Nail fungus: Polish, cream or tablets?

(PantherMedia / Iakov Filimonov)

Nail fungus can be very persistent. Topical treatment with nail polish may take up to one year. Tablets for treating fungal nail infections usually have to be taken for several weeks or months. They are much more effective than topical treatments, but they have more side effects.

Brittle (crumbly) nails and a whitish-yellowish or brownish discoloration are typical signs of nail fungus. The nails may also become thicker and change shape. The affected part of the nail sometimes detaches from the nail bed. The treatment options for nail fungus include nail polishes and creams as well as tablets. Nail polishes and creams are available in pharmacies without a prescription.

What topical (external) treatments are there?

Nail polishes

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 have to be used:

• Amorolfine is applied one to two times a week.
• Ciclopirox products are usually applied 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.

With both treatments, the old layer of polish has to be removed using an alcohol swab before applying the new layer. Cosmetic nail polish can be applied on top of the medicated nail polish. Newer ciclopirox nail polishes are water-soluble. They are applied daily, and the remaining polish is removed using water before each new application.

Sets with creams and a nail scraper

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.

How effective are topical treatments?

So far, only a few studies have looked into topical nail fungus treatments with nail polishes or creams. Because these studies had weaknesses, the results should be interpreted with caution. 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 32 out of 100 people who used ciclopirox no longer had a detectable fungal nail infection.

In other words, treatment with ciclopirox got rid of the fungal infection in about 22 out of 100 people. But even if the fungus had gone away, the cosmetic result wasn’t always satisfying. The nails only looked healthy after treatment in 7 out of 100 people.

Treatment with sets containing urea and bifonazole cream was tested in one study. It was compared with a treatment in which only urea cream was applied and the nail was removed, but without applying bifonazole cream afterwards. Three months after treatment was completed, it was found that:

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

In other words, the combination of urea and bifonazole got rid of nail fungus in an extra 10 participants. But there was no difference between the two groups six months after treatment. Also, the fungal infection returned in many participants, so it’s likely that neither of the two treatments can increase the chances of getting rid of the fungus in the long term.

People did not take part in the study if their fungal infection covered more than half of the affected nail area or if the infection started at the base of the nail.

What oral medications are available?

To treat fungal nail infections from inside the body, you can take tablets that inhibit the growth of fungi or kill them. They are all prescription-only. Terbinafine and itraconazole are typically used for this purpose.

• Terbinafine is preferred if the nail fungus is caused by a skin fungus (dermatophyte). This 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. But they are used differently:

Terbinafine

In continuous treatment, the medication is usually taken once a day for three months (dose: 250 mg).

In treatment with breaks, the medication can be taken as follows:

• 500 mg terbinafine (2 tablets) daily for a week, then a three-week break
• Or: 250 mg terbinafine (1 tablet) daily for four weeks, then a four-week break

Even in this approach, the treatment typically doesn't take any longer than three to four months.

Itraconazole

In continuous treatment, itraconazole is taken once daily for a maximum of three months. The dose is then 200 mg per day (two 100 mg tablets).

In treatment with pauses, 400 mg of itraconazole is taken daily for a week (two 100 mg tablets in the morning and two in the evening). That is followed by a three-week break in treatment. This treatment also lasts three months or less.

Fluconazole

Fluconazole is only used if other treatments didn’t work or aren’t an option for other reasons. It is taken once a week (dose: 150 mg). But fluconazole has to be taken for about 6 to 12 months to work properly.

How effective are tablets in treating nail fungus?

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. Overall, the study results showed that tablets are considerably more effective than nail polishes or creams.

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.

In other words, the treatment with terbinafine got rid of the fungal infection in about 59 out of 100 people.

Itraconazole also proved to be effective. After one year,

• 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 had this treatment no longer had a detectable fungal nail infection.

In other words, the treatment with itraconazole got rid of the fungal infection in about 36 out of 100 people.

Some studies directly compared itraconazole and terbinafine with each other. They confirm 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.

What side effects and drug-drug interactions do the tablets have?

The possible side effects of itraconazole include 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, as well as certain sleeping pills. It is therefore important to let your doctor know about any medication you take. Itraconazole is not an option for people with heart failure (cardiac insufficiency). It also isn’t suitable for women who are pregnant or breastfeeding.

Terbinafine can cause gastrointestinal (stomach and bowel) problems and a temporary loss of taste and smell. It can also interact with certain antidepressants and heart medications. Overall, terbinafine has far fewer drug-drug interactions than itraconazole. Nevertheless, it’s still important to tell your doctor if you are taking any other medication. As a precaution, this medication should not be taken during pregnancy or if you are breastfeeding.

The studies only rarely reported on how often the different side effects occurred. But most people tolerate nail fungus medications well. Only a few people in the studies stopped treatment because of side effects.

But 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.

What can be expected of products such as tea tree oil?

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.

When are the different treatments considered?

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.

Additional treatments

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. Another option for severe fungal nail infections is professional medical footcare. If the nail is filed off, it’s important to ensure good hygiene and disinfect the area, because the removed nail tissue could contain infectious fungal spores.

Sometimes people with a fungal nail infection are offered laser treatment. This involves shining infrared or ultraviolet (UV) light on the nail in order to kill the fungi. Laser treatments haven’t been proven to work in good quality studies. Because statutory health insurers in Germany don’t cover the costs of this treatment, people have to pay for it themselves.

Which treatment is right for me?

Nail fungus is usually harmless. But many people find discolored or thickened nails unpleasant to look at and want to get rid of the fungus as soon as possible. Fungal nail infections can also spread, and may infect other people. Regardless of the treatment you choose, it will take a while until the nail looks normal again. It’s especially important to be patient where toenails are concerned. It can take a year for a healthy big toenail to grow back. Nail fungus can sometimes be very persistent despite treatment. It can also come back after successful treatment.

Topical treatment (polish or cream) isn’t likely to get rid of a fungal nail infection. Treatment with tablets is considerably more effective and takes less time. But some people can’t take tablets because of the very rare, yet serious risks. How you feel about the pros and cons of the different treatment options is a personal matter. You can also discuss the options with your doctor.