Toenail fungus, known medically as onychomycosis, is a common problem. Toenail fungus can be unpleasant to live with, causing a bad smell, crumbly toenails, and itchiness around the affected nail. It can also spread to other people.
If you have diabetes or a compromised immune system, a fungal toenail infection may put you at risk of severe complications.
Treatment is available but can take several months, depending on the type of treatment. Your doctor can advise on the best options for you.
What Is Toenail Fungus?
Toenail fungus, also known as onychomycosis, can damage your toenails. It involves an infection of some or all of the toenail, and can spread easily to other nails. It is also contagious and can spread to other people. It leads to the discoloration of the toenail over time. Treatment is with topical applications or medication. Drug treatment is more effective but can lead to adverse effects and is not suitable for everyone.
Types of Toenail Fungus
Various types of toenail fungus can cause a toenail fungal infection. The main symptoms are similar regardless of the cause, but your treatment options may differ.
The three main causes of toenail fungus are:
Dermatophytes This skin fungus is responsible for 75 to 90 percent of toenail fungal infections.
Molds Aspergillus and other molds account for around 10 percent of cases.
Yeasts Yeasts, most commonly Candida albicans, can also cause onychomycosis.
You may have a toenail fungus if your toenails are:
Brittle
Crumbly
White, yellow-brown or otherwise discolored
Thick or misshapen
Detached from the nail bed
You may also have bleeding, pain, or swelling around the nails, and there may be an unpleasant smell.
Other signs of toenail fungus include white, orange, yellow, or brown bands or lines on the nail. Infection usually starts in the nail of the big toe but may involve other nails. It often occurs alongside tinea pedis, commonly known as athlete’s foot.
Depending on the type, symptoms may start at the tip of the nail, across the upper surface, or the bottom of the nail. As the fungus advances, the toenail may break down completely.
You can develop onychomycosis if your nails come into direct contact with certain fungi, such as dermatophytes, molds, or yeasts.
The risk may increase if you:
Wear tight or closed shoes
Are an older adult, as the risk increases with age
Have other fungal infections, such as athlete’s foot
Live in an urban environment
Have obesity
Have a history of toenail infections
Sweat a lot
Participate in sports or fitness activities
Injure the nail
Don’t keep your nails clean and trim
Use public swimming pools or bathing facilities
Share a household with someone who has onychomycosis
Have certain genetic factors that increase your risk
Smoke
Have a compromised immune system
Have Down syndrome
Have certain health conditions, such as:
Diabetes mellitus
Psoriasis
Circulatory problems affecting your feet, such as peripheral vascular disease
Hallux vagus
Asymmetric gait nail syndrome
To diagnose a toenail fungal infection, a healthcare provider may:
Assess any visible nail symptoms
Use a tool known as a dermoscope to differentiate a fungal infection from other causes
Take a sample, such as a clipping or a nail scrape, to study under a microscope
Laboratory testing can help differentiate onychomycosis from other causes of similar symptoms, such as psoriasis, lichen planus, or melanoma.
Doctors then use an onychomycosis severity index to assess if the infection is mild, moderate, or severe.
There are various treatment options, and some are more effective than others.
The choice will depend on:
The extent and severity of the infection
Your age, as oral medication is not suitable for children
The cost of treatment and if your insurance covers it
How you react to the side effects of any drugs
Other health conditions you may have
Topical treatments may help if the infection is in only one to three nails, covers less than half of each nail, and does not affect the toenail bed.
Medicated Nail Polishes
Clear nail polishes containing anti-growth and antifungal agents can help remove a toenail infection. They are available over the counter as well as through prescription. You can choose between polishes containing amorolfine or ciclopirox. Treatment can take up to a year.
You apply amorolfine once or twice a week.
You apply ciclopirox every second day for the first month, at least twice a week in the second month, and weekly thereafter.
With both treatments, you’ll need to:
Remove the old polish with an alcohol swab.
Trim and file down the nail as far as possible.
Apply a new layer of antifungal polish.
Some ciclopirox polishes are water soluble. You’ll need to wash them off and reapply daily.
Creams
This option involves three components:
A cream containing urea, which softens the nail.
An antifungal cream containing bifonazole
A nail scraper or spatula
To use this treatment, you’ll need to:
Soak the toe in warm water for 10 minutes.
Dry thoroughly.
Apply the urea-based cream.
Cover with an adhesive bandage for 24 hours.
Remove the dressing and soak the nail in warm water until soft.
Scrape the surface of the nail with the spatula.
Reapply the urea-based cream and cover with a new bandage for another 24 hours.
Repeat the above procedure for 14 days, until the infected part of the nail has disappeared.
Apply bifozanole cream for another four weeks.
Some small studies suggest that, in people with limited infections, these treatments may remove visible signs of infection in 3 to 5 people out of 10. There is no evidence that they stop the fungus from coming back in the long term.
But they are less likely to have adverse effects or interact with other drugs, compared with oral medication. Infections can go away in around 6 weeks with the use of creams.
Medical Nail Avulsion (Removal)
Medical nail avulsion involves the use of chemicals to remove all or part of an infected nail.
This procedure is usually painless, takes place in a medical office, and involves the following steps:
Your healthcare provider covers the healthy skin around the nail with cloth adhesive tape.
They apply urea ointment on the nail surface and cover it with plastic and tape.
Over the next 7 to 10 days you’ll keep the dressing and nail dry while the ointment softens the nail.
At the next appointment, the doctor will gently lift the nail away from the nailbed or cut out the infected part.
This procedure may not be fully successful, as fungi may be growing under nearby nail folds.
Oral Medication
Your healthcare provider may prescribe oral medication if a fungal infection is present in more than three nails, covers more than half the nail surface, or affects one or more nail beds. They may also prescribe medication if topical treatment has not helped after six months.
Oral medication is more effective than topical treatments, but all the options can have side effects and may interact with other drugs. With oral medications, toenail fungus can go away in several months, sometimes weeks.
Here are some options:
Combination Treatments
In some cases, your healthcare provider may prescribe oral medication alongside topical treatments.
Complementary and Integrative Therapies
Some people use the following to treat toenail fungus. They are unlikely to cause harm, but there is not enough evidence to show they are effective:
Products containing camphor or menthol, such as Vicks Vaporub
Light Therapies
Laser treatment with infrared or ultraviolet (UV) light may also work. Photodynamic therapy is another type of light therapy for toenail fungus. In these methods, a laser targets the affected nail, raising the heat. This results in the death of fungal cells.
Here are some tips for preventing toenail fungus or stopping its spread.
Wear shower shoes in public locker rooms, baths, and pools.
Wash your feet and dry them thoroughly before putting on socks and shoes.
Wear properly fitting shoes that allow your feet to breathe.
Moisturize dry skin after bathing to prevent cracking, as pathogens can enter through cracks.
Sprinkle your shoes with an over-the-counter antifungal product to prevent a new infection.
Alternate your shoes to allow them to dry out fully.
Check your feet and toenails regularly for changes in appearance or texture.
In case of a fungal infection in your feet or toenails, seek medical advice and follow up any treatment plan your doctor recommends.
After treating an infection, throw away old shoes as they might still harbor the fungus.
Ensuring household members also check for fungal infections, as they can spread easily.
Sanitize your nail clippers and other pedicure tools between uses.
Ensure your pedicurist follows appropriate safety and hygiene standards, including sanitizing equipment.
Trim your toenails straight across.
Avoid nail polish and artificial nails, as they can trap moisture, increasing the risk of infection.
Toenail fungus can be very persistent. Treatment can be effective, but it can take a long time.
With treatment, depending on the type, toenail fungus can go away anywhere between several weeks to a year.
The infection can also recur. If treatment is incomplete, the toenail may look healthy but the fungus can reappear, especially if you don’t follow preventive measures.
Research suggests that infection recurs in 10 to 53 percent of cases, usually within three years of finishing treatment, either due to a new infection or the return of the previous one.
How long it takes to treat toenail fungus and the success of treatment will depend on factors such as:
The extent and severity of the infection
Other health conditions
Measures taken to follow the treatment plan and prevent a new infection
Onychomycosis can spread to other nails and other people and potentially cause complications if left untreated.
For instance, it can:
Increase the risk of bacterial infections, such as cellulitis and paronychia
Cause pain, discomfort, and tingling
Make standing and walking difficult
Lead to nail deformities that make it hard to find suitable shoes
Cause difficulty with keeping nails trim
Affect your quality of life and self esteem
Worldwide, toenail fungus affects around 5.5 percent of people.
In North America and Europe, studies suggest it is present in around 4.3 percent of people but 8.9 percent of those in a hospital.
The frequency also increases with age. Onynomycosis affects 0.44 percent of children under 18 in North America but up to 35 percent of those age 65 and over.
Research is underway to find new treatments for toenail fungus. Possible therapies include:
New broad-spectrum antifungal agents
New topical treatments
New ways of enabling medications to penetrate the nails
A redox gas solution that treats the nail while you insert it in a special chamber
Black peel (cosmetic peel typically used to treat acne)
Plasma therapies
Research suggests that Black Americans, Filipinos, Native Americans, and Native Alaskans may be at higher risk of fungal infections overall.
Factors that may contribute include:
Living and working conditions, which can increase exposure to pathogens
Limited access to healthcare, which can delay diagnosis
Limited access to insurance, which can affect the affordability of treatment
Lower quality nutrition due to a low income and inaccessibility of nutritious food options
Higher rates of diabetes and other conditions that increase the risk of an infection and its complications
Currently, there’s no data specifically on how toenail fungus affects underprivileged groups, but the risk is higher for those who already have another fungal disease.
Experts are calling for more awareness and action to reduce health inequity in treating fungal diseases.
Toenail fungal infections often occur alongside athlete’s foot. Those at higher risk of complications include people with other conditions, such as diabetes and obesity.
Many unrelated conditions have similar symptoms to toenail fungal infections, such as:
Fungal toenail infections, also known as onychomycosis, are a common problem that can cause toenails to thicken, change color, and break down.
Fungal toenail infections are often unsightly and uncomfortable. In some cases, they can lead to severe complications, such as the bacterial infection cellulitis.
Treatment is available for fungal toenail infections, but it can take time to work.
The sooner you seek treatment, the easier it is to get rid of a fungal toenail infection.
