Onychomycosis, or toenail fungus, is a problem that affects millions of people worldwide. Onychomycosis can be mild and only a cosmetic concern — but for many, the nail changes that occur result in pain and can sometimes result in secondary bacterial infection.
Most cases of toenail fungus are notoriously difficult to eliminate, mostly because the fungus resides throughout the nail, and even on the nail bed beneath it. The structure of the nail itself is not easily penetrated by topical agents, which makes topical treatments less effective than oral antifungal medicines. But oral antifungal medicines are not for everyone, either due to their cost, side effects, or just personal preference for topical treatments.
There are plenty of success stories out there when it comes to using topical treatments for onychomycosis, especially for early cases where the thickening or discoloration is mild and affects the edge or top surface of the toenail.
Where to Start
It's a good idea to start with a podiatrist to have your nails evaluated and to discuss treatment options. If you decide to try topical treatment, regular nail debridement (trimming of infected nail) by a podiatrist will help the medicine better penetrate the nail. One big reason for treatment failure is that many people think they have a nail fungus when the thickening or discoloration is actually due to another problem, such as nail trauma or bacterial infection. A sample of the nail may be taken and sent to a laboratory to see if and what type of fungus is present.
Prescription Topical Antifungals
To date, one of the most frequently prescribed topical treatments for nail fungus has been Penlac® (ciclopirox) Nail Lacquer, which is a clear lacquer that the patient applies to the nail for a prescribed period of time, usually months. Penlac® is only recommended for mild to moderate cases of onychomycosis, where the fungus has only affected the tip of the nail and has not extended back to the nail's matrix, or growth center. Since The antifungal medicine in Penlac® (ciclopirox) only targets certain types of fungi, it is best to have a laboratory test to determine if and what type of fungi are present. One clinical study indicated that less than 12% of patients experienced a partial or total clearing of their nails after treatment with Penlac®. With this in mind, it is best to combine Penlac® with another type of treatment as well. Interestingly, A study published in 2013 showed that children being treated for fungal toenail infections using the ciclopirox nail lacquer had much better treatment results than what we've seen for adults.
The success of the treatment depends on how much of the nail is involved and how well the prescribing instructions were followed — having the affected part of the nail professionally removed on a regular basis is recommended as part of the treatment. This would mean monthly nail debridement (trimming away of affected nail parts), ideally by a podiatrist. A podiatrist or dermatologist may also prescribe a topical medicine to thin the nail or even remove it to enhance the treatment. This is often done with a topical medication known as urea.
Urea paste or cream is applied to the affected nail regularly, under the care of the prescribing doctor, for a few weeks until the affected part of the nail slowly breaks away from the nail bed. One study found that this urea treatment had good results after a 2 to 4 week treatment period, in that the symptoms of the nail infection improved. The study found that using a specific topical antifungal cream along with the urea enhanced the results by eliminating more of the fungus that caused the infection. This type of treatment may not be convenient for most because it usually requires the medicine to be placed under an occlusive bandage.
Over-the-Counter Antifungal Treatments
There are plenty of OTC topical antifungal treatments out there, some of them promising to cure nail fungus, which is probably unrealistic. Most of these products do not penetrate through the nail and reach the nail bed which is also infected. So if you have a very thick nail with advanced signs of fungal infection, such as discoloration and texture changes, chances are you won't have much success with these products alone. The key to improving the treatment outcome is regular nail trimming/debridement and faithful use of the product, which may mean months of regular application.
There are a few natural remedies that have been popularized as nail fungus cures. Two of the better known products rumored to be effective against nail fungus are tea tree oil and Vic's VapoRub®. Both of these products not only have antifungal properties, but they also have an oily texture, which may be better absorbed by the nail.
One small study using Vic's VapoRub® for nail fungus showed promising results. After 48 weeks, 10 of the 18 participants had at least partial clearing of their symptoms, while 5 had complete clearing. More research is needed to get a better idea of how this product compares to others.
Derby R, et.al. Novel treatment of onychomycosis using over-the-counter mentholated ointment: a clinical case series. Journal of the American Board of Family Medicine. Jan-Feb 24 2000(1):69-74.
Friedlander, SF, et. al. Onychomycosis does not always require systemic treatment for cure: a trial using topical therapy. Pediatric Dermatology. May-Jun 2013;30(3:316-22.
Daily Med. Penlac® (ciclopirox) solution [Dermik Laboratories]. Accessed 7/14/13.
Tietz, HJ, et. al. Efficacy of 4 weeks topical bifonazole treatment for onychomycosis after nail ablation with 40% urea: a double-blind, randomized, placebo-controlled multicenter study. Mycoses. Jul 2013;56(4):414-21.