Toenail Fungus Treatment: Oral vs. Topical Options

Treatment for Nail Fungus

Hello Dr.
Wu,
Recently, I discovered a black object resembling a fungus on the outer side of my left big toe nail (next to the toe web).
After examination at the hospital, I was diagnosed with onychomycosis.
The clinic physician mentioned that while topical medications have low side effects, they typically need to be applied for six months to a year, and the cure rate is below 20%, which is quite poor.
Therefore, they recommended oral medication, which is usually taken for 3 to 4 months until the infected old nail is completely replaced by new nail growth, with a cure rate of about 70%.
Following the physician's advice, I chose oral medication, and the doctor prescribed Terbinafine tablets.
However, I have some questions I would like to ask:
1.
The purpose of taking the medication is to enable the body to develop the ability to fight off the fungus, preventing skin infection, right? But if the fungus is already present in the nail, it shouldn't be able to be killed, correct? Doesn't this still pose a risk of infecting other healthy nails? Or could it even infect the new healthy nail growing behind the old infected nail? Alternatively, could I ask the hospital physician to remove the entire nail, which might speed up treatment and improve effectiveness?
2.
Since I am taking Terbinafine tablets, would you recommend that I also purchase a topical Terbinafine treatment from the pharmacy to apply to the affected area to enhance efficacy and reduce the surface fungal infection?
3.
The outpatient doctor mentioned that the affected area of onychomycosis is typically confined to the nail region and that there is no need to worry about skin infection.
However, after returning home, I noticed that the skin between my toes is also stained with black fungus and cannot be scrubbed off.
Can this also be treated with oral medication? Or if the skin is infected, does that indicate that it is not just onychomycosis but possibly another type of infection?
4.
The cure rate for the oral medication is only 70%, which is not particularly high.
If, unfortunately, I fall into the 30% where it is ineffective, what other treatment options are available?
I apologize for the numerous questions, and I appreciate your guidance.
Thank you.

David, 30~39 year old female. Ask Date: 2022/04/12

Dr. Wu Yuxin reply Dermatology

1.
That's correct, so we need to eliminate the fungus at the nail matrix and prevent the spread of the fungus on the toenails.
Removing the nail is quite drastic and is generally not performed casually; it is even less likely to be done if there are multiple roots involved.

2.
There is no need for that.

3.
A fungal infection of the toenail that spreads to the skin is known as tinea, and it also requires treatment.

4.
Switch to antifungal medications with different active ingredients.

Reply Date: 2022/04/12

More Info

When it comes to treating toenail fungus, also known as onychomycosis, there are several options available, both topical and oral. The choice between these treatments often depends on the severity of the infection, the specific type of fungus involved, and the patient's overall health.
1. Understanding Treatment Mechanisms: Oral antifungal medications, such as Terbinafine (Lamisil) and Itraconazole (Sporanox), work systemically to eliminate the fungal infection from within the body. They are effective because they circulate through the bloodstream and target the fungus wherever it may reside, including in the nail bed. While it is true that these medications do not directly kill the fungus already present in the nail, they help to prevent the fungus from spreading and allow the new, healthy nail to grow in without infection. This is why it is crucial to continue the medication until the infected nail has completely grown out and been replaced by a healthy nail, which can take several months.

2. Topical Treatments: Topical antifungal treatments, such as clotrimazole or amorolfine, are applied directly to the nail and surrounding skin. While they have fewer systemic side effects, their effectiveness is often limited, particularly for more severe infections. As you mentioned, topical treatments may require a long duration of use (up to a year) and often have lower cure rates compared to oral medications. However, they can be beneficial for mild cases or as an adjunct to oral therapy.

3. Nail Removal Considerations: In some cases, particularly when the infection is severe or if the nail is causing pain, a healthcare provider may recommend removing the affected nail. This can expedite the healing process and allow for better penetration of topical antifungal treatments. However, this decision should be made in consultation with a healthcare professional, as it may not be necessary for all patients.

4. Combining Treatments: It is often beneficial to combine oral and topical treatments to enhance efficacy. Using a topical antifungal in conjunction with oral medication can help reduce the fungal load on the nail surface and surrounding skin, potentially improving overall treatment outcomes. However, this should be done under the guidance of a healthcare provider to avoid potential drug interactions and ensure the best approach for your specific situation.

5. Skin Involvement: If you notice that the skin around your toenail is also affected by a fungal infection, it is important to address this as well. Oral antifungal medications can help treat the skin infection, but topical treatments may also be necessary to directly target the affected skin. If the skin shows signs of infection, such as redness, swelling, or discharge, it may require additional treatment.

6. Addressing Treatment Failure: If you find yourself among the 30% of patients who do not respond to initial treatment, there are alternative options. These may include trying a different oral antifungal medication, using a combination of treatments, or exploring newer therapies that may be available. Additionally, lifestyle modifications, such as keeping feet dry and well-ventilated, can help prevent reinfection.

In conclusion, toenail fungus treatment requires a comprehensive approach that considers the type and severity of the infection, the patient's health, and the potential for combination therapies. Always consult with a healthcare provider to determine the most appropriate treatment plan tailored to your specific needs.

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