Yelllow, discolored, thick toenails is one of the most common things a podiatrist see’s in their patients. The cause is usually, but not always, a fungal infection. The fancy name for this nail infection is called onychomycosis. Sometimes it is called tinea unguium. Onychomycosis is defined as a fungal infection of the nail bed or nail plate and it accounts for more than half of all nail diseases. Greater than 90% of toenail fungus cases are caused by Trichophyton rubrum. Fungal nails affect a large portion of people throughout the world and the frequency is increased with age and more common in adults but can also be seen in children.
Now that I have introduced you to what onychomycosis is, let’s talk about the causes, presentation, and treatment. I’m going to give you the practical discussion here, not something worded from a textbook.
What causes a fungal nail? There could be many reasons. The number one reason is some sort of trauma to the nail. For instance, if you hit your big toe on the bedpost and you lifted the nail up slightly. This small opening gives way to fungus (which is everywhere!) and so begins the process. Even wearing tight shoes could cause enough trauma to allow the fungus to enter. Second, you must understand what fungus likes... and they like warm, moist environments! What better place than your sweaty feet in socks and a shoe? Fungus is everywhere, but some places it is more prevalent. If you walk around barefoot at the gym where the humidity is high and water is all over the floor, there is a good chance you can get a fungal infection (ex: Athletes foot/Tinea pedis).
Treatment for fungal nails is difficult. It’s not like bacteria and you simply take an antibiotic to kill it. Fungus is more difficult. And there is no 100% cure. There are both topical and oral medications which can help, and for some people, completely get rid of the problem. Let me start by saying there are two main types of fungal infections we see in the office: infection of the nail itself and infection of the skin. The former would be yellow, thick, discolored nails while the latter would be something like “Athletes foot”. The latter is also easier to get rid of because it is limited to the skin. So the treatments I am listing here are for fungal infections of the nail.
The best treatment is an oral medical known as Lamisil. Studies have shown this to be 60-70% effective. The downside is you have to take a pill every day for 90 days. Also, Lamisil is metabolized through the liver so you do have to get your liver enzymes checked to make sure you have a healthy liver. Though it is rare, liver problems can develop with this drug. So often the doctor will order to have your blood drawn and liver markers evaluated. Typically they do this twice, once at the beginning of treatment and the other after 45 days of treatment. Also, results do not come overnight and it takes a full 90 day course to see maximum results.
What about creams? Creams are....creams. To be honest they simply aren’t that effective but it is definitely worth trying for some people. The older creams like topical Lamisil or Clotrimazole have a less than 10% chance at improvement. Newer creams are being developed such as Jublia which is shown to have about a 17% success rate, which isn’t great but it’s better. You must apply the creams every day and again it takes months and months to see improvement, if any.
Lasers are a new treatment that is gaining popularity. The problem is, insurance does not cover laser treatment and you have to pay out of pocket, which can get expensive! You will be paying upwards of $1000 with many practitioners. It’s a developing treatment, but studies are showing promising results but again it is not a 100% cure by no means.
Now, prevention is key especially if you just overcame a fungal infection and want to keep it away. This includes getting new shoes or spraying your old ones with an anti-fungal spray, avoid going barefoot in fungal prone places like the gym showers, not putting lotions in between your toes, and avoiding moist conditions for your feet.
So again, what is the best treatment? For a patient with several moderately to severely infected toenails I do a combination of everything to increase the odds of beating the fungus. I prescribe oral lamisil (and get the labs as well), prescribe a strong anti-fungal cream, dremmel and cut the nail to allow better penetration into the nail, and finally laser treatment as well (though at a significantly lower price). Once cured, preventative measures are then taken as described above. I’m estimating this protocol is effective in over 90% of patients and superior to just using one treatment by itself.
As a 24/7 house & hotel Las Vegas Podiatrist I take pride in my thorough evaluation and treatment of fungal toenails. My treatment of fungal nails are backed by peer reviewed journals and research and in my opinion are the best treatment of onychomycosis. I do not use "cheap" supplies and my inventory is stocked with only the most up to date and high quality supplies. Please call now if you are around Las Vegas and suffer from heel pain, plantar fasciitis, neuroma, ingrown toenail, painful nails, warts, thick and long fungal nails, diabetic feet, ankle sprain, or any other foot/ankle pain.
Dr. Sean Reyes
24/7 Podiatrist in Las Vegas