Nail fungus (onychomycosis) is a common nail infection that causes toenails to yellow or discolour. As the infection advances, nails become thick, brittle and separate from the nailbed. Nails may become painful.
While it can be difficult and a long-term goal, we can successfully treat nail fungus using a range of treatment options at our Melbourne clinic.
Toenail fungus treatment options
- Topical toenail fungus treatments
- Oral antifungal medications
- Laser toenail fungus treatment, using the PIQO 4, a Nd:YAG 1064nm laser, that has been cleared by the FDA to be both a safe and effective method of toenail fungus treatment
Contact us to arrange a consultation with one of our cosmetic dermatology specialists to discuss your toenail fungus treatments.
How we treat toenail fungus
There are many fungal strains that affect the toenails and nailbed. Nail fungal infections can be difficult to treat, even with the most effective treatments. Antifungal medications are used either topically or orally (or both), while also treating the affected nails with lasers.
The laser heats up the nail and the surrounding skin where the fungus is embedded, though this doesn’t cause pain. Multiple treatments are required depending on how the fungus has spread. Between treatments, topical antifungal ointment is applied at home.
For more extensive infections, we use the Deep FX laser. The laser applies thermal energy through the nail and nailbed so the topical solutions are able to penetrate the affected area. The Deep FX treatment is performed by Dr Rich, as it is a specialist laser that requires care in its application.
Contact us to arrange a consultation with one of our cosmetic dermatology specialists at our Melbourne clinic to discuss your toenail fungus treatments.
Laser toenail fungus removal
We often use the laser for toenail fungus removal because it’s very effective. Laser treatments for toenail fungus takes about 30 minutes, but several sessions are required, usually at four-weekly intervals.
We tend to see results within 6-12 months, as nails grow very slowly. Clear, uninfected nail will start to appear gradually. During laser toenail fungus removal treatments, you can expect a warm sensation on your toes, but no pain. Most people experience at least some improvement in their toenail fungus after laser treatments, but ongoing care at home is also important.
About fingernail and toenail fungus
All nail fungus starts to appear as a white or yellow smudge under a nail – toenails or fingernails. The same fungus that causes tinea (athlete’s foot) between toes can also cause nail infections, but tinea is not the only culprit – toenail fungus can be any fungus or mould. Fungus seeps deep into the nail bed, causing nails to change colour or become crumbly or brittle. Nail fungus may only affect one nail, or it might affect many. It doesn’t usually affect all nails on a hand or foot.
Mild fungal infections may not require treatment, but anyone with thick, brittle, discoloured nails requires treatment. Nail fungus is hardy, so seeking treatment early and using self-care at home is important.
Symptoms of nail fungus
- Thickening nails
- Crumbling, brittle nails
- Nails change shape and become irregular and distorted
- Nail is dull without shine
- Nails become discoloured
- Infection may cause nails to separate from the nailbed (onycholysis)
- Nails may smell
- Nails may be painful
About fungus that causes infections in nails
Fungi live without light and enjoy warm, moist environments. Fungi love shower floors, which is why flip flops are recommended in public showers.
Fungi can enter your skin via any small opening, including the tiniest of gaps between the toenail and nailbed. If your hands are often wet and warm there is no die-off period, so the fungi multiply without hindrance.
Toenail fungus versus fingernail fungus
We see more toenail fungus than fingernail fungus for several reasons. The main factor is that feet are constantly wrapped up in dark socks and shoes, and are often sweaty. Your immune system doesn’t have access to the crevices in our toenails, so it’s harder for the body to fight fungus.
Why do some people get toenail fungus more than others?
There are a few factors we know that increase the risk of toenail fungus. One important factor is decreased blood flow, which occurs as we age. Nails also grow slower and fungus has a longer brewing time. Sweat can also contribute since it keeps your feet damp.
If you work in a humid environment with your hands in water frequently (bartending, cleaning), or wear socks that don’t breathe or wick away moisture, you’re also at risk.
Being around other people with nail fungus increases your risk of contracting nail fungus. We know that people with a family history of nail fungus are more likely to have it, which is proximity to other family members with nail fungus. Wet communal areas harbour fungi, like swimming pools, change rooms and gyms, but the family shower can also be a breeding ground.
If you already have tinea, athlete’s foot, or toenail fungus, you are more likely to see the infection spread to the nail bed. Psoriasis can also increase the risks of developing toenail fungus, along with diabetes, poor circulation and poor immunity. We see more toenail fungus in children with Down’s syndrome.
Toenail fungus treatments – pharmacy treatments
Pharmacies often advertising toenail fungus treatments. You see those huge posters of infected toenails in the windows. Pharmacy treatments are usually the first port of call for consumers, but they don’t necessarily do the trick.
Prescription drugs and laser treatments are the next, more advanced option.
Toenail fungus treatments – medication
You may start you off with oral antifungal drugs. The new nail can grow free from infection, which over time grows in place of the infected nail. The treatment doesn’t appear to be working for at least 6-12 months, as the nail grows out. You take the antifungal medication for a few months and then wait and see.
People over age 65 don’t tend to respond as well to antifungal medication, but we often combine treatments to knock the infection out. There may be side-effects from antifungal drugs, such as a rash or liver issues, so we do regular blood tests. Some people can’t take antifungals.
Toenail fungus treatments – medicated nail polish
There is a nail polish treatment, ciclopirox (Penlac) painted onto infected nails and surrounding skin each day for a week. The polish is rubbed off with alcohol and the process starts again, potentially for a year.
Toenail fungus treatments – medicated nail cream
Antifungal cream may be prescribed, rubbed into the nail and nailbed after soaking in water to enhance penetration of the cream.
Toenail fungus treatments – surgical removal of the nail
In some cases, nail infections may very deep and painful, requiring removal of the entire nail. Once the infection is treated, the new nail can grow unimpeded and uninfected. Medication topically or orally may be used in conjunction with surgical removal of the nail.
Helping yourself at home
- When you notice any white spots on the nails, file them off and immediately use an antifungal cream
- Make sure you treat athlete’s foot or any other easily-treated fungal or bacterial infections
- Keep your feet and toes clean and dry
- Urea can be used to thin nails out to provide access to anti-fungal creams
- Keep your nails short and your hands dry
- Wear socks that wick moisture away from feet (such as wool)
- Change socks regularly when sweating
- Wear open-toed shoes
- Throw out old shoes that could be harbouring fungus or give them a good antifungal rinse (with rubber gloves on!)
- Wear rubber gloves if you have your hands in water a lot
- Keep the skin around your nails intact – don’t pick, bite or cut
- Always wear shoes in public places, especially wet public areas
- Make sure anywhere you get your nails done is using excellent hygiene practices
- Avoid constant use of false nails or nail polish that can trap fungus – give your nails time to breathe
*Results may vary from person to person
Frequently Asked Questions
There are several reasons why toenail fungus is hard to treat and takes a long time. Fungi sit deep in the nail bed, which is challenging access with topical treatments. Bloodflow tends to be low in these areas, since nails do not have a blood supply, relying heavily on nearby vessels to deliver immunity and antimicrobial activity.
Another reason for slow results is patient compliance with treatments since the treatments tend to go for a long time (a year, sometimes longer). Results may be so slow to appear that it can be dispiriting.
Toenail fungus is simply challenging to treat, so adhering to your treatment protocol is one of the best ways to achieve success.
Because our fingers and toes are separated without equal susceptibility to infections (for example trauma to a nail), nail fungus doesn’t spread evenly in feet or hands. It can spread between digits or between those who share items such as towels, showers and other wet areas like changing rooms
We typically treat minor nail plate fungal infections with topical antifungals. Topical antifungals cause fewer and less severe side-effects. However, you can expect extended treatment times because nail plate penetration is low.
Oral antifungals penetrate the nail bed and nail plate as they absorb throughout the body via the blood. Oral treatments may come with unpleasant side-effects, such as headaches, digestive tract symptoms, nausea and rashes.
- Nail trauma
- Wearing enclosed footwear
- Playing sports that include running or swimming
- History of fungal infection elsewhere on the body
- Modern footwear manufactured with synthetic fibres
- Immunocompromised individuals
- Living longer
- Increased urbanisation, with people living closer together and sharing more facilities
We contract fungal infections by direct skin-to-skin contact and shedding of infected dead skin cells or nails. Fungal infections can be spread from nail to nail on the same person, and infect web spaces, toes and potentially the entire foot.
When left untreated, infections can result in other skin problems like eczema, hives and swelling, and infections in other areas of the body. In severe cases, fungal infections of the nails can result in the amputation of the extremity (especially in people with diabetes). Amputation is very rare but is a potential risk with untreated nail fungus in some individuals.
Treatment can take up to 18 months to work, and there is up to a 25 per cent chance that it won’t work at all. Relapse rates are high. Treating nail fungus thoroughly and sticking to treatments is essential, so follow the advice of your dermatologist and seek treatment early before the problem advances.
Biofilms are a dense matrix that resists treatment. Think of a biofilm as a thick layer of clingfilm that protects a microbe (bacteria, fungi, yeast), and helps it build a healthy colony. Biofilms are treatment-resistant, so any treatment, such as the laser, needs to be able to penetrate for treatment to be effective.
Planktonic (free-floating) fungi can be destroyed with antifungals, while laser treatments can penetrate biofilms and remove the colony. Thus, we use a dual treatment strategy to kill fungal infections in nails.
There are some advantages to natural treatments for toenail fungus over traditional antifungals, including cost. There are low adverse reactions to natural therapies, for example, skin irritations and pain.
Bioactive ingredients in plant-based treatments are complex, reducing drug resistance. Some natural remedies have shown promise in terms of antifungal capacity. Still, research is in its early stages and efficacy has not been demonstrated (as yet) compared with medicines.
Some plant-based treatments currently under study include:
- Ageratina pinchinchenisis (topical) showed equivalency to ciclopirox nail polish.
- Coniferous resin nail polish showed a cure rate of 65 per cent in one study, but only 13 per cent in another trial, comparable to weekly treatments with amorolfine nail polish, and less effective than three months of oral terbinafine.
- Propolis (honeybee resin) showed complete clinical cure in just over 55 per cent of patients when used for six months, with no adverse outcomes.
Laser therapy applies a thermal effect to fungus, causing cell death. Lasers have been approved by the United States Food and Drug Administration (FDA) and the Australian Therapeutic Goods Administration (TGA) for nail fungal infections.
Combination treatments have proven to be the most effective of all, using topical and/or oral treatments with laser therapy.
Photodynamic therapy works on toenail fungus via a photosensitising agent that is absorbed by the fungus that destroys infected tissue.
Side-effects can include mild pain, burning, swelling, redness and blistering that resolves once treatment ceases.
A clinical trial with biweekly treatments of photodynamic therapy showed a cure rate of 90 per cent at six months and 80 per cent at 12 months in 40 patients. Each visit to a clinic for this treatment is long, several hours each, which is not attainable for many patients.
Plasma therapy involves applying plasma to the nail surface using strong electrical fields which produce antifungal components, including ozone. A study found a clinical cure rate of nail fungus over 50 per cent, without side-effects.
A visual nail examination, nail clippings or scrapings can help diagnose a nail fungal infection. Some other conditions can look similar to nail fungal infections, such as psoriasis or bacterial infection. Once confirmation has come from the lab (if necessary), treatment can begin
Once treatment has commenced, you have to wait and see if healthy nail grows out, which takes time.
Fingernails grow at a rate of about 2-3mm per month, while toenails grow about 1mm each month. Nail growth rates slow as we age, which is why older people suffer more fungal infections that are more difficult to treat and last longer.
Cutting your nails simply removes the excess nail, but does not cure the infection that sits in your nail bed. More in-depth treatments are required to access the areas under the nailbed and down the sides of your nails.
Removal of the entire nail can be successful in severe toenail fungal infections. While nobody wants to have their nail removed (it’s very unpleasant!), it may be recommended in some cases where other treatments have been ineffective.
Once we remove the nail, a new, healthy nail will take about a year to grow. The underlying skin is much easier to treat without the nail blocking treatments. You can expect in most uncomplicated cases to have a clear toenail in a year post-removal, sooner in fingernails.
When we remove nails, your comfort is our top priority. We use an anaesthetic to numb the entire area. You won’t feel a thing. While the immediate after-effects can be soreness, the soft, tender nail bed quickly adapts. If you’ve ever pulled a piece of the nail off your finger or toe, you’ll remember the tenderness of the underlying nail bed. You’ll also remember that after a day or two, the skin adapts, and you no longer feel pain.
Fingernails are easier to treat than toenails because the nail is thinner, smaller and overall more straightforward in terms of applying treatments. Depending on the severity of your infection, we will use antifungals topically or orally, plus laser treatments and medicated polish, as necessary. Your doctor will advise you of the best treatment in your case.
Fake nails provide a breeding ground for fungus because the area is enclosed under the nail. The synthetic nail offers a safe haven for fungus, resulting in those with fake nails seeing a higher incidence of nail fungal infections.
We do not advise the use of nail polish if you have nail fungus. It might be tempting to cover up a discoloured nail with nail polish, but nail polish provides another surface for fungus to attach itself to and can block your natural immunity around your fingernails or toenails.
Polish often gets down the sides of the nail and on the surrounding skin, which can also block treatments from being absorbed. You want your nail to be free from any coverings, including fake nails and nail polish.
Medicated nail polish/lacquer treatments are the exception.
The usual treatment regime is every 1-3 months, depending on severity. Your doctor will advise you which treatment schedule will suit your infection and get the best results.
No, laser treatments are very comfortable. You’ll feel some warmth as the laser penetrates your nail, but this is not at all uncomfortable.
Laser therapy for nail fungus is considered to be low risk and without side-effects. The laser doesn’t cause any tissue damage, so there are no cuts or abrasions to the skin. The laser penetrates the nail bed with thermal energy, debilitating fungus over several treatments.