Toenail fungus treatment

The short answer

Toenail fungus almost never goes away on its own, and clearing it takes prescription medicine; over-the-counter skin creams aren’t enough.^[5,4] For most people, the first step is to confirm that it really is fungus. Then you choose tablets or a medicated nail solution based on how severe it is, your health and your preference.^[1] We thin the thickened nail and treat any athlete’s foot. Then comes the slow part: waiting for clear nail to grow in.

Is it really fungus?

Fungal nails usually become thick, yellow or brown and brittle, and they can lift away from the skin underneath or develop an unpleasant smell.^[1] But nails damaged by repeated minor injury, and nails affected by psoriasis, can look just like a fungal infection.^[2] Very thick, curved, overgrown nails can also come from psoriasis or poor circulation, and they need professional trimming.^[6] Because treatment takes many months and tablets can have side effects, the diagnosis should be confirmed before you start.^[1]

Fungal nails are more likely with age, after a nail injury, with a bunion, athlete’s foot, sweaty feet or tight shoes, and with psoriasis, diabetes or poor circulation.^[7]

A dark streak is different. A new or changing brown or black streak in a toenail should be checked promptly for melanoma, a serious skin cancer. Not every dark streak is melanoma, but melanoma caught early is easier to treat.^[6]

How we confirm it

We examine your nails and both feet, including between the toes, and ask about injuries, sports and footwear. Then we take a small sample in the office: a clipping of the affected nail and some of the crumbly material underneath it.^[4] A laboratory looks for fungus under the microscope and, depending on the test, grows it in culture, stains the nail (a PAS stain) or tests it for fungal DNA (PCR).^[1] If it doesn’t find fungus, we look again at other causes before committing you to months of medication.

Treatment options

Prescription tablets. Terbinafine is the usual first choice for toenail fungus: it works well, is generally well tolerated and is inexpensive.^[2] In a Cochrane review of 48 trials, terbinafine and the azole antifungals (such as itraconazole) cleared toenail infections far more often than placebo, and terbinafine probably worked better than the azoles, with a similar rate of side effects.^[8] For toenails, terbinafine is taken once a day for 12 weeks. Side effects are usually mild, such as headache, rash or an upset stomach. Liver damage is possible but rare, so a liver blood test is recommended before you start, and some doctors repeat it about six weeks in.^[4,1] We also review your other medicines, because terbinafine can interact with some antidepressants, beta blockers and tamoxifen.^[1]

Prescription nail solutions and lacquers. Efinaconazole, tavaborole and ciclopirox are applied to the nail every day, usually for about a year.^[4,3] They have fewer side effects and drug interactions than tablets and suit mild to moderate infections, but they clear the fungus less often.^[1] In a Cochrane review they worked better than an inactive solution, yet complete clearing of the nail was relatively uncommon.^[3]

Nail debridement. Thinning a thick nail in the office makes shoes more comfortable and walking and trimming easier, and it helps medication work better.^[4,1] On its own, though, thinning doesn’t remove the infection, because the fungus also lives in the nail and the tissue beneath it.^[5]

Treating athlete’s foot too. Fungus on the skin of the feet commonly spreads into the nails, and a mild case can pass for dry skin, so we check for it and treat both together.^[5] See athlete’s foot.

How long until the nail looks normal?

The damaged part of the nail doesn’t heal; it has to grow out. A 12-week course of tablets can clear the fungus, but the old, discolored nail stays until healthy nail grows in from the base and pushes it forward.^[5,4] For a big toenail that takes a year or longer, and up to about 18 months.^[5,1] Smaller toenails take less time. We check progress at follow-up visits and keep the nail thinned as it grows. Our article on how long toenail fungus takes to go away explains what to expect.

Preventing reinfection

About a quarter of treated infections come back, and having had nail fungus once raises the chance of another.^[1,4] Dermatologists recommend these habits to lower the risk:^[9]

• Wear clean socks every day and change sweaty ones. Let shoes dry for 24 hours between wears, and use an antifungal powder or spray in them.
• Wear sandals in locker rooms, shared showers and on pool decks.
• Don’t share nail clippers, towels or shoes, and disinfect your clippers after each use.
• Keep toenails short and trimmed straight across.
• Treat athlete’s foot as soon as it starts, and make sure anyone you live with who has it, or nail fungus, is treated too.
• Throw away or disinfect the shoes you wore before treatment, and wash socks in hot water.

After the infection clears, some people are advised to keep using a medicated nail treatment for a year or longer to help keep it away. This can be especially helpful for people with diabetes, poor circulation or a past nail injury.^[4] See also preventing athlete’s foot.

Toenail fungus and diabetes

In a systematic review of ten studies with more than 5,600 people with diabetes, about 3 in 10 had onychomycosis. It was more common in people with nerve damage (neuropathy) or a higher A1C, the long-term measure of blood sugar. Most of the studies were of low quality, and the review found no clear link between fungal nails and foot ulcers.^[10] Nerve damage matters for another reason: with numb feet you may not feel a blister or a cut, and small sores can become infected.^[11]

If you have diabetes, have a foot doctor trim your toenails if they are thick or yellowed, or if you can’t see, feel or reach your feet.^[11] Nail care and regular foot checks are part of our diabetic foot care.

Common questions

Can a Foot and Ankle Surgeon or podiatrist treat toenail fungus?

Yes. Dr. Ozturk is a Foot and Ankle Surgeon and podiatrist, and confirming fungal nails, prescribing treatment and thinning thick nails are routine care at our offices in Lyndhurst, Paramus and Millburn, NJ.

Will toenail fungus go away on its own?

Almost never. It can spread to other nails, and to other people through shared towels, nail clippers and wet floors. Mild infections caught early are the easiest to treat.^[5]

Do over-the-counter creams or home remedies work?

Not on the nail. Over-the-counter terbinafine cream works on the skin for athlete’s foot, but it can’t get through the nail to the infection. Home remedies such as tea tree oil and mentholated rubs have been tested only in small studies, so how well they work is unknown.^[4]

Is terbinafine safe?

For most people, yes: it is generally well tolerated.^[2] It usually isn’t prescribed if you have liver disease. Serious liver problems are rare, and the liver blood test checks for them.^[1,4] Call us right away, or get emergency care, if you notice yellowing of the skin or eyes, dark urine, pale stools, pain in the upper right part of the abdomen, extreme tiredness, or nausea, vomiting or loss of appetite. Terbinafine can also change or dull your sense of taste or smell, sometimes for a long time, so tell us if that happens.^[12] It isn’t taken while breastfeeding, and treatment can usually wait until after pregnancy.^[4] If tablets aren’t right for you, a nail solution with regular thinning is a reasonable option for milder infections.^[1]

What if the treatment isn’t working?

First, we make sure it really is a fungal infection; nails damaged by repeated minor injury or psoriasis look very similar.^[2] Fungus that resists terbinafine, the usual first-choice tablet, is also becoming more common, including in toenails. These infections may need specialized testing and longer treatment.^[2] Keep in mind that a big toenail takes a year or longer to grow out clear, so old, discolored nail isn’t always a sign that treatment has failed.^[5]

When to seek care