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Fungal Toenails

Written by: Becki Murray

Updated by: Alice Hart-Davis

Last Updated: 5 January 2024

Even a quick glance at fungal toenails suggests that they’re bad news — and that is indeed the case. Not only can the discolouration and thickening make your nails look unsightly, but fungal toenails are a medical issue that can spread, so it isn’t something to just ignore. Read to discover what exactly a fungal toenail is, what causes the condition and the array of treatment options that are available to get rid of them for good. You should be feeling more comfortable in your sandals (and just in general) in no time…

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Fungal Toenail

What are fungal toenails?

Fungal toenails are infections that affect the toenails, discolouring them and making them thick and brittle. The condition is medically known as onychomycosis, from the Greek words for nail (ónyx) and fungus (mykēs), and, unfortunately, it can be hard to eliminate. What’s more, if you have fungal toenails, you can pass them on to others, and equally you can pick them up from other people too, or even give them to yourself.

What causes fungal toenails?

Fungal toenails are caused by a fungal infection invading the toenail. They are typically caused by dermatophyte fungus, a pathogenic fungus that grows on skin and other living surfaces and that can cause athlete’s foot and similar conditions.

The fungus works its way into the nail and into the nail bed beneath the nail. Typically you’ll first see a white spot or a yellow spot underneath the tip of the toenail, because this is where the fungus can most easily get into the nail. The infection then grows and spreads.

What treatments are available for fungal toenails?

Five main treatments are available for fungal toenails:

  •       Topical antifungal treatments
  •       Medicated nail creams
  •       Oral antifungal medications
  •       Laser and light-based therapies
  •       Surgery to remove the fungal toenails

This section discusses these treatments in detail. First, though, you should make sure that your toenail problem is indeed fungal toenails.

1a) Getting your condition diagnosed

Normally, the best way to start is by going to your doctor for a definitive diagnosis rather than trying to treat the problem with over-the-counter medications. Assuming that the diagnosis is indeed fungal toenails, the doctor will likely prescribe a prescription-strength topical antifungal agent, which is discussed next.

1b) Topical antifungal agents

The first line of attack on fungal toenails is topical antifungal agents. Some antifungal agents are available over the counter, but the heavier-duty antifungal agents are prescription medicines. If you have a mild case of fungal toenails, an over-the-counter antifungal agent may be enough to clear it up. Generally, however, you are better off using a prescription-strength antifungal agent to get rid of the infection without giving it time to take root. Getting rid of a fungal toenail can take a year or more, so it is best to start immediately.

Of these prescription antifungal agents, the most widely used is ciclopirox, which comes as a lacquer that you apply to your fungal toenails and the surrounding skin once a day. You will typically need to file down the nails, removing loose parts and rough surfaces to enable the lacquer to penetrate farther into the nail and the nail bed. Another lacquer-style treatment is amorolfine, which you apply once or twice a week to your affected toenails. Two newer daily treatments are tavaborole and efinaconazole. With efinaconazole, you do not need to file down your toenails.

2) Medicated nail creams

Medicated nail creams are another means of tackling fungal toenails. These creams usually contain one of four antifungal agents — ciclopirox, terbinafine, clotrimazole, or ketoconazole — and are applied to the skin around the nails and to the nails themselves. Medicated nail creams may not be effective enough to clear up deep-seated fungal infections on their own. Doctors sometimes prescribe them alongside oral antifungal medications, discussed next.

3) Oral antifungal medications

If topical antifungal medications do not clear up your fungal toenails, or do not clear up the infection completely, the next means of treatment is oral antifungal medications. These have a systemic effect — working on your entire body, not just topically on the toenails — and are typically effective for clearing up severe or extensive fungal infections. The disadvantage is that oral antifungal medications can have unpleasant side effects.

These are the three oral antifungal medications most widely used for fungal toenails:

  •       Terbinafine. A course of treatment for fungal toenails typically lasts 12 weeks. The side effects can include gastrointestinal upsets, headache, rash, and (rarely) liver problems.
  •       Itraconazole. A course of treatment for fungal toenails lasts about 12 weeks, but the treatment may be pulsed (delivered on and off) rather than continuous. Side effects may include rash, nausea, and liver enzyme elevations.
  •       Fluconazole. A course of treatment for fungal toenails typically lasts several months. Side effects may include nausea, abdominal pain, and liver problems.

4) Laser and light treatments

Other means of treating fungal toenails include laser treatment and photodynamic therapy (PDT):

  •       Laser treatment: The practitioner uses a laser, such as an Nd:YAG laser, to heat the toenail and the fungus, trying to stop the fungus from spreading. The treatment normally requires multiple sessions a few weeks apart. The treatment appears to work in some people, but further research is needed to determine the best way to treat fungal toenails with lasers.
  •       Photodynamic therapy (PDT): The practitioner applies a photosensitising agent — such as 5-aminolevulinic acid (5-ALA) or methyl aminolevulinate (MAL) — to the nail, and then activates it using a specific wavelength of light. This treatment usually requires multiple sessions, and its success rate and long-term effects are still being determined.

5) Surgical removal of the toenail

The last resort for dealing with fungal toenails is to remove the affected toenails surgically. This operation is called avulsion or nail excision and is performed under local anaesthetic. Depending on the severity of the infection, either the whole toenail or just part of it is removed, exposing the underlying nail bed. The nail bed is then usually treated with a topical antifungal agent to reduce the risk of reinfection. After the operation, the nail grows back. But, it is important to note that this takes several months, and there is a risk that the nail may become ingrown or grow back crooked.

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Are fungal toenails contagious? How can I avoid getting them?

Yes, fungal nails are contagious. That means you can get them in several ways. These are listed here, with countermeasures you can take to avoid infection:

  • Direct contact. Touching another person’s fungal toenail or their foot can transfer the fungus to you.

Countermeasure: Avoid direct contact with infected toenails or feet.

  • Contact with infected surfaces. Fungi can not only survive but also thrive in warm, moist conditions, such as on surfaces in locker rooms, showers, saunas, and swimming pools. Your bare feet can pick up a fungal infection in such places.

Countermeasure: Wear shower shoes or flip-flops rather than going barefoot.

  • From your own athlete’s foot. Athlete’s foot is a fungal infection of the skin. You can easily transfer it to your toenails.

Countermeasure: If you get athlete’s foot, treat it immediately. After washing your feet, dry them thoroughly, making sure to dry fully between your toes. If you are prone to getting athlete’s foot, use an antifungal spray or powder on your feet and toes.

  • Sharing nail clippers, socks, or shoes. If you share such items with someone who has fungal toenails, you may well collect the fungus.

Countermeasure: Avoid sharing shoes and socks. Disinfect nail clippers, nail files, and nail lifters after use.

How should I cut my fungal toenails?

When cutting fungal toenails, make sure you use suitable tools and take care to prevent the fungal infection from spreading to unaffected nails.

1) Start by lining up the tools you need:

  • Toenail clippers. Use clippers with straight blades. Don’t use fingernail clippers with curved blades.
  • Nail file. You may need to file down rough or broken pieces of toenail.
  • Hydrogen peroxide or alcohol wipes. You need one or the other to disinfect the clippers and nail file after cutting your nails.

2) Next, wash your feet with soap and water, then dry them thoroughly, especially between your toes. Optionally, put on disposable gloves, such as medical treatment gloves.

3) With the clippers, trim each toenail straight across at the end of the toe tip. Avoid rounding the corners of the toenail, because doing so can cause the toenail to turn inward and become ingrown.

4) File down any rough parts of the nail. If the nail has grown thick, you can also file down the thickness. Sometimes you may need to file a nail down before you can cut it with the clippers.

5) After cutting your nails, use the hydrogen peroxide or alcohol wipes to disinfect the clippers and nail file. If you wore gloves, remove them and dispose of them; if you didn’t wear gloves, wash your hands thoroughly.

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