Nail abnormalities are a common concern among my patients. It is generally something they have been dealing with for years before a medical provider lays eyes on it. Treating nails is difficult because they can take so long to grow out completely. I’m talking up to 12 months for toenails! In this article, I am going to discuss how to treat nail fungus once and for all.
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DETERMINE IF IT IS INDEED NAIL FUNGUS
Sometimes looking at nails is all you need to determine if there is a fungal infection present or not. Other times it is not as obvious. If the latter is the case then the first thing you need to do is a nail clipping to determine it is actually onychomycosis- a fungal infection of the nails. The clipping is sent out to pathology so they can look for signs of fungus. Very commonly, they can’t find evidence of a fungal infection. This could be due to a number of reasons including the clippings weren’t large enough, the patient having tried treating it already, or it being due to something else such as trauma to the nail.
EVALUATE THEIR MEDICAL HISTORY
If the clipping is positive for a fungal infection then you really have two effective options. A topical antifungal solution or an oral antifungal. If I want to be more aggressive, an oral antifungal is the way to go. Does that mean anyone can go ahead and start an oral antifungal? No. Oral antifungals can be harsh on the liver. They can also interact with some medications such as blood thinners. The medical provider will first need to collect the patient’s medical history and list of medications prior to prescribing the medication.
CHOOSE A TREATMENT AND CHECK BLOOD WORK
Once I have reviewed the risks with my patient and have reviewed their medical history, then we will try a 6-week course of oral terbinafine (Lamisil) for fingernails and a 12-week course for toenails. I have the patients come back at week 4 to check their liver enzymes. If there is anything in their history that concerns me of liver abnormalities then I will do baseline blood work to ensure liver enzymes are normal before initiating treatment.
If the patient does not want to risk negatively impacting his or her liver (which I favor) I will prescribe a topical antifungal called ciclopirox or efinaconazole (Jublia). These medications look similar to clear nail polish. The patient needs to apply it to clean nails and skin around the nails daily for an entire 12 months (and sometimes longer) in order to see improvement. The medicine will build up a film and this should be removed with nail polish remover once a week. I also recommend patients pare down their nails regularly. I typically will not recommend the topical treatments to anyone whose onychomycosis involves more than 50% of the nail because, at this point, the likelihood of clearance is low with topical treatment alone.
The moral of the story is nail fungus can be difficult to treat. Oral antifungals can be effective however you have to weigh benefits versus risks with the patient and make sure to check their liver enzymes when appropriate. I will typically follow up with the patients every 3-6 months to ensure the nails are growing out appropriately. Taking photos at these intervals is in my opinion the easiest way to track progress!
*Disclaimer: Opinions expressed are solely my own and do not express the views or opinions of my employer. Information on this website is for education and entertainment purposes only. Content is my opinion. It is not substituted for your own doctor’s medical care or advice. One should not make any health or medical-related decisions based in whole or in part on any content on this site. Content is not intended to replace the services of a licensed, trained health professional. Content may not apply to you as an individual. Although I will update my website with current information, this website is not a definitive guide to dermatology.
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