The Agony of Da-feet……..

It seems a lot of us in the Great Northwest have problems with nails that discolor and thicken, especially toe nails. Frequently the culprit is dermatophytes, a specific type of nail fungus, although yeasts, molds or bacteria can also be participants. (See your doctor for a definitive diagnosis.) For this article we’ll zero in on nail fungus. A nail fungal infection may begin as a white or yellow spot under the tip of the nail, but often spreads deeper into the nail. When this happens the nail will discolor, thicken and may develop crumbling edges. The nail can distort and rise up. This can be quite painful, unsightly and a serious problem for those with additional health issues (e.g. diabetics).

The inside of shoes is akin to Disneyland for fungus. That is why we see nail fungal infections in toe nails more than finger nails - because fungi love moist, warm, dark environments. Damp public places such as swimming pools, gyms and showers are another favorite haunt – more like a fungi water park.

So how do we eliminate these pesky devils? The treatment list covers the gamut from home remedies to thousand dollar prescriptions. Nails are slow growing, so any treatment takes months to complete and more months to see results. Very often topical treatments (which take at least six months of use) only seem to keep the nails clear while we use them. Even oral medications, taking three months of treatment for toe nails, may require a later re-treatment to eradicate the fungus, if they are successful at that. Here is a very brief list of options. (Stop by the pharmacy if you want to discuss them more fully.) Keep in mind that topical treatments seem to be more successful if you are diligent about roughing up the surface of the nail before application. You can use a pumice stone, a file, even a Dremel on low, to rough up the nail.

Home remedies don’t carry the support of good studies, but some report anecdotal success. Most home remedies I found do not give a good idea of how many times to perform the soak or application, which is one problem with these suggestions. Some OTC and home remedy options:

• Vicks VapoRub® - apply to nail twice daily.
• Terbinafine 1% cream – apply to nail twice daily.
• Fungi-Nail® - 25% undecylenic acid - apply to nail twice daily
• Fungoid Tincture® – 2% miconazole solution (shows approx 11% cure rate)
• Vinegar soak – soak foot 15-20 minutes in mixture of 1 part white vinegar to 2 parts warm water. Rinse feet and pat dry when done.
• Corn meal soak – place 1 inch of corn meal in basin, add hot water to cover and steep 1 hour. Then add enough warm water to make comfortable, soak foot 20 – 40 minutes.
• Tea Tree oil – apply to nail twice daily. (Tea Tree oil can cause blistering of skin in sensitive individuals.)

Prescription Treatments come with their own set of pros/cons.

• Penlac® - an Rx topical nail lacquer is applied once daily for months. Once very costly, there is now a generic for this (ciclopirox) that is very inexpensive. It involves a daily routine of roughing the nail surface, painting on the lacquer & allowing it to dry. Once a week you remove the accumulated build up with alcohol. As the nail softens, you peel off accumulated layers of thickened nail. This is effective in about 9-12% of patients after a year of use.
• Terbinafine 2% compounded suspension – applied 1-2 times daily for months.
• Lamisil® (terbinafine 250mg) tablets - once very costly (over $1100 for 3 months) this is now available generically for a heck of a lot less (usually less than $70 for 3 months), plus many insurances will cover this. It involves taking one tablet every day for 3 months for toe nails (only 2 months for finger nails). Treatment requires a current liver function test before beginning, and at the mid point of treatment. Anyone with compromised liver function should not take this. Studies differ, but show success rates with terbinafine in the range of 60-85%.
• Sporanox® (itraconazole 100mg) capsules – the usual dose is 200mg daily. Precautions are the same as with terbinafine (liver) plus there are a lot more potential drug interactions with itraconazole. Additionally, this treatment is still relatively costly, with lower cure rates and higher relapse rates, but itraconazole is a broader spectrum antifungal so it will be effective against a wider range of fungi.
• Griseofulvin – Rx oral tablets – don’t work as well as other oral options.
• Diflucan® (fluconazole) – this is still being studied for nail fungus. Like itraconazole, this is a broader spectrum antifungal agent that also has some problems with drug interactions. However fluconazole is dosed just once per week. Clinical trials are looking at doses ranging from 150 – 450 mg once weekly for 6-12 months for toenails. Cost will vary, based on dose, but would probably range from $25-35 per month. Cure rates appear to be in the 45-65% range.

Prevention - if you don’t already have nail fungus, trust me, you don’t want it. Here are a few tips to prevent nail fungus or lessen the chance of recurrence after treatment.

• Keep nails short (but not too short), clean and dry. Trim nails straight across; file down thickened areas. Dry between toes after bathing. Don’t trim back or pick at skin around nails as this could increase the chance of infection.
• Wear socks that wick away moisture. Surprisingly synthetic socks may do this even better than cotton or wool. Change socks often if your feet perspire a lot.
• If possible allow shoes to dry inside between uses or alternate the shoes you wear every other day. If you are like me and only have one pair of everyday shoes, tuck them by the wood stove or heat source for more thorough drying overnight.
• Use antifungal sprays or powders inside shoes.
• Do not go barefoot in public pools, showers or locker rooms.
• Use a reputable manicure/nail salon and forego the use of nail polish and artificial nails.
• Wash your hands after touching infected nails
• Clean your shower/tub with a good disinfectant.

As always seek professional advice before beginning any treatment option to help you weigh the benefits and risks. Ask your doctor or pharmacist if you have any questions.