Toenail Infections or Onychomycosis affect 14% to 28% of the over 60 yo in the United States3 and 11% of the population worldwide. Toenail infections are not uncommon in young active individuals especially runners, hikers, and other athletes. It is characterized by changes to the nail including discoloring, thickening, debris under the nail and lifting of the nail from the nail bed.
There are different types and severities of onychomycosis defined by the amount of involvement and location of the toenail infections.
Toenail infections can cause significant problems with secondary bacterial infections, wounds, and pain. Onychomycosis also causes undo stress and embarrassment in those afflicted, causing them to wear shoes or cover their feet. Toenail infections are caused by dermatophytes 80% of the time, there are a number of other pathogens making up the remainder of infections.
- Trichophyton rubrum
- Epidermophyton Floccosum
- Acremonium species
- Alternaria species
- Botryodiplodia theobromae
- Fusarium species
- Onycochola canadensis
- Scytalidium dimidiatum
- Scytalidium hyalinum
- Geotrichum candidum
- Cladosporium carrionii
- Scopulariopsis brevicaulis
- Candida albicans
Dermatophytes are common skin flora rarely causing issues. The most common dermatophyte involved in toenail infections is trichophyton rubrum causing 80% – 90% of the cases.1 Treatments over the years have evolved with the technologies and medications available. Today laser treatments with the 1064 nm Nd:YAG are becoming more and more popular as research demonstrates superior results with no side effects. Below is a detailed list of current treatments.
- Lamisil is the most commonly used medication due to its safety profile.
- Oral medications usually cost $300- $600
- Oral medications are effective less than 50% of the time with the rate of recurrence ranging from 10%-53%.
- After one year the medication is no longer present in the nail.
- Possible side effects include liver failure, loss of taste, and gastrointestinal problems.
- Serious considerations concerning drug interactions needs to be addressed.
- Terbinafine Packaging Information
- Ciclopirox nail solution (Penlac) is the only FDA approved topical at this time.
- Rarely effective (between 5.5% and 8.5%) and only in mild cases due their inability to penetrate the nail plate6-11.
- Cost of use is a serious consideration, between $20 and $150 for a 6.6ml bottle. A 48 week supply is needed ~3-4 bottles.
- There are no known side effects.
- The medication requires time, it must be put on daily and removed weekly by filing the nails.
- Other topical treatments like Fungoid Tincture, Tineacide, Vicks Vapor Rub, Tea tree oil do NOT work. I have had patients develop allergic reactions to tea tree oil causing blisters, blisters and infections.
- Check out Totally Feet Podiatry and Laser Center for More on Laser Treatments
- A resent study shows 51% of patients had complete resolution of the nail fungus with all tests being negative for fungal infection, 81% of the patients had complete to moderate clearing of the nails.12
- The treatment can cost anywhere from $300- $1500 and insurance does not cover the treatment. At Totally Feet we have several packages available using the newest laser technology.
- There are a number of lasers available for the treatment on onychomycosis, not all of them work the same.
- There are have NOT been any documented side effects.
- Not all nd:yag 1064nm lasers are created equally. Many spas are trying to treat onychomycosis with hair removal lasers. Often times, these lasers do have the proper setting needed for the treatment of onychomycosis. Check out our laser treatment page for a detailed description of appropriate settings needed for the treatment of onychomycosis.
How many laser treatments are needed for Toenail Infections?
The number of treatments an individual needs will depend on the severity of the toenail infections. Because the infection is usually progressive it often depends on the amount of time a person has had toenail infections. Mild cases of toenail infections where discoloring is isolated to the tip of the toenail and thickening is minimal, 1 treatment may be enough.
People with more than half of the nail infected and thickening of the nails, I recommend our 3 treatment package. This will offer the best results for these more moderate to severe cases. These cases have been present for years with little to no effective treatment. Patients with complete nail involvement and severe thickening of the nail may have limited improvement in their nails. If the nail is infected around the root of the nail, permanent nail damage may have occurred. There is no real easy way to know if damage to the root of the nail has taken place. I recommend a treat and see approach.
The bottom line: No treatment is 100% effective for the treatment of toenail infections, the laser at totally feet podiatry and laser center is more effective than any other treatment on the market and has no side effects.
- Manual debridement has been the old standby. This is performed by a trained professional and requires removing as much infected nail as possible.
- Manual debridements of toenail infections is often utilized in conjunction with other treatments to increase the effectiveness of the other treatment.
- This is NOT a cure but more of a maintenance option.
- This has been the treatment of choice for individuals with sever onychomycosis, traumatically injured nails, and patients who are not candidates for oral medication, or find oral and laser treatments too costly.
Permanent Nail Removal
- Permanent Removal of the nail is effective, but the nail is gone permanently.
- This is often the treatment recommended for severe cases of onychomycosis that do not respond to other treatments.
- If there is no nail there is no nail fungus.
- Risks of infection and regrowth of the nail are always possible.
Is Nail Fungus Contagious?
This is one of the most common questions I get from my patients. The answer is- it depends and in most cases yes, or at least there is an increased risk of infection. It is important to understand we are always dealing with probabilities when talking about these issues. Most people have a very low probability of catching a fungus from another person. In most cases we are constantly being exposed to these fungi.
As stated earlier there are many factors to take into consideration when determining how likely an individual maybe to catching nail fungus from someone else. These factors include but are not limited to genetics, circulation, immune conditions, medications, injuries, environment, and shoe gear.
The Genetic makeup of an individual is probably the most important factor when determining the likeliness of an individual catching toenail infections. Genetically, some people do not have the same ability as others to fight fungal toenail infections. This group of individuals is very likely to have fungal infections in their nails.
Circulation and immune conditions go hand and hand so they will both be covered here. The arteries take red and white blood cells (WBCs) to the extremities. The white blood cells are the front line defense to fighting off toenail infections. When we have diminished WBCs getting to our toes the risk of infection goes up. Likewise, if our WBCs are getting there but are not able to identify or combat the infection effectively, the infection will take hold.
Some medications can decrease our bodies ability to fight infections. The medications most commonly include Methotrexate and Corticosteroids. These medications are commonly given to reduce inflammation, or immunity.
An injury to a toenail can open the nail or cuticle to an infection. Any time an opening presents itself for an infection, the infection is waiting. If the opening is too great for our immune response, again the infection will take hold.
Environmental factors and shoe gear are very closely related so I will cover these two together. As talked about earlier these fungi thrive in warm, dark, moist places. If you are wearing leather steel toed boots in Miami, in the summer, the conditions are going to be perfect for developing the infection.
Obviously, the more risk factors existing, the more likely someone would be to developing these infections. Factors contributing to a decreased ability to combat fungal infections will significantly increase the risk of catching the nail fungus.
- Ghannoum, MA, Hajjeh RA, Scher R, et al., “A large-scale North American study of fungal islolates from nails: the frequency of onychomycosis, fungal distribution, and antifungal susceptibility patterns,” J Am Acad Dermatol 43, 641-648 (2000).
- Elewski BE, Leyden J, Rindali MG, et al. Office Practice-Based Confirmation of Onychomycosis A US Nationwide Prospective Survey. Arch Intern Med. 2002;162:2133-2138.
- HochmanLG. Laser treatment of onychomycosis using a novel 0.65-millisecond pulsed Nd:YAG 1064-nm laser. Journal of Cosmetic and Laser Therapy. 2011; Early Online:1-44.
- Scher RK, Tavakkol A, Bact D, et al. Onychomycosis: Diagnosis and definition of cure. A Am Acad Dermatol. 2007;56:939-944.
- Epstein E. How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data. Arch Dermatol. 1998;134(12):1551-1554. Review.
- Elewski BE: Onychomycosis: pathogenesis, diagnosis, and management. Clin Microbiol. 1998;11:415-429.
- Gupta AK, Ryder JE, Johnson AM: Cumulative meta-analysis of systemic antifungal agents for the treatment of onychomycosis. Br J Dermatol. 2004;150:537-544.
- Hiruma M. Onychomycosis: recent progress in the epidemiology, diagnosis and treatment. Jpn J Med Mycol. 2006;49:69-73.
- Watanabe S, Ogawa H, Nishikawa T, et al. A Randomized, Double-blind, Parallel-group Comparison Study of Itraconazole pulse therapy with a one-year follow-up for Toenail onychomycosis: optimal Dosages and Cycles. Jpn J Dermatol. 2004;114:55-72.
- Gupta AK, Uro M, Cooper EA. Onychomycosis Therapy: Past, Present, Future. J Drugs Dermatol. 2010;9:1109-13.
- Elewski BE, Tavakkol A. Safety and tolerability of oral antifungal agents in the treatment of fungal nail disease: a proven reality. Ther Clin Risk Manag. 2005;1(4):299-306.
- Kimura U, Takeuchi K, Kinoshita A, Takamori K, Hiruma M, Suga Y, et al. Treating Onychomycoses of the Toenail: Clinical Efficacy of the Sub-Millisecond 1064 nm Nd: YAG Laser Using a 5mm Spot Diameter. J of Drugs in Dermatol. 2012;4: 496-504.
Keywords: Nail Fungus Onychomycosiss, laser nail, laser fungus Westminster, nail infection, nail disease, nail, toenail, Laser toenail, laser fingernail,