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Treating toenail fungus

Expensive prescription drugs are rarely worthwhile

Published: July 2010

Rarely does the lowly toenail generate much interest. But quite the opposite is true in the drug marketing field.

Millions of dollars are spent each year on ads to promote medications to be used in mostly futile attempts to eradicate onychomycosis, or nail fungus, a hardy, microscopic organism that infects some 35 million people in the U.S.

The deformed grayish, greenish, yellowish toenails of fungal infection are hard to miss or misdiagnose. Occasionally they may be confused with the nails of psoriasis (lichen planus) or nails that have been traumatized by a heavy object falling on the nail bed. In advanced cases, the nail can be crumbly or difficult to cut.

Treatment is only occasionally medically necessary, and then mostly to prevent secondary bacterial infections. That's especially true for diabetic patients, who seem to be more affected, and for those with compromised immune systems. Most people treat toenail fungus for cosmetic reasons.

Home remedies

Illustration: Mark Matcho

A Google search on toenail fungus treatments produces more than a half-million hits, with plenty of ads for do-it-yourself topical liquids, salves, and creams. Several of the treatments contain ingredients loosely regulated by the Food and Drug Administration and categorized as supplements, such as acetic acid, and a variety of oils, including jojoba, lavender, lemongrass, and tea tree. Some are capable of killing some fungi. All clamor for your attention and dollars. Some offer money-back guarantees that expire long before you're able to see any success. Randomized, controlled trials are lacking, and evidence for cures is scant.

Two popular over-the-counter or home remedies are water-diluted vinegar foot soaks and Vicks VapoRub. Details of use are up to you since neither comes with printed instructions for treating toenail fungus. Because it is relatively cheap and nontoxic, we think that VapoRub— which contains eucalyptus, menthol, camphor, and other oils—may be worth a try.

Prescription options for toenail fungus

If you decide to treat with a prescription drug, for whatever reason, it will cost you. Bear in mind that there is no medicine that is effective or safe for everyone. Two prescription oral antifungal drugs, Terbinafine (Lamisil and generic) and itraconazole (Sporanox and generic), have been in use for several years and have been shown to be effective in up to 50 percent of takers. Monitoring is necessary since either can be toxic to the liver. Costs for a three-month course of treatment can run up to several hundred dollars, not including doctor's visits and cost of tests.

Ciclopirox (Penlac Nail Lacquer and generic) is a less effective paint-on medication and has to be applied daily for at least four months and probably longer. Laser treatment recently arrived on the scene, and a single treatment, usually by a podiatrist, may be effective nearly 90 percent of the time, but at around $1,200 a pop.

Marvin Lipman, M.D.

Chief Medical Adviser and Medical Editor
   

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