Nail fungus: Polish, cream or tablets?

Lots of people first try to treat nail fungus with a colorless nail polish. Before applying the nail polish, the affected nail has to be cut and filed down as much as possible. The nail polishes contain the growth-inhibiting and antifungal ingredients amorolfine or ciclopirox. The products differ in how often they need to be used:

• Amorolfine is applied one to two times a week.
• Ciclopirox is usually applied as an acrylic polish every other day in the first month, at least twice a week in the second month, and once a week starting from the third month. It is applied as a water-soluble polish one time per day.

With both treatments, the old layer of polish has to be removed using an alcohol swab before applying the new layer. You can put cosmetic nail polish on over medicinal nail polishes without any problem. Newer ciclopirox nail polishes are water-soluble. Any remaining polish can be washed off with water before each new application.

Treatment sets that contain two creams and a nail scraper (spatula) can also be used for the topical treatment of nail fungus:

• One cream has urea in it, which softens the nail so it can be removed.
• The other cream contains bifonazole, which has an antifungal effect.

For this treatment, the affected toe or finger first has to be soaked in warm water for ten minutes and then dried. After that, the urea-based cream is applied to the nail, and the nail is covered with an adhesive bandage. After 24 hours, the bandage is removed and the toe or finger is held in warm water again. The softened layer of the nail is then scraped off using a spatula, the cream is applied again and the nail is covered with a new bandage. This treatment is carried out over 14 days. Once the infected part of the nail has been scraped away completely, the skin beneath is treated for another four weeks with a bifonazole cream.

Only a few studies have looked into topical nail fungus treatments with nail polishes or creams. Amorolfine has not yet been well studied. Ciclopirox polish and treatment sets with urea and bifonazole cream were tested in a few studies.

Research on the effectiveness of nail polish containing ciclopirox showed that, after one year:

• About 10 out of 100 people who did not use ciclopirox no longer had a detectable fungal nail infection.
• About 30 out of 100 people who used ciclopirox no longer had a detectable fungal nail infection.

But even if the fungus had gone away, the cosmetic result wasn’t always satisfying – for instance because the nails no longer looked like they used to.

Treatment with sets combining the application of urea cream and then putting on bifonazole cream was tested in one study. That study compared that with a treatment in which only urea cream was applied and the nail was removed. Three months after treatment was completed, it was found that:

• No fungus was detectable in about 51 out of 100 people who used both urea and bifonazole cream.
• No fungus was detectable in about 41 out of 100 people who only used urea cream.

But there was no difference between the two groups six months after treatment. Also, the fungal infection returned in many participants,

The tablets for treating nail fungus are prescription-only, so they have to be prescribed by a doctor. The main options for treating nail fungus are the drugs terbinafine and itracionazole.

• Terbinafine is preferred if the nail fungus is caused by skin fungal infections (called dermatophytes), which is usually the case.
• Itraconazole is generally used if the nail infection is caused by yeast or mold.

Itraconazole and terbinafine tablets can both be taken either continuously or with breaks between treatments. It is best to talk to your doctor about which type of use is right for you. The treatment – whether it is done with or without breaks – takes at most 3 months with itraconazole and about 3 to 4 months with terbinafine.

Fluconazole is another medication taken in tablet form. It is only used if other treatments didn’t work well enough or aren’t an option for other reasons. Fluconazole is taken once a week for about six to twelve months.

Tablets for the treatment of nail fungus have been tested in several studies. All participants had an infection on their toenails caused by a skin fungus. The studies showed that both terbinafine and itraconazole are effective in treating nail fungus.

One year after a three-month treatment with terbinafine:

• About 17 out of 100 people who didn’t have this treatment no longer had a detectable fungal nail infection.
• About 76 out of 100 people who had this treatment no longer had a detectable fungal nail infection.

One year after treatment with itraconazole:

• About 7 out of 100 people who didn’t have this treatment no longer had a detectable fungal nail infection.
• About 43 out of 100 people who didn’t have this treatment no longer had a detectable fungal nail infection.

Some studies directly compared itraconazole and terbinafine with each other. They found evidence suggesting that terbinafine is somewhat more effective than itraconazole.

Treatment with breaks is thought to be about as effective as continuous treatment. But that has only been looked into in a few studies.

The studies on the tablets provided very little information about how commonly certain side effects occurred. But most people apparently tolerated the medications well. Only a few participants in the studies stopped treatment because of side effects.

Itraconazole may cause headaches, dizziness, stomach and bowel problems, and rashes. Itraconazole can also interact with a number of other drugs. These include cholesterol-reducing and blood-sugar-lowering medications.

Itraconazole should not be taken by people with heart failure. There is a very small risk of liver damage from taking itraconazole or terbinafine. For this reason, people with a liver disease are only given these medications if it’s absolutely necessary.

Sometimes home remedies such as applying tea tree oil or vinegar are recommended for the treatment of nail fungus. But there aren’t any good quality studies on whether these or other products help to treat nail fungus.

How you feel about the pros and cons of the different treatment options is a personal matter. Factors like how far the fungus has spread or how often you have already had nail fungus in the past might play a role. You can also discuss the options with your doctor.

Most doctors recommend treating nail fungus with nail polish or cream if

• not much more than half of the nail is affected by the fungus,
• the base of the nail is not infected, and
• only some nails are affected.

Topical treatment is also usually recommended for children. One reason for this is that most oral medications aren’t suitable for children. Another reason is that children have thinner nails that grow more quickly, so it’s assumed that treatment with nail polish or creams is more likely to work in children than in adults. White superficial onychomycosis is also often treated with a nail polish or cream.

If several nails are infected by the fungus, or if the infection has spread out more on the affected nails, it’s usually necessary to take oral medication. And if the infection started at the base of the nail, it’s highly likely that only tablets will help.

If the fungal nail infection is severe, tablets can be used in combination with nail polish or cream. For example, if the nail is very thick, urea cream can be used (in addition to taking tablets) to gradually remove or partially file off the affected nail. Combining these treatments may also be an option if there are large collections of fungi beneath the nail.

It is also possible to see a podiatrist (foot care specialist) to deal with a severe fungal nail infection. Then your nails will be treated professionally and thick nails can be filed off, for instance. The podiatrist can also advise you on what you can do yourself and on the best ways to maintain hygiene and disinfect your nails. That is important because the nail material that is removed may contain infectious spores. In Germany, public health insurance will cover the costs if the treatment has been prescribed by a doctor.

Sometimes laser treatment is offered. This involves shining infrared or ultraviolet (UV) light on the nail in order to kill the fungus. Laser treatments haven’t been proven to work in good quality studies. Because public health insurers in Germany don’t cover the costs of this treatment, you have to pay for it yourself.

A fungal nail infection is unpleasant, but it is not a serious illness. Many people find discolored or thickened nails unpleasant to look at, though, and want to get rid of the fungus as soon as possible. Fungal nail infections can also spread and destroy the nails, and they may infect other people. Whichever treatment you choose, it will take a while until your nail looks normal again. So you need to be patient, especially if the fungus is on your big toe. It can take up to one year for it to grow back and be healthy again.

Nail fungus can sometimes be very persistent despite treatment, and can also come back again even after successful treatment.