Toenail Fungus Treatment (Onychomycosis)
Toenail Fungus is known as Onychomycosis (also known as
"toenail fungus," "fingernail fungus," "dermatophytic
onychomycosis," "ringworm of the nail," and "tinea unguium") means
fungal infection of the nail. It is the most common disease of the
nails and constitutes about a half of all nail abnormalities.
This condition may affect toenails or fingernails, but
toenail infections are particularly common. The prevalence of
onychomycosis (toenail fungus) is about 6-8% in the adult
population, although estimates are as high as 18% in the American
(United States) adult population.
There are four classic types of onychomycosis (toenail fungus):
- Distal subungual onychomycosis (toenail fungus) is the most
common form of tinea unguium, and is usually caused by
Trichophyton rubrum, which invades the nail bed and the
underside of the nail plate.
- White superficial onychomycosis (WSO) is caused by fungal
invasion of the superficial layers of the nail plate to form
"white islands" on the plate. It accounts for only 10 percent of
onychomycosis (toenail fungus) cases. In some cases, WSO is a
misdiagnosis of "keratin granulations" which are not a
but a reaction to nail polish that can cause the nails to have a
chalky white appearance. A laboratory test should be performed
- Proximal subungual onychomycosis (toenail fungus) is fungal
penetration of the newly formed nail plate through the proximal
nail fold. It is the least common form of tinea unguium in
healthy people, but is found more commonly when the patient is
- Candidal onychomycosis is Candida species invasion of the
fingernails, usually occurring in persons who frequently immerse
their hands in water. This normally requires the prior damage of
the nail by infection or trauma.
Signs and Symptoms of Toenail Fungus
The nail plate can have a thickened, yellow, or cloudy
appearance. The nails can become rough and crumbly, or can separate
from the nail bed. There is usually no pain or other bodily
symptoms, unless the disease is severe.
Dermatophytids are fungus-free skin lesions that sometimes form as a
result of a fungus infection in another part of the body. This could
take the form of a rash or itch in an area of the body that is not
infected with the fungus. Dermatophytids can be thought of as an
allergic reaction to the fungus.
Patients with onychomycosis (toenail fungus) may experience
significant psychosocial problems due to the appearance of the nail.
This is particularly increased when fingernails are affected.
Causes of Toenail Fungus
The causative pathogens of onychomycosis (toenail fungus) include
dermatophytes, Candida, and nondermatophytic molds. Dermatophytes
are the fungi most commonly responsible for onychomycosis (toenail
fungus) in the temperate western countries; while Candida and
nondermatophytic molds are more frequently involved in the tropics
and subtropics with a hot and humid climate.
Trichophyton rubrum is the most common dermatophyte involved in
onychomycosis (toenail fungus). Other dermatophytes that may be
involved are T. interdigitale, Epidermophyton floccosum, T.
violaceum, Microsporum gypseum, T. tonsurans, T. soudanense
(considered by some to be an African variant of T. rubrum rather
than a full-fledged separate species) and the cattle ringworm fungus
T. verrucosum. A common outdated name that may still be reported by
medical laboratories is Trichophyton mentagrophytes for T.
interdigitale. The name T. mentagrophytes is now restricted to the
agent of favus skin infection of the mouse; though this fungus may
be transmitted from mice and their danders to humans, it generally
infects skin and not nails.
Other causative pathogens include Candida and nondermatophytic
molds, in particular members of the mold generation Scytalidium
(name recently changed to Neoscytalidium), Scopulariopsis, and
Aspergillus. Candida spp. mainly cause fingernail onychomycosis
(fingernail fungus) in people whose hands are often submerged in
water. Scytalidium mainly affects people in the tropics, though it
persists if they later move to areas of temperate climate.
Other molds more commonly affect people older than 60 years, and
their presence in the nail reflects a slight weakening in the nail's
ability to defend itself against fungal invasion.
Risk factors of Toenail Fungus
Risk factors for onychomycosis (toenail fungus) include family
history, increasing age, poor health, prior trauma, warm climate,
participation in fitness activities, immunosuppression (e.g., HIV,
drug induced), communal bathing, and occlusive footwear.
Diagnosis of Toenail Fungus
To avoid misdiagnosis as nail psoriasis, lichen planus, contact
dermatitis, trauma, nail bed tumor or yellow nail syndrome,
laboratory confirmation may be necessary. The three main approaches
are potassium hydroxide smear, culture and histology. This involves
microscopic examination and culture of nail scrapings or clippings.
Recent results indicate the most sensitive diagnostic approaches are
direct smear combined with histological examination, and nail plate
biopsy using periodic acid-Schiff stain. To reliably identify
nondermatophyte molds, several samples may be necessary.
Treatment of Toenail Fungus
Treatment of onychomycosis (toenail fungus) is challenging
because the infection is embedded within the nail and is difficult
to reach. As a result, full removal of symptoms is very slow and may
take a year or more.
Pharmacological Treatment of Toenail Fungus
Most treatments are either systemic antifungal medications, such
as terbinafine and itraconazole, or topical, such as nail paints
containing ciclopirox or amorolfine. There is also evidence for
combining systemic and topical treatments.
For superficial white onychomycosis (toenail fungus), systemic
rather than topical antifungal therapy is advised.
Other methods include oral medication, such as: itraconazole (Sporanox),
fluconazole (Diflucan), or terbinafine (Lamisil). These medications
permit the nail to grow infection-free, gradually replacing the
infected part of one’s nail. These medications must be consumed for
six to twelve weeks, but the final result will not be seen until the
nail fully grows out. However, it may take four months or longer to
eliminate an infection, depending on the severity of the infection,
as well as the rate at which one’s nails grow. Future infections are
likely to occur, principally if one continues to expose the nails to
warm and/or moist conditions. Drawbacks of this method include side
effects, such as headache, upset stomach, skin rashes, or allergic
reactions to ingredients in the medication. Other side effects (of a
more serious nature) include: liver damage and heart failure.
Relative effectiveness of toenail fungus treatments
Amorolfine is currently the most effective topical treatment for
onychomycosis (toenail fungus), but is not approved in the United
States or Canada. Amorolfine 5% nail lacquer in once-weekly or
twice-weekly applications has been shown in well designed,
placebo-controlled studies to be between 60% and 71% effective in
treating toenail onychomycosis (toenail fungus); complete cure rates
three months after stopping treatment (after six months of
treatment) is estimated to be between 38% and 46%.
Itraconazole is effective for oral treatment of onychomycosis
(toenail fungus). Pulse dosing (escalating drug levels early in the
dosing interval followed by a prolonged dose-free period) is 61% to
75% effective in providing a complete cure.
In July 2007, a meta-study reported on clinical trials for topical
treatments of fungal nail infections. The study included six
randomized, controlled trials dating up to March 2005.
The main findings are:
- There is some evidence ciclopiroxolamine and butenafine are
both effective, but both need to be applied daily for prolonged
periods (at least 1 year).
- There is evidence topical ciclopiroxolamine has poor cure
rates, and that amorolfine might be substantially more
- Further research into the effectiveness of antifungal agents
for nail infections is required.
A 2002 study compared the efficacy and safety of terbinafine in
comparison to placebo, itraconazole and griseofulvin in treating
fungal infections of the nails. The main findings were for reduced
fungus, terbinafine was found to be significantly better than
itraconazole and griseofulvin, and terbinafine was better tolerated
- A small study in 2004 showed ciclopirox nail paint was more
effective when combined with topical urea cream.
- A study of 504 patients in 2007 found aggressive debridement
of the nail, combined with oral terbinafine, significantly
reduced symptom frequency over terbinafine alone.
- A 2007 randomized clinical trial with 249 patients showed a
combination of amorolfine nail lacquer and oral terbinafine
enhanced clinical efficacy and is more cost-effective than
Drug pipeline of toenail fungus treatments
Most drug development activities are focused on the discovery of
new antifungals and novel delivery methods to promote access of
existing antifungal drugs into the infected nail plate. Active
clinical trials investigating onychomycosis (toenail fungus):
A medicinal nail lacquer, MycoVa™ from Apricus Biosciences,
contains terbinafine as the active ingredient and a permeation
enhancer DDAIP which facilitates the delivery of the drug into the
nail bed where the fungus resides.
A comparison of delivery methods for itraconzole
Safety and tolerability of topical terbinafine
Bifonazole cream application after nail ablation with urea paste
A topical treatment, AN-2690, is being developed by
Schering-Plough Corp and Anacor Pharmaceuticals. It is active
against Trichophyton species.
Posaconazole, taken orally.
A topical treatment, NB-002, is being developed by NanoBio
Corporation. It has completed Phase II trials.
Drug-free treatments of toenail fungus
Nd:YAG lasers are being used for treatment of toenail
fungus. These lasers target the fungus while leaving surrounding
nail and tissue undamaged. Published research has shown an
effectiveness between 70 and 80%, and in many cases, a single
treatment is sufficient. This treatment is safe and has no side
effects, since the laser is applied directly to the infection.
A Noveon-type laser, already in use by physicians for some
types of cataract surgery, is used by some podiatrists, although the
only scientific study on its efficacy, while showing positive
results, included far too few test subjects for the laser to be
proven generally effective.
The Ontario Osteopathic and Alternative Medicine Association in
Ontario, Canada, have developed a laser-based method, "LAFT", which
is claimed to have a 96% success rate based on "hundreds of
treatments given". However, no scientific studies seem to have been
performed and the website promoting the treatment has shown to
contain biased and false information on the efficacy of conventional
To date, there are several lasers seeking approval and one that has
been cleared by the Food and Drug Administration.
Natural remedies for toenail fungus
As with many diseases, there are also some scientifically
unverified folk or alternative medicine remedies.
- Australian tea tree oil has been tested, but there is
insufficient information to make recommendations for its use for
onychomycosis (toenail fungus).
- Grapefruit seed extract as a natural antimicrobial is
not demonstrated. Its effectiveness is scientifically
unverified. Multiple studies indicate the universal
antimicrobial activity is due to contamination with synthetic
preservatives that were unlikely to be made from the seeds of
- Thymol, an ingredient common in mouthwashes and
medicated chest rub ointments, has been shown to have a
potential to be effective against the fungus that commonly
- Snakeroot leaf extract has, in studies, shown ability
to treat superficial onychomycosis (toenail fungus), although
the results show it is less effective, and equal to conventional
drugs ciclopirox and ketaconazole, respectively.
List of tinea infections
List of cutaneous conditions
NOTE: The above information originated from Wikipedia, the free
Readers Write About Toenail Fungus
Home remedies for toenail fungus
Onychomycosis (toenail fungus) can be caused by many
different fungi, and many other conditions like a psoriatic nail and
paronychia can look so much like it that dermatologists still need
to have a lab workup done. What was the causal agent, if any, of the
wife's onychomycosis (toenail fungus) that was relieved with
vinegar? How can anyone possibly give universal medical advice based
on one person's kitchen experiments with the application of 19th
century hygiene principles to an (I strongly suspect) undiagnosed
Mercurochrome contains mercury and is banned in the US. All sorts of
these common home disinfectants were tested against fungal skin and
nail infections in the 1910's to 1950's and the only one that stood
out as somewhat effective was Whitfield's ointment, with the active
ingredient benzoic acid. But even it doesn't stand up to scientific
comparison as a serious onychomycosis (toenail fungus) remedy. The
common fungi causing dermatophyte onychomycosis are too deeply
seated in the nail to be affected by materials applied to the
surface (unless the materials are combined with chemical nail
softeners under occlusion). Mercurochrome is commonly used in
developing countries to treat fungal ear canal infestation (otomycosis),
but there the fungus is right at the surface. Mercurochrome can't
even penetrate to kill the endospores within spore-forming bacteria.
Toenail fungus isn't life-threatening but casual treatment
recommendations based on anecdotes are no more helpful here than
they are in any other disease. No doubt carrot juice and staying
optimistic cured somebody's wife's cancer somewhere, but there's a
serious ethical problem with extending this observation into a
general prescription. Yes, any individual could make a novel
observation -- but there's nothing novel about applying vinegar,
iodine, garlic, lemon peel, oregano, etc. against fungal skin
infections. It's been done. Tea tree oil is still being
investigated but results are mixed (for references go to Entrez
PubMed website and search on keywords: tea tree oil onychomycosis
(or toenail fungus). Also: tea tree oil tinea. Also: tea tree oil
dermatophyte). Keywords for the otomycosis statement above are
Summerbell 18:32, 26 September 2006
Remember, Wikipedia does not exist to provide medical or health
advice. For medically oriented articles such as this one the focus
of the article is etiology and the popular treatments, peer reviewed
scientifically proven treatments as well as popular folk remedies.
Even if these folk remedies are totally useless or even counter
productive and dangerous. This provides those reading the article a
good overview of all the available "treatments," and more
importantly the place of the disease within our society as a whole.
Besides anyone reading Wikipedia as their sole source of diagnoses
and treatment information has greater problems. 9 October 2007
What is the life cycle of toenail fungus?
Mercurochrome cured it for me. Unfortunately, this probably counts
as original research. -- ProveIt 4 January 2006
Anyone interested in a picture for this article?
I could get one. The question is, would anyone really want to see
The article lacks a good quality image, go for it. Pgr 21 October
My wife had an infection and cured it by soaking the infected toe
for 30 minutes in vinegar every day for 3 months. She would keep the
nail as trimmed as possible the whole time. Don't cause your body
stress with something like Lamisil. Save your money and health.
FDA Topical Antifungal Monograph
I wanted to add something on the FDA OTC Topical Antifungal
Monograph, but all I could find were some very general bits of info
on the FDA website. I also haven't been able to find anything on the
FDA's 1994 ruling that said that no OTC anti-fungal product was
effective on nails, and required the wording "this product is not
effective on scalp or nails" on all OTC anti-fungal products (even
if they were still allowed to use trademarks such as Fungi-Nail!).
The closest I could find was this DOC file Comparison of Labeling
for All Topical Antifungals Treating Athlete’s Foot. Can anyone
provide better information? BlankVerse 29 August 2006
Ineffectiveness of Tea-tree oil - evidence?
Tea tree oil is a known antifungal. The topical application of high
levels is a verified remedy for some dermatophytic skin infections
although not for onychomycosis (toenail fungus), where the fungus is
often too deeply nested in dense subsurface nail tissue to be full
expunged by topically applied materials of any kind.
The article that is referenced does not say that tea-tree oil
doesn't work because the fungus is too deep subsurface. This needs
more evidence or is WP:OR. 13 June 2007
Removal of passage
The section related to tea tree oil
was removed from the
'natural remedies' section via this edit by User:Was this removal in
accordance with consensus? --User:Ceyockey 1 July 2007
I think it was because of the WP:OR reference to the fungus being
too deep to be treated by Tea tree oil. If you want to put it back
in and either find a source for this claim or remove it feel free.
Personally I tried treating my fungus militantly with Tea tree
oil, with four treatments a day. During this period the fungus,
which had been advancing, went into remission in all my nails, but
the fungus under a few toe nails was persistent. I eventually
stopped treatment and the fungus has not returned in any nails, but
has grown back in the nails where it was still present. 9 October
Here is a summary of this topic from a 2002 article in the Journal
of Antimicrobial Chemotherapy:
Based on both its inhibitory and fungicidal action,
tea tree oil
may be a useful agent for treating dermatophyte infections.
However, exactly how this in vitro activity translates into in vivo
effectiveness is unclear.
[... summary of two clinical trials ...]
Given that onychomycosis (toenail fungus) rarely responds to topical
therapy and is therefore usually treated systemically, it is perhaps
not surprising that the topical application of tea tree oil was of
limited effectiveness in these two clinical trials. This emphasizes
the need for more clinical trial data, particularly in relation to
tinea pedis, which can often be treated successfully topically.
So it seems there is little-to-no evidence to support the claim
either way. Furthermore, given topical treatments don't really work
for toenail fungus, there are grounds for believing tea-tree oil
won't work either. Pgr 94 9 October 2007
Crocodile Oil: There is something amazing in the crocodile’s immune
system, there are strings of peptides that were only discovered very
recently in the last eight or nine years and they are a powerful
mechanism for fighting bacteria and fungal infections. Repcillin
Crocodile Skin Balm is made in South Africa and uses the fat from
CITES approved Crocodile farms in Africa.
Is this verifiable? WP:V Pgr94 26 June 2007
This completely unverifiable: the only sources discussing Crocodile
Oil are those selling it, usually trying to blind with
pseudo-science. For more on this see the discussion for Crocodile
Oil Almost-instinct 19 April 2008
Wanted: images for each type of onychomycosis (toenail fungi)
There are different types of onychomycosis. It would be good to get
images of each type. For example see Pgr94 18 September
Different types of toenail fungus will look mostly the same,
be somewhat misleading (as for the most part, this is not a tool
used to diagnose the type of fungus... and may be somewhat trivial
to categorize. Certainly additional fungi photos of a general nature
are always of value. —Preceding unsigned comment added by Spamwatch
(talk • contribs) 13 November 2007
Vinegar passage removed. As no evidence has been found for
vinegar since Feb. 2007, I have removed it.
Distilled white vinegar. Drops are applied to the cuticle
twice a day. This method does not kill the fungus, but the vinegar
allegedly changes the pH (acid content) of the new nail formed in
that 12-hour period. (The scientific perspective, however, is that
vinegar is unlikely to penetrate the dense keratinous tissue
thoroughly enough to have any significant effect. Instead, it may be
absorbed by the skin above the nail and work its way to where the
nail is actually forming.) As the old, infected nail grows and is
cut away, it is said to be replaced by an acidic nail, uninhabitable
by fungi. Several months of consistent application are involved. 29
I went to a podiatrist who told me to soak my foot in white vinegar
for three months but I won’t see the results for one year. June 1
2009. —Preceding unsigned comment added 13 May 2009
If someone with access to good sources could examine these issues
and possibly amend the article it would be appreciated.
The fungus "infects" the nail. Could this be clarified as to
whether fungus is growing under and around the nail, or within the
material of the nail itself?
Also the difficulty of treatment seems to be because of the
difficulty of getting the treating agent to the best location. Is
drilling holes in, or filing of, the toenail a workable option?
Thanks, Wanderer57 30 March 2008
Recent reviews (Aug 2008)
Short of time right now so this a note to self, or anyone who else
wants to follow recent developments. see reviews PubMed and PubMed...
check differential diagnosis of psoriatic nails. 20 October
Listerine and vinegar
I've had severe toenail fungus for just over forty years. It started
when I lived in the tropics.
At this writing, the fungus is completely expelled in two nails, is
almost done being expelled in four others, and halfway gone in the
big toes. Two were already clear.
How? I soak the toes in 50% Listerine, 50% white vinegar, for 30-45
minutes every night. I started about four months ago. I didn't make
this up - a Google search for "Listerine toenail fungus" finds many
testimonials, and occasional discussions of the method of operation.
It seems that the fungi can't handle eucalyptol and thymol, plus the
other assorted toxins that make Listerine lethal when a lot is
Not sure if a photo of the half-clear big toes would be helpful. —
Preceding unsigned comment added by MoonDJ 31 July 2010
On recommendation from my GP, using a cotton swab, applying a single
drop of undiluted bleach twice a day underneath my toenail is
rapidly removing the fungus. Half of the nail bed has recovered in 6
months. Application is quick and there seems to be no tissue damage.
If considered, use caution though... RudiBosbouer 14 January
The above info originated from Wikipedia:
Click for Wiki References to the section above about "Toenail
End of material originating from Wikipedia.