the reasons for low positivity rates of fungal cultures is due to poor sampling. Samples should be collected underneath the nail as close to the base of nail where the abnormality is present which can be painful. Most clinicians do not do this and would likely require numbing the toe to do this. However, taking a fungal culture and PAS stain can increase sensitivity to 81-91% according to this review in American Family Physician journal: Frazier WT, Santiago-Delgado ZM, Stupka KC 2nd. Onychomycosis: Rapid Evidence Review. Am Fam Physician. 2021 Oct 1;104(4):359-367. PMID: 34652111. 

PCR Testing: A more expensive test would be polymerase chain reaction (PCR)test which is a DNA test and this results quickly. It is only positive in 37% on specimens which increases to 52% when combined with potassium hydroxide (KOH) staining for fungal elements in a study by Litz CE, Cavagnolo RZ. Polymerase chain reaction in the diagnosis of onychomycosis: a large, single-institute study. Br J Dermatol. 2010 Sep;163(3):511-4. doi: 10.1111/j.1365-2133.2010.09852.x. Epub 2010 May 11. PMID: 20491764.

PCR tests may not be covered by insurance and be sure to ask your doctor which test they are using to test for fungus so you can choose to decline the test and not get a hefty surprise insurance bill for lab cost.

Many podiatrists may treat the onychomycosis topically without testing . However, if treating orally the American Academy of Dermatology recommends getting a confirmatory test first.

My experience with these tests have been so- so . I have found them to be unreliable and the clinical diagnosis has been shown to be more accurate in my practice. But I have to admit that I likely do not sample far back enough under the nail due it causing pain. Certain insurances also will not pay for the medications unless there is a confirmatory test. These tests are expensive and becoming increasingly difficult for patients to afford and this many times is the reason for lack of testing .

The sometimes difficult sampling technique affects test result: Overall, as seen in clinical experience and scientific research on onychomycosis testing there are many pitfalls. Proper sampling is lacking which I think is the most important part of getting an accurate test result. So, this will create inaccuracy and lack of clarity. Because of cost, lack of accuracy, and the fact that onychomycosis is primarily a clinical diagnosis, podiatrists may treat without obtaining a culture or other testing.

How do I get rid of it?:

In the majority of cases, in my opinion, a oral anti-fungal would be needed to treat the fungal infection unless the fungus is located toward the end of the toenail involving less than 10-20% of the nail as seen in the picture of the thumb to the left below. Most of the nail fungus in the picture below appears to have been debrided/ trimmed away . But the white crumbly material on the nail bed tells me that it is still present and growing out. .

In the cases where there is a small amount of fungus at the end of the nail, the topicals I would recommend are prescription Penlac , Kerydin and Jublia.

Penlac is the least expensive around $20-40.

Kerydin

and Jublia

can cost hundreds of dollars.

The cost is quite ridiculous. There are discount cards offered by the pharmaceutical companies to keep out of pocket cost lower for commercial insurance payers but NOT for the Medicare drug program. Ask your podiatrist for a copay card.

Length of time prescription topicals need to be used: These medications need to be used everyday for 48 weeks and only have 20% clinical cure rate (clear nail).

Ways to increase success of treatment:

However, if you are diligent at trimming your nails regularly , letting your toes and shoes out in the sunlight on occasion (ultraviolet light kills fungus), keeping your feet as dry as possible, this all would increase success.

More ways to enhance appearance and treatment success: Also using also a keratolytic such as a urea cream on the nail would be helpful . Urea cream would reduce the keratin present for the fungus to feast on so in effect starving the fungus somewhat. Kerasal nail lacquer https://www.amazon.com/dp/B007ADOL28/?tag=drgaffneybestfoot-20

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Penlac is another topical for onychomycosis/ fungal nail infections involving the end of the toenail. Of the 3 prescription topicals, Jublia, Kerydin, and penlac, penlac is the least expensive $20/ bottle vs $430 for Kerydin and $805- $1419 for Jublia. Penlac however is the most inconvenient application. It is sticky and goes on daily as a sticky lacquer. One must let it dry or lint sticks to it. It is applied once daily for a week then it is recommended that all the layers are removed with a non-acetone nail polish remover or rubbing alcohol. All of the topicals have a low clinical cure rate ( complete nail clearance) less than 20%. However, with regular debridement a better outcome can be achieved.

Other topicals such as tree tea oil , oregano oil,(link for tea tree and oregano oil coupon code SHARE YL for 10% off https://www.youngliving.com/us/en/myaccount/wishlist?listId=65d152c5260567000af7d31f&enrollerId=2691720&sponsorId=2691720&userName=Melissa)vinegar, and vicks vaporub have had evidence of effectiveness in small scientific studies. I have used all of these except vinegar and found results equal to penlac in my practice. I reserve many of these for maintenance of fungal cure after oral treatment is complete.

Oral medication needed for nails with greater than 20% nail affected:

Oral lamisil is the most effective in treating toenail fungus of any severity. It is inexpensive . It is contraindicated in those with liver disease. There is a 3 % chance of liver enzyme elevation and white blood cell count decrease so I typically check a WBC and liver enzymes with a blood draw prior to treatment and sometimes 1 month into treatment . Drugs that may interact with concomitant terbinafine therapy include certain antidepressants, tamoxifen, atypical antipsychotics, and beta blockers. Lamisil is taken 250mg every day for 12 weeks. If more than 2 days are missed , I recommend starting all over again. Clinical cure rate ( clear nail) is only 38-76% (Onychomycosis: Rapid evidence review: WINFRED TAYLOR FRAZIER, MD, MPH, ZULEICA M. SANTIAGO-DELGADO, MD, AND KENNETH C. STUPKA, II, MD, MPHinfo Am Fam Physician. 2021;104(4):359-367)

Unfortunately, the toenail fungus takes a long time to grown out.

After the oral anti-fungal medicine irradicates the fungus in the nail root and bed which takes 3 months, it will take an additional 6-12 months for the healthy nail to grow out ( 😱yikes). So, if you want nice looking nails for the summer start treating in the previous fall at the latest.

Ways to enhance success of oral antifungal treatment: Also there is still nail fungus in the nail as it grows out so another trauma may push it back into the nail root and nail bed again. Therefore, I recommend to my patients use a topical anti-fungal at the same time and keeping the nail trimmed back to have a better chance at the desired outcome/ clear nail. Also, continuing the topical one or twice a week after a clear nail is achieved is helpful in preventing recurrence .

If not using topicals with the oral therapy , in my experience the recurrence rate is about 50% sadly even though studies show around 23% recurrence rates. I think because I see these patients for a longer period of time for other foot problems vs. shorter follow-up time for patients in a study. Hence, there is more time to get a recurrence.

Sporanox is another oral medication used however it does seem to have more drug interactions . In my experience, it does not work as well and this has been shown in scientific studies as well. Also, Sporanox is fungistatic meaning it just inhibits fungal growth . Unlike lamisil which is fungicidal meaning it kills fungus.

Diflucan orally can used be used as well but is not FDA approved for onychomycosis however clinicians use it when oral lamisil and sporanox are not tolerated.

Voriconazole is another prescription oral anti-fungal medication that can be used. However, it is mainly used to treat molds. Generally, Voriconazole, is not a first line treatment.

Patience and diligence in treatment is vital for success: One must be diligent and patient when treating toenail fungus because it can take 12-18 months for the fungus to grow out with new nail growth as stated above. This is why I have patients use a topical after the 12 week course of medication because the fungus that is growing out can reinfect the nail root and bed. Also, keeping the nail trimmed and gently clearing the loose crumbly fungal debris with debridement is important as it grows out.

Can’t I just dig out all the fungus or just have my nail plate removed to get rid of it?

NO.

The nail fungus has infected the nail root and bed and it will continue to produce a fungal nail. But trying to forcibly dig out the crumbly debris, it just causes irritation and wounding that is painful. Sometimes the nail debris is loose and with soaking it can easily be removed. This is the only time I think it is ok to remove the crumbly debris otherwise you are traumatizing the nail bed and could introduce a bacterial infection.

The only time I would recommend removing the nail plate is if it is:

a. painful despite debridement,

b. has a secondary bacterial infection, or

c. has recurrent nail fungus after oral antifungal treatment.

If there is recurrent or failed oral antifungal treatment, I would recommend nail plate removal followed by topicals and another round of oral antifungal treatment after obtaining a nail culture and possibly PCR test to identify the fungal organism .

There is laser treatment which has not had good lasting results and is very expensive and not covered by insurance.

Ways to prevent fungal nails and prevent recurrence after treatment:

1. Keep nails trimmed.

2. Do not keep toenail polish on too long. It takes fungus 24-48 hours to grow in correct environment like being occluded under nail polish . So no longer than 2 days. I never wear nail polish . If you must wear nail polish, use anti-fungal nail polish sold on Amazon .

3. Do not push back nail cuticle . It’s there to keep fungus and bacteria out.

4. Use prescription topical antifungal daily when being treated with oral antifungal then continue using topical antifungal until nail grows out healthy. After treatment, use topical antifungal twice weekly to prevent recurrence if you have sweaty feet.

5. After any toenail trauma, use tree tea oil to prevent onychomycosis. If there is any sign of nail fungus go get prescription topical as soon as possible. Link for tea tree oil ( use coupon code SHARE YL for 10% off): https://www.youngliving.com/us/en/myaccount/wishlist?listId=65d152c5260567000af7d31f&enrollerId=2691720&sponsorId=2691720&userName=Melissa

6. Let your feet see the sun . But of course be careful of sunburn. UV light kills fungus .

7. As part of antifungal treatment process either get new shoes , expose inside of shoes to sun , get a shoe sanitizer or spray with Lysol. Link to pedifix shoe sanitizer : http://shrsl.com/4f6wl As a pedifix affiliate, I earn from qualifying  purchases

8. If you have sweaty feet, use underarm antiperspirant on your feet. Wear white cotton or bamboo socks. Air our feet regularly.

9. Kerasal can be used topically on toenail while it’s being treated for fungus to theoretically enhance treatment success.

Lastly, oral Lamisil has been on the market since the mid-90’s and used widely . Therefore, in recent years we have been seeing antifungal resistance. This also may cause treatment failure.

I hope this helps you navigate the challenging landscape of onychomycosis treatment and gets you on the right track. Don’t fall for the quick fix social media ads. There is no quick fix .

Thanks for reading !

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