Toe Nail Fungus

Aug 17, 2017

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

"There was a commotion in Canadian Tire," Eric told me. I asked if he caused it, and he denied it. To back up a bit, we were in Wawa, Ontario, the town on the North Shore of Lake Superior that my Dad grew up in. We were there for a mini-family reunion. Getting to Wawa was an unnecessarily eventful 2 day drive. It started with my wife waking me up a 3am to tell me she wasn't feeling well. That progressed into her being violently ill for 4 hours. So, instead of starting our first 8 hour driving leg at 8 am, we didn't leave until 2 pm. Yeah… family road trip! But that was all behind us, and this was our first full day in Wawa. It was hot out and we were going swimming at Sandy Beach on Lake Superior. Doris and I stopped at the liquor store, I told Eric to walk around the corner to Canadian Tire to see if he could find a mask and snorkel for the beach. This was the same Canadian Tire my grandfather had sent me to with a pocket full of Canadian Tire money 35 years earlier. When I caught up to Eric, he was looking a little freaked out and told me about the commotion. Apparently, there had just been a robbery. Eric didn't see the robber, but saw the Canadian Tire staff chasing him as he fled the store.

Eric didn't get a look at the alleged robber's face, let alone his toe nails. Toe nails are specialized parts of the skin that protect the ends of our digits. The nail grows out from the small area inside the white half moon by the cuticle. It is estimated that 6.5% of Canadians have toe nail fungus. It is more common in older people. It is estimated that over 30% of people between the ages of 60 and 70 have toenail fungus. People with nail problems like having a nail injury or psoriasis near the nail are more likely to get toe nail fungus. People who wear footwear that don't let the feet breathe, people with poor circulation to their feet, people with diabetes and people with compromised immune systems are also more likely to get fungus. The medical term for toe nail fungus is onychomycosis. Onchomycosis is caused mainly by dermatophytes.

You can get infected toenails through contact with an infected person or through contact with an infected surface like a bathroom floor where the fungus is present. It is common to get toenail fungus at the same time as you get athlete's foot.

Fungus infected toenails look weird, but are not itchy or painful. In the most common type of toe nail infection, the end and/or sides of the nail get thicken and yellow. The infection can spread in all the way up to the cuticle and the nail matrix. Crumbling yellow debris is usually seen under the nail edge. We think of toenail fungus as just being ugly to look at. However, there are some non-cosmetic problems that can result from a fungal infection. The nail fungus can spread to other nails or even other parts of the body like the groin or scalp. In diabetics, the thickening nail can add extra pressure to the toes and lead to ulcers or sores. In extreme cases with diabetics, sores on the feet can lead to amputation, but that is rare.

What can be done if you have toenail fungus? First you should have a doctor have a look at the nail. There are other things besides fungus that can cause nail problems. Once a definite diagnosis has been made, you and your doctor need to decide how you want it treated. In some cases, the infected part of the nail can be removed. Onychomyconsis can also be treated with medication. There are both oral pills and topical medications to apply to the nail.

The two most common oral medications for toenail fungus are terbinafine (lamisil) and itraconazole (sporanox). It is difficult to say which medications work the best because the studies about toenail fungus are very small and not that well done. The studies usually talk about when the nail is fungus free. A patient has to remember that even after the nail is fungus free, it will still take months and months for the nail to grow out and the yellow, thick, discolored areas to disappear. Toe nails can take a year to grow back.

Terbinafine has to be taken every day for 3 months to cure toenail fungus. Like all antifungals it can cause liver damage but the chances are remote. Your doctor should test your liver function before you go on it and repeat the liver function test in about 6 weeks. Depending on where I looked, I saw cure rates with terbinafine at about 46%.

Itraconazole is another antifungal oral medication, but it can be given as pulse therapy. That means you take the pills everyday for a week and then take 3 weeks off. You repeat this for 3 months. This pulse therapy can be more convenient for many people. Again there is the risk of liver damage and you doctor should check you out. The cure rates for itraconazole I found were around 23%.

If you aren't sure you want to get your liver function checked or have your toenail removed there are other options. Ciclopirox (Penlac) looks like nail polish. You apply it everyday and wipe off any excess about once a week with nail polish remover. Again, it will need to be used for about 3 months. The cure rate I found was about 7%.

A newer prescription toe nail fungus nail polish on the market. It is called Efinaconazole (Jublia). Its cure rate is listed at 17%.

The Dauphin Clinic Pharmacy makes another anti-fungal nail polish. For better or worse several of the doctor's have dubbed it "Trevor's Magic Nail Polish". It is made with the anti-fungal fluconazole. There are no large clinical studies on it, so I have no cure rate to give you, but anecdotally some patients who used it found it worked well.

Which ever nail fungus treatment you choose there are some things you can do on you own to help your toenails. Keep your nails short, dry, and clean. Keep your feet dry - make sure your feet (including between your toes) are completely dry before putting on shoes and socks. Wear absorbent cotton socks , and change them at least once a day. Wear proper fitting shoes and rotate shoes to allow them to dry out between uses. Don't go barefoot in damp public places like public showers - wear shower shoes. People with nail fungus shouldn't share shoes, socks or nail clippers with others. If you have diabetes, make sure your blood sugar is under control. As mentioned we don't want people with diabetes having their toe nail fungus causing sores and ulcers.

Eric didn't need a mask and snorkel to see Huskie the Muskie in Kenora, Vermillion Bay's Sasquatch, Max the Moose in Dryden, the Terry Fox Memorial near Thunder Bay or of course the new and improved giant steel Canada Goose in Wawa. But witnessing a "commotion at Canadian Tire" did end up being worth the minor trauma. In the crystal clear waters around Wawa, Eric found lots of rocks in Lake Superior on a very warm day, and a gold hoop ear ring in Wawa Lake. The mask and snorkel also seemed to have magic thermoprotective properties. Just before leaving Wawa, we went back to Sandy Beach on Lake Superior, but it was a much colder day. The water was so cold, my feet hurt just wading out to my calves. The cold didn't stop Mr. Commotion and his mask and snorkel from underwater treasure hunting though.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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As always if you have any questions or concerns about these or other products, ask your pharmacist.


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