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Toenail Fungus

Reviewed by
Dr. Joseph DAmico

toenail fungusOnychomycosis, more commonly known as toenail fungus, is a progressive disease that is often ignored due to the lack of pain or other symptoms during the initial stages. Typically it is caused by tinea species (fungus), but it can also be caused by candida species (yeast). The foot is prone to fungal infections because shoes are dark, moist environments. Fungal infections can be passed from person to person through physical contact or by coming into contact with an area that allows for transmission of the fungus, such as a public shower floor. Studies show that toenail fungus doesn’t affect children and adolescents as often as it does adults. It’s estimated that 50 percent of people will contract the condition at least once before the age of 70.

The initial stages of a fungal infection can last for years, giving the infection plenty of time to grow and spread. The infection is generally located underneath the nail. A toenail fungus infection can cause foul smells and discoloration. The fungus that grows under the nail eats keratin, the protein that makes our nails strong and hard. Our big and little toes are most prone to developing fungal infections because they are the toes that most often come into direct contact with our footwear. Some people walk in such a way that the large toe rides upward during propulsion, causing it to rub against the top of the shoe, loosening its furthermost attachment and increasing the likelihood of fungal infection from the repetitive microtrauma to the nail.

There are several risk factors for developing toenail fungus, including:

  • Having a minor skin or nail injury
  • Wearing shoes and socks that do not allow your feet to breathe
  • Psoriasis or skin conditions
  • Excessive sweating
  • Working or living in damp or humid environments
  • Diabetes, circulation problems, or a weak immune system
  • Biomechanical problems that cause repetitive microtrauma to the affected toenail
  • Age

Toenail Fungus Symptoms:

  • Yellow toenails
  • Thick or hardening toenails
  • Foul odor from toenail
  • Toenail appears to be crumbling
  • Splitting of the toenails
  • Pit marks in the toenails
  • Tenderness in the toe around nail borders
  • Pain, ranging from mild to severe; may be constant or intermittent
  • Appearance of debris build-up under the infected nail

In cases of white superficial onychomycosis, the infected toenail turns white instead of green or yellow, and the surface softens, dries, and turns powdery.

What Causes Toenail Fungus?

Toenail fungus can be caused by many different things. As with athlete’s foot, a person can contract toenail fungus by using public showers, locker rooms, gyms, or even home showers that are shared by multiple family members. Any warm, damp place can be a breeding ground for fungi. Fungal infections in the nails are typically caused by a group of fungi called dermatophytes, but yeasts and molds can also cause toenail fungus. Other common things that can cause toenail fungus include:

  • Improper footwear, especially tight-fitting shoes
  • Medical conditions such as diabetes and other circulatory conditions
  • Toenail polish that is applied in layers
  • Hosiery, socks, and shoes that do not allow the feet to breathe
  • Emery boards or instruments that are not properly sterilized between uses, especially those found in nail salons

People who suffer from immune diseases and circulatory conditions are at higher risk for contracting toenail fungus. This is another reason why it’s important to have your feet inspected by a podiatrist or foot doctor at the first sign of trouble.

Diagnosing Toenail Fungus

It won’t take much more than a visual exam for your doctor to determine whether a fungal infection is present. Your doctor will more than likely ask you questions about your symptoms, personal habits, normal activities, family history, and personal medical history. He or she may take samples of the fungus to be examined in a laboratory.

Toenail Fungus Treatment

Your podiatrist will determine the proper treatment method for you based on the severity and extent of the infection. For milder infections, he or she may prescribe a medicated solution containing an antifungal ingredient such as that found in Tincture of Fungaoid, Formula 3, Elon, Fungasil, or Penlac. You apply the polish yourself, generally twice a day until the infection is gone, which could take up to a year. During the course of topical treatment the doctor may suggest that you come in periodically to have the nail thinned in order to allow the medication to penetrate more effectively. If the infection is more severe, your doctor may offer you an oral antifungal medication such as Sporanox or Lamisil. Oral treatments should be considered for individuals who are in good health and have tried topical treatments, especially if multiple nails are involved and the nails are painful. Lab work is required prior to oral treatment in order to assess liver function and safety. If these treatment methods fail, your doctor may consider surgical or chemical removal of your infected toenail. This method is a simple in-office procedure requiring minimal healing time. Removing the infected nail allows a new nail to grow in unless a procedure is performed that permanently destroys the nail matrix (root), but regrowth may take up to a year. Even after use of an oral antifungal medication, the fungus can return, so topical antifungal powers and nail solutions can be used to help prevent recurrence.

Photodynamic laser therapy is a new method being used to treat nail fungus. The nail is exposed to intense light after it’s been treated with an acid. This new method is promising, as many cases have been treated successfully, but this treatment method is not available everywhere. Talk with your doctor about this treatment option.

There are also home remedies you can try to help rid your nails of fungus. Always consult with your doctor before using home remedies. Soaking your foot in a solution of one part vinegar to two parts warm water is one remedy. It is recommended that you soak your feet for fifteen to twenty minutes daily, or at least two to three times per week. This solution is not known to cure nail fungus, but it is proven to prevent the growth of certain bacteria. Vicks VapoRub may also be effective, but you will need to talk with your doctor about how much you should apply and when, because there is no consensus on how to use it for nail fungus. Still, many people believe it works.

It’s very important for a person with toenail fungus to understand that the infection will not go away on its own. Allowing the infected part of the nail to grow out may work for a short time, but the risk is high that the infection will spread to the new nail growing in its place.

Preventing Toenail Fungus

Here are some tips to help you prevent toenail fungus from developing:

  • Avoid wearing socks that do not absorb moisture during warm weather.
  • Avoid shoes that do not allow your feet to breathe in warm weather. Instead, wear sandals.
  • Change your socks every day or after physical activity.
  • Keep your nails short, dry, and as clean as possible.
  • Use antifungal spray or powder if you are at a higher risk for developing toenail fungus.
  • Avoid picking or trimming the skin around your toenails, regardless of whether there is an infection.
  • Air your shoes out between uses.
  • Throw out old, worn-out shoes and socks.
  • Do not share towels, bathmats, or nail clippers with people known to have a nail fungus.
  • Avoid walking barefoot in wet, public places such as locker rooms, pools, gyms, and public showers.
  • Avoid toenail polish, or remove it immediately after social functions.
  • Choose a reputable nail salon for manicures and pedicures. Make sure the salon sterilizes nail instruments and equipment before grooming you. If you are unsure, bring your own nail pack to the appointment.
  • Correct foot dysfunction that may be contributing to the problem
  • Talk with a podiatrist about toenail fungus as soon as it develops.

Questions to Ask Your Doctor

Here are some questions you may want to ask your doctor about toenail fungus:

  • Which over-the-counter products will work best for my toenail fungus? Which products should I avoid?
  • Do you think my infection is severe enough for prescription-strength medication? What lab work do I need?
  • What do you think caused my toenail fungus?
  • How do I avoid spreading my infection to family members who live with me?
  • Should I limit my normal activities during the treatment process?
  • What additional symptoms may begin to develop after treatment begins? If they do, how long should I wait to contact you?
  • What should I do if I know someone who has a fungal infection?
  • Which home remedies do you recommend?
  • Do you have a brochure that I can take home about toenail fungus?
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Medical References:

  1. American Medical Association "Family Medical Guide" 4th Edition (John Wiley & Sons, Inc. 2004) 123; 1073
  2. Taber's Cyclopedic Medical Dictionary, 21 edition (F.A. Davis Company, 2005) 2324-2325
  3. M. Beers "Merck Manual of Medical Information" 2nd home edition (Pocket Books, 2003) 1225
  4. Berkeley Parents Network: Advice about Toenail Fungus, http://parents.berkeley.edu/advice/health/toenailfungus.html
  5. Mayo Clinic, Nail Fungus, http://www.mayoclinic.com/health/nail-fungus/DS00084

This page was last updated on May 30th, 2014



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