There are a number of home remedies that have been tried over the years to treat onychomycosis and fungal nail infections. The problem with all of them and even with topical prescription medicines is that the remedy is not always able to penetrate the nail to the site of the infection. This keeps many home remedies from being very effective on onychomycosis. Also, there are no clinical trials that have looked at the various home remedies in the treatment of nail fungus. On the other hand, there is very little risk associated with the popular home remedies and most are inexpensive. Also there is some anecdotal evidence that they could work for some people.

Just as with prescription onychomycosis treatments, if the nail bed and lunula are affected, topical, over-the-counter, home remedies will not be effective. An oral medication is required and, currently, these medications are only available with a prescription.

One of the popular, inexpensive treatments that has been tried is to soak fingernails or toenails in Listerine. Listerine contains ethanol, thymol, eucalyptol, and benzoic acid. Listerine is known to kill bacteria and has recently been shown to have antifungal properties. In fact, this treatment was potent against Candida infections which cause one of the four main types of onychomycosis. Therefore, Listerine could theoretically eradicate a nail fungus infection if it could penetrate to the site of the fungus.

No clinical trials have been performed looking at Listerine and onychomycosis but proponents of the treatment suggest soaking fingernails or toenails in Listerine for 10 minutes each night. Listerine’s ability to kill dermatophytes is less impressive and less well known. Since most onychomycoses are caused by dermatophytes, Listerine may not be universally effective.

Another onychomycosis along these same lines is vinegar. Vinegar, also known as acetic acid, can potentially destroy the dermatophytes that cause onychomycosis. The process is the same for Listerine—people that would like to try this remedy should soak their fingers or toes in one part vinegar and two parts water for 20 minutes per day. Treatment should be continued until symptoms resolve or the skin around the nail becomes irritated. There is no advantage to using apple cider vinegar versus other vinegar types since they all contain acetic acid primarily. Also, over-the-counter preparations that contain acetic acid as their primary ingredient are not more or less special than plain vinegar.

One of the more promising home remedies for onychomycosis is Vicks VapoRub. Again, there are no clinical trials supporting this treatment, however physicians have witnessed improvements in some people using this ointment. Why might this home remedy work where others fail? In the case of Vicks VapoRub it is as much about the carrier as it is about the active ingredient. The oils and petroleum jelly in Vicks can dissolve and soften the nail when used repeatedly over time. This allows the active ingredients like menthol to penetrate the nail and fight the fungal infection.

The only really way to use Vicks VapoRub is topically; the precise “dose” and duration of therapy is anyone’s guess. Many people apply it to their affected toenails or fingernails at night and wear a sock or glove to keep the Vicks VapoRub next to the nail. Unfortunately this also tends to hold moisture next to the nail and moisture promotes fungus growth. If you are going to use Vicks VapoRub and a sock or glove, make sure the covering is 100 % cotton and “breathes” to prevent moisture accumulation.

One natural product that has fairly impressive antifungal activity is tea tree oil or Melaleuca alternifolia. When used in vitro (meaning in a dish), tea tree oil was able to kill or inhibit all of the major causes of onychomycosis including Trichophyton rubrum, Trichophyton mentagrophytes, and Candida species. There have been two clinical trials of tea tree oil on onychomycosis one showing a 20% cure rate and the other showing a 0% cure rate. Apparently 100% tea tree oil needs to be used to see an effect. While cure was only achieved in a fraction of patients (or none) nail appearance improved in many more.
Interestingly tea tree oil was very effective in treating tinea pedis, a superficial fungal infection of the foot. In this case the topical agent can easily reach the offending fungus.

One topical treatment that contains Tea Tree Oil is Zetaclear.

Another herbal preparation that has some antifungal activity is Camellia sinensis or green tea extract. In a dish, this herb was able to kill Candida glabrata. It is affect on dermatophytes is unknown and there have been no clinical trials to determine if it has an effect on patients with onychomycosis.

References
Hammer KA, Carson CF, Riley TV. In vitro activity of Melaleuca alternifolia (tea tree) oil against dermatophytes and other filamentous fungi. J Antimicrob Chemother 2002;50:195-199.
Hart R, Bell-Syer SE, Crawford F, Torgerson DJ, Young P, Russell I. Systematic review of topical treatments for fungal infections of the skin and nails of the feet. BMJ 1999;319:79-82.
Turchetti B, Pinelli P, Buzzini P et al. In vitro antimycotic activity of some plant extracts towards yeast and yeast-like strains. Phytother Res 2005;19:44-49.

Onychomycosis, or a nail fungus infection, is defined as a fungal infection of the nail bed, nail plate (what we think of as the nail itself) or the area very closely surrounding the fingernail or toenail. Most cases of nail fungus are caused by a dermatophyte called Trichophyton rubrum. Many other cases are caused by Candida albicans, which is a yeast. These organisms can invade deeply into the nail or stay near the surface. They can begin their infection process near the cuticle or at the tip. (Nail Fungus under a microscope)

Onychomycosis is responsible for one third of all fungal skin infections and half of all nail infections. Even so, that means that half of all nail infections are not caused by fungi. Therefore it is important to distinguish between a nail fungus and a bacterial infection of the nail. A fungal infection is treated with an antifungal while a bacterial infection is treated with an antibiotic.

Fungal nail infections can cause a number of abnormalities in the nail. Almost all cases of nail fungus will include white, yellow, or white-yellow crust in or on the nail. This is the fungus itself. The white-yellow patches can be in the form of streaks that are parallel to the finger. Alternatively, the lesion can appear across the tip or the cuticle. When the crust spreads, it can cover the entire surface of the nail.

If the fungus penetrates underneath the nail plate (the nail itself), which is often does, it can form irregularities in the nail bed. The bumpy nail bed is less able to hold onto the nail and so it becomes loose. Since dermatophytes consume keratin and produce destructive wastes, the nail can become pitted and misshapen. This may cause ridges and grooves in the nail.

If the nail fungus infection becomes severe or contains Candida, the nail folds and skin surrounding the nail may become red and swollen. These are signs of inflammation which can cause discomfort and even pain. The skin may express (ooze) pus, which is a whitish material common of white blood cells from the immune system.
Pus is usually a sign of bacterial infection and, if it is present, may be a “red herring” for the physician trying to make the diagnosis.

A nail that is expressing pus may be assumed to be caused by a bacterial infection, as is often the case. If you are experiencing pus it is particularly important to get a correct diagnosis for the nail infection. In addition to bacterial nail infection, there are a number of diseases that can mimic a nail fungus. Examples of mimickers include hallopeau acrodermatitis, lichen planus, nail bed melanoma, nail bed psoriasis (may occur with fungal infection of the nail), onycholysis, paronychia, Reiter syndrome, or yellow nail syndrome. This means that one or more diagnostic tests are necessary to make the correct diagnosis of onychomycosis.

Testing for a nail fungus requires that a piece of the diseased nail be taken for further study and analysis. If the disease affects the tip of the nail, like in distal subungual onychomycosis, a small piece of nail can be trimmed from the end. Unfortunately in proximal subungual onychomycosis the nail must be removed down to the base. On the positive side, this nail removal can be therapeutic as well as diagnostic. In white superficial onychomycosis, the lesion is scraped away from the top of the nail.
Once a piece of the diseased nail is harvested, two main tests are performed on the sample. Some of the nail can be treated with a strong base, namely potassium hydroxide, and viewed under a microscope for the presence of fungi. The remaining piece of nail can be sent for a fungal culture. The sample is placed in an environment in which fungus can grow and thrive and, after a few days, the sample is checked for growth of new fungus. The presence of fungus in one or both of these tests is good evidence that an onychomycosis is present. If neither the potassium hydroxide wash nor the culture show fungus, the nail can be taken, pulverized, and sent to a pathologist for analysis. Alternatively a portion of the nail can be sent for a bacterial culture in case the nail infection is not fungal.

If you suspect that you have nail fungus symptoms, the diseased nail or nails should be looked at by a physician, ideally a dermatologist. Proper diagnosis of the illness is important for directing care and ruling out for serious problems.

References
Hainer BL. Dermatophyte infections. Am Fam Physician 2003;67:101-108.
Jaffe R. Onychomycosis: recognition, diagnosis, and management. Arch Fam Med 1998;7:587-592.
Kaur R, Kashyap B, Bhalla P. Onychomycosis–epidemiology, diagnosis and management. Indian J Med Microbiol 2008;26:108-116.

Lamisil is unable to kill other fungi that may be involved in onychomycosis like Candida albicans. Therefore Lamisil treatment is limited to dermatophytoses of the nail. For this reason it is important for doctors to accurately diagnose the organism that is causing the onychomycosis before starting treatment.

Lamisil is available as 250 mg tablets. The traditional way that Lamisil is administered is in a continuous regimen, once daily, for several weeks. If onychomycosis is affecting the fingernails, a single 250 mg dose is taken orally each day for six weeks. If onychomycosis is on the toenails, the treatment is prescribed for twelve weeks.

Recently, good results with Lamisil have been achieved using a pulse therapy regimen. In this approach, two 250 mg tablets (500 mg total) are taken each day for one week with three weeks of no drug. This one week on/three weeks off system is used for four weeks in fingernail onychomycosis and for eight weeks in toenail onychomycosis. This pulse regimen has not been approved by the Food and Drug Administration but is still used. While larger clinical trials are needed to determine if the pulse system is equally effective as continuous dosing, this approach would be less expensive overall and would minimize potential side effect risk.
The most commonly reported side effects are dyspepsia, which is also known as upset stomach or indigestion. There is also a slightly increased occurrence of headache in people taking Lamisil. People sometimes get a generalized rash when taking terbinafine (Lamisil).

Lamisil, as with all antifungal drugs, has the potential to cause liver problems. In fact, anyone with a history of liver disease will usually not receive one of these drugs to treat onychomycosis. To make sure that people do not experience liver problems while they are taking the drug, a liver function test will be done prior to starting the medication. This is a blood test that measures enzymes from the liver, among other things. The test will be repeated at four weeks to make sure no problems have occurred. If they have, Lamisil is stopped and the problem usually goes away on its own. In some rare cases Lamisil has caused liver failure.
Another rare but potentially serious Lamisil side effect is that it can cause a drop in the number of white blood cells in the blood. Because of this, doctors routinely take a blood sample before treatment called a complete blood count or CBC. This can be done at the same time as the liver function test. Then, after four weeks, the CBC is repeated to check for a drop. If there is a drop, the drug is stopped. Stopping the drug is usually enough to see this white blood cell number return to normal.
The onychomycosis drug has been linked to very severe skin reactions called Stevens-Johnson syndrome and toxic epidermal necrolysis. These are very rare Lamisil side effects, but if they occur, they can cause the skin to blister and come away from the body. Stevens-Johnson syndrome and toxic epidermal necrolysis require hospitalization and close supportive care.
Compared to other antifungal and onychomycosis treatments, Lamisil interacts with relatively few drugs. It may cause cyclosporine (immunosuppressant) to be less effective. Alternatively, the toxicity of cimetidine (acid-reducing pill) and rifampin (antibiotic) may increase.
While the drug may be safe it is not always possible to know for sure, therefore Lamisil should not be started in pregnant women or nursing mothers. Onychomycosis treatment can be postponed until after pregnancy and nursing is complete.

The occurrence of onychomycosis in children is very rare compared to the rate of occurrence in adults. However, should it occur, Lamisil could potentially be used to treat the disease. While it has not been approved by the FDA for use in children, a Lamisil treatment dose can be prescribed based on the weight of the child. Children weighing less than 25 pounds or younger than 12 years old should not be treated with Lamisil.
Lamisil treatment of onychomycosis is faster than it was with older agents like griseofulvin. While Lamisil can cure onychomycosis in a majority of patients taking the medication within several months, the nail itself is not normal for some time, even after the dermatophytosis has been eliminated.
After Lamisil treatment is complete, the drug can be detected in the nails for up to three months after the drug is stopped. It can be detected in the blood for up to six weeks after treatment cessation.
Lamisil 250 mg tablets costs the National Health Service in Great Britain £3.44. Canadian retailers charge $80 to $160 for a one month supply. In the United States the cost of Lamisil varies, but the unsubsidized cost could be as high as $400 a month or more.

References
Terbinafine (Lamisil) prescribing information
Gupta AK, Lynch LE, Kogan N, Cooper EA. The use of an intermittent terbinafine regimen for the treatment of dermatophyte toenail onychomycosis. J Eur Acad Dermatol Venereol 2009;23:256-262.
Takahata Y, Hiruma M, Shiraki Y, Tokuhisa Y, Sugita T, Muto M. Treatment of dermatophyte onychomycosis with three pulses of terbinafine (500 mg day for a week). Mycoses 2009;52:72-76.

The days of onychomycosis being considered simply a cosmetic problem are over. Nail fungus is certainly unpleasing to the eye but it can be much more than that. The emotional and social impact of onychomycosis can be significant. Those afflicted with onychomycosis avoid public places and social functions. They avoid touching friends and loved ones with affected hands which can lead to real interpersonal conflict.

Beyond the psychological suffering associated with onychomycosis, the nails of the fingers and toes provide normally provide protection against trauma. The nails contribute to the way in which we sense the world. Nails affected by onychomycosis can be painful and interfere with sensation and walking. In addition, a fungal infection of the hands and feet may lead to a process called a superinfection in which bacteria and viruses also invade and infect the tissue on top of the fungal infection.

Because of these symptoms and complications, physicians are treating onychomycosis more aggressively than they once did. Patients are increasingly requesting onychomycosis treatment from doctors as well, whether it is topical, oral, or even surgical.

Medical prescription treatments for onychomycosis fall into two main categories: oral and topical (placed directly on the infected nail). The decision to use one or the other treatment is dependent on several factors. If the lunula is involved in either distal subungual onychomycosis or proximal subungal onychomycosis, than an oral agent is the only way to eradicate the disease. Patient preference factors into the decision, too. In many cases, a combination of oral and topical drugs is prescribed because this leads to a more rapid clearance of the infection and full eradication of the onychomycosis, in general.
Despite psychological and physical discomfort, oral prescription treatment of onychomycosis should not be entered into lightly. All antimycotic (antifungal) treatments used for onychomycosis have the potential to damage the liver. In fact, if the patient has any history of liver disease whatsoever, oral prescription treatment for onychomycosis should not be used. Even without a history of liver disease, it is usually recommended that the treating physician check liver enzymes before starting oral antifungal onychomycosis treatment. For some treatments, liver function should be checked again after four weeks. Also any sign of liver disease such as jaundice (yellow skin or whites of the eyes), dark urine, pale colored stools, upper abdominal pain, fatigue or malaise should be reported to the doctor immediately.

Historically, Griseofulvin was the only oral treatment for onychomycosis. While it worked reasonably well (not great) it was associated with a lot of side effects, especially at moderately high doses. Griseofulvin also required long treatment courses and the disease would often come back once the drug was stopped. Fortunately there are newer, more effective oral antifungal onychomycosis treatments. In fact, there are three main prescriptions in use today.

Terbinafine, also known as Lamisil, is very good against onychomycosis caused by dermatophytes, which most cases are. Terbinafine is given as a 250 mg pill once a day for six weeks if treating fingernails and twelve weeks if treating toenails. Pulse therapy has been effective in some cases. Pulse therapy delivers a higher Lamisil dose but separated by times that no drug is administered. A complete blood count and liver function tests should be performed before treatment is started and after four weeks of therapy.
Itraconazole (Sporanox) is usually administered in pulse dosing. The most common treatment schedule is 200 mg orally once a day for one week per month over three months. Itraconazole can interact with a number of other medications so you must tell your doctor about all of your medications, both prescription and over-the-counter. Liver function tests should be performed before treatment is started and after four weeks of therapy
Fluconazole (Diflucan) is administered once per week (150 or 300 mg) until the symptoms resolve. Treatment may be six to nine months long before results are seen. This antifungal may interact with several other medications and must be used judiciously. Fortunately no blood tests are required when using fluconazole (though they may be performed anyway).
Topical prescription onychomycosis treatments are of limited usefulness and are usually combined with oral or surgical treatments. One of the more effective topical prescription products is ciclopirox (Penlac). This 8% topical solution is applied once a day, usually at night. While it is safer than oral antimycotics, complete cure was achieved in about 5% of those treated with ciclopirox alone.
In cases where prescription treatments for onychomycosis fail, there are a number of surgical options. They fall into three broad categories: chemical, mechanical, or surgical nail avulsion. A concentrated solution of urea (~50%) can remove the fungus and even a very thick nail. This approach is painless and can be quite effective. The nail can be mechanically or surgically avulsed (forcibly torn away) which may require local anesthesia because of the pain caused by the procedure. In people with severe disease, however, the nail may already be pulled away from the finger and avulsion is therefore less painful than it would be in the nail’s natural state. Avulsion is rarely painless, however, which should be considered in your treatment decisions. Also the finger or toe is left without a nail for a period of time after removal.

References
Ciclopirox (Penlac) prescribing information
Fluconazole (Diflucan) prescribing information
Itraconazole (Sporanox) prescribing information
Terbinafine (Lamisil) prescribing information

A laser, which is a concentrated beam of light energy, has the ability to selectively destroy certain biological structures, vaporizing them in very real terms. Depending of the wavelength of the light used in the laser, the type of biological structure being destroyed can be selectively targeted (more or less) and preferentially destroyed.

The use of lasers to treat nail fungus is not new. Researchers have been trying to use lasers to treat onychomycosis since the 1980s. The approach at that time, however, was a little different. Before newer antifungal treatments like Lamisil and Sporanox, the only oral medical treatments that existed for onychomycosis were griseofulvin and, a little later, ketoconazole. These drugs took a very long time to work, had potentially severe side effects at even modest doses, and often did not even work at all. The original application of lasers in the treatment of nail fungus was to use the laser to create holes or channels in the nail. This process, called fenestration, was meant to give topical onychomycosis treatments better access to the fungus. The laser could open up a pathway so that the medicine applied to the nail could get at the fungus and kill it.

This approach did not meet with much success. The process was expensive and did not seem to improve the topical treatment of onychomycosis to any great degree. As lasers were evolving and more widely available to physicians and surgeons, a better approach was adopted. By using a laser with a specific wavelength of laser light energy, the fungus could be targeted and killed, while leaving the skin and nail intact. Instead of making large tunnels in the nail, the light was focused on the fungus directly. In essence, the laser energy heats the fungus to the point that it is killed but does not burn the surrounding tissue.
It is this latter approach that is gaining ground among dermatologists is the United States. While the FDA has not approved any laser systems specifically for the treatment of nail fungus or onychomycosis, similar devices have been cleared by the FDA for use in other diseases and medical fields. Some companies are waiting on FDA clearance for this application but at least one company has not. Outside of a clinical study, patients having nail fungus laser treatment will be getting that treatment from this device manufacturer that released the technology before FDA clearance.
It is not yet clear whether nail fungus laser treatment actually works.

There have only been a couple of small clinical trials that have looked at the efficacy of laser onychomycosis treatment. As with many small, early trials of a new technology or application, the results have been favorable. However, as medical science has witnessed many times before, when these same technologies that perform well in small studies were tried in larger groups of people with more rigorous test protocols, many of them fail to show the same degree of benefit. At this point it is too early to say if nail fungus laser treatment is worth the price.
The Treatment can be expensive. Nail fungus laser treatment costs between $1,000 and $2,500. The laser onychomycosis treatment is not covered by health insurance since onychomycosis is viewed as a cosmetic disease (which is more or less correct, barring complications or severe disease). Therefore the cost of laser nail fungus treatment must be covered in full by the patient.
The procedure is very safe with remarkably few side effects. Therefore the risk to the patient is basically just money. Are you willing to risk a thousand dollars on a new, unproven application of laser technology? Some people are willing since nail fungus laser treatment promises to shorten the course of treatment by weeks over oral medicines. When faced with an unappealing and potentially disfiguring disease, patients are willing to spend reasonably large sums of money for a rapid solution to the problem.
It may be possible to find a clinical trial of laser onychomycosis treatment in your area. These studies are usually conducted at or near a large academic hospital, but may be conducted at an office near you. The website www.clinicaltrials.gov provides a listing of all of the clinical trials registered in the US and in several other countries. While you risk having a placebo (fake) treatment if you enroll in one of these clinical trials, you may also save yourself $1,000 or more.

Reference
Bornstein E. A Review of Current Research in Light-Based Technologies for Treatment of Podiatric Infectious Disease States. J Am Podiatr Med Assoc 2009;99:348-352.

Onychomycosis is generally a disease of older patients with most cases occurring in patients older than the age of 40. It is 30 times more likely for the disease to occur in adults that in children. Onychomycosis is very common and becomes more prevalent as people age. About 20 percent of all people between age 40 and 60 have onychomycosis. In fact, it has been estimated that as many as 90% of elderly patients have the disease.

Onychomycosis tends to occur more often in men than in women; however women are more likely to have an infection of a specific type of fungus called Candida. The disease occurs equally across all races.
Doctors have noticed that the number of cases of onychomycosis has been increasing over the past few decades. One major reason for this trend is that people are living longer lives. Since onychomycosis is extremely common in older people, an increasingly older population brings more cases of the illness.

As people are living longer, they are also dealing with chronic medical conditions that increase the likelihood of contracting onychomycosis. For example, diabetes is quite prevalent and we know that diabetes leads to problems with wound healing and increased susceptibility to certain infections.

Poor peripheral circulation, a problem for many people in Western countries, leads to poor wound healing, too. Poor circulation in the legs and feet is thought to provide an ideal situation for fungal infections since the immune system is less able to defend the body.

A fungal infection of the nails does not usually cause any symptoms, especially at first. By far the most common complaint from people that have onychomycosis is the way that the nail looks. The disease leaves the nail looking unappealing. Onychomycosis often disfigures the nail.

This cosmetic affect should not be dismissed—people often avoid social interactions because of the significant embarrassment and shame that a nail fungus can cause. Patients and associates may worry that the fungus is infectious or that the diseased nail means that the afflicted person is unhealthy or unclean. The psychological, emotional, and social impact can be surprisingly profound.
While the disease may start as purely cosmetic, over time onychomycosis may cause pain in the affected finger or toe. Because the nail can become thick, patients report that they cannot feel things like they normally would. In the hands, this lack of sensation leads to problems with writing and other daily activities. In the feet, people may have trouble sensing the floor which causes them to stumble or fall. This is a particular problem in patients with diabetes and peripheral vascular disease—diseases that already cause problems with the nerves of the legs.
There are four main types of onychomycosis: distal subungual onychomycosis, proximal subungual onychomycosis, white superficial onychomycosis, and candida onychomycosis. Distal subungual onychomycosis is the most common form of onychomycosis and is usually caused by a dermatophyte called Trichophyton rubrum. This dermatophyte invades the nail plate and nail bed. The term subungual means under the nail so in distal subungual onychomycosis, the infection the infection can be seen as a white-yellow growth under and on the nail, usually towards the tip. From the tip of the finger or toe, the infection can move under the nail toward the cuticle. The nail can become pitted and folded and yellow streaks can appear in the nail.
In proximal subungual onychomycosis, the onychomycosis is again under the nail, but the infection starts at the near the base of the nail at the cuticle side. The infection moves toward the tip as the nail grows. Proximal subungual onychomycosis is the least common cause of onychomycosis in healthy people though it is fairly common in patients that have immune system deficiencies. Proximal subungual onychomycosis is most often caused by Trichophyton rubrum, but can also be caused by molds and other fungi.
White superficial onychomycosis is found in only one out of ten cases of onychomycosis. This fungal infection occurs on top or in the topmost layers of the nail. As expected by the name, the lesion in this type of onychomycosis is white and forms islands on fungus on the nail. The disease can spread and cover the entire nail plate. In contrast to the other types of onychomycosis, white superficial onychomycosis is usually caused by Trichophyton mentagrophytes, another dermatophyte.

Candida onychomycosis, the fourth form, usually begins as a chronic mucocutaneous candiasis. Chronic mucocutaneous candiasis is a long-lasting yeast infection of the skin. The yeast is called Candida (usually Candida albicans). While the other infections stay primarily on or in the nail, Candida onychomycosis often causes infection of the skin around the nail, in the proximal and lateral nail folds. Several nails are affected in Candida onychomycosis and the nails can be virtually or literally destroyed by this serious fungal infection.

References
Hainer BL. Dermatophyte infections. Am Fam Physician 2003;67:101-108.
Jaffe R. Onychomycosis: recognition, diagnosis, and management. Arch Fam Med 1998;7:587-592.
Kaur R, Kashyap B, Bhalla P. Onychomycosis–epidemiology, diagnosis and management. Indian J Med Microbiol 2008;26:108-116.

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Unfortunately there are few topical treatments, whether prescription or over-the-counter that can effectively treat nail fungus infections. One over-the-counter topical onychomycosis drug that has been shown to be effective in a few clinical trials is amorolfine. Amorolfine is available without a prescription in the United Kingdom, New Zealand, and certain other countries. It is marketed under the brand name Loceryl. Amorolfine is distributed as a nail lacquer and the effective concentration is also the way in which it is sold, namely 5%. Amorolfine nail lacquer is painted on the nail, like polish, and then dries, leaving behind the drug. The drug is able to penetrate the nail and reach the site of the fungal infection. This drug penetration takes place over a week’s time.

Amorolfine is able to kill fungus by inhibiting with the cell membrane of the fungus. It can only be used on distal (or lateral) subungual onychomycosis and is ineffective on proximal subungual onychomycosis and superficial white onychomycosis. Therefore it is important to determine the correct type of onychomycosis.
It is unclear why amorolfine is not available in the United States, especially when it is available over-the-counter in other countries. The possible side effects are infrequent and mild when used as directed. Some patients report a burning sensation when they apply the lacquer at first, which goes away. With the advent of online pharmacies, it might be possible to purchase this medication from wholesalers or retailers based in other countries, but the cost may be prohibitive. Prices quoted for a single 5 ml tube of Loceryl can range as high as $100 or more.

While Lamisil is available as a tablet and is a reasonably good oral onychomycosis treatment, the Lamisil that is available over-the-counter is a topical ointment or cream. While the topical Lamisil may do a good job at treating some fungal infections of the skin, like athlete’s foot, it is not terribly effective at treating nail fungus.

There are various over-the-counter nail fungus treatments that have not been rigorously tested in clinical trials. Therefore it is difficult to make any strong recommendations about them. One medicine that is sold as an anti-fungal nail liquid is undecylenic acid. There have been two papers published looking at undecylenic acid in the treatment of onychomycosis, one published in 1965 and the other in 2008. The 2008 paper shows a positive effect but undecylenic acid was combined with two other ingredients cyanoacrylate and hydroquinone. It is not clear whether this topical onychomycosis drug is effective on its own.

While clotrimazole (Lotrimin) is an over-the-counter fungus treatment, it is not effective at curing onychomycosis. Studies report a cure in less than 15% of those that use it to treat nail fungus. It may lead to an improvement in nail appearance but the disease is very likely to recur after treatment is stopped. Clotrimazole is better suited to other forms of tinea like jock itch (tinea cruris), athlete’s foot (tinea pedis), and ringworm (tinea corporis).

One slightly promising over-the-counter treatment for nail fungus is tea tree oil (Melaleuca alternifolia). Recent, small studies have shown that 100% concentrations of the oil may be able to cure 20% of those that use it and improve nail appearance in about two-thirds of patients. A 0.05 ounce bottle of the oil costs less than ten dollars. In head to head comparisons between twice daily application of 100% tea tree oil and 1% clotrimazole, tea tree oil may have been slightly more effective. Once such over-the-counter treatment that contains tea tree oil is Zetaclear.

Tolnaftate (Tinactin) is another over-the-counter antifungal that is better suited to treat skin fungus. It is not effective in nail fungus treatment. Miconazole is sometimes found in over-the-counter fungal treatments but also suffers from being ineffective against nail fungus infections.

The statements made about these topical products assume that the affected nail has not been subjected to any surgical intervention. It is possible that surgical, mechanical, or chemical removal of the nail prior to over-the-counter nail fungus treatment may improve the effectiveness of the topical agent used. If you are considering surgery for onychomycosis treatment, ask your surgeon about nail fungus aftercare treatment options.

If you are not considering surgery for onychomycosis but are serious about getting rid of the nail fungus, the highest chance of success is through the use of oral antifungal agents. These nail fungus treatments are currently only available with a prescription.

References
Hammer KA, Carson CF, Riley TV. In vitro activity of Melaleuca alternifolia (tea tree) oil against dermatophytes and other filamentous fungi. J Antimicrob Chemother 2002;50:195-199.
Hart R, Bell-Syer SE, Crawford F, Torgerson DJ, Young P, Russell I. Systematic review of topical treatments for fungal infections of the skin and nails of the feet. BMJ 1999;319:79-82.
Rodgers P, Bassler M. Treating onychomycosis. Am Fam Physician 2001;63:663-668.
Turchetti B, Pinelli P, Buzzini P et al. In vitro antimycotic activity of some plant extracts towards yeast and yeast-like strains. Phytother Res 2005;19:44-49.

Proximal subungual onychomycosis can cause a number of visible changes in the fingernail or toenail. In this disease, the nail plate becomes white and/or yellow near the cuticle. The distal portion of the nail (near the tip of the finger) is usually unaffected by the disease. This is especially true early in the course of proximal subungual onychomycosis. The fungus invades the nail rather deeply and can cause the nail bed (the soft fleshy area underneath the hard nail) to become bumpy and irregular. The nail near the cuticle is often destroyed as part of the disease process. As the nail grows it may have folds and pits. The combination of an irregular nail bed and misshapen nail plate may cause the nail to become loose.

Like distal subungual onychomycosis, most cases of proximal subungual onychomycosis are caused by a dermatophyte called Trichophyton rubrum. Another dermatophyte, Trichophyton mentagrophytes may be to blame in some case. Proximal subungual onychomycosis is sometimes caused by the invasion of molds.
Another curious feature of proximal subungual onychomycosis is that the skin surrounding the nail may become red, inflamed, and swollen. This is especially true if the disease is caused by molds. The nail and surrounding area may ooze pus in proximal subungual onychomycosis.

The inflammation and pus are what cause many physicians to incorrectly diagnose proximal subungual onychomycosis as a bacterial infection rather than a fungal infection. This can be a problem if antibiotics are prescribed since antibiotics do not kill fungi. An antifungal medication is required to kill dermatophytes, molds, and yeasts.

Proximal subungual onychomycosis is a fairly uncommon form of onychomycosis. It occurs most often in people with depressed or deficient immune systems. A person may have a depressed immune system due to certain blood cancers or because they are undergoing treatment for cancer like chemotherapy or radiation. Any immunosuppressive treatment can depress the immune system, by definition. Patients may be on an immunosuppressant if they are being treated for an autoimmune disease or have had an organ transplant and are on anti-rejection drugs.

While proximal subungual onychomycosis can occur in any of these patient groups, it seems to occur particularly frequently in patients with human immunodeficiency virus or HIV. In fact, it occurs in this patient population so frequently that when proximal subungual onychomycosis occurs in a patient without an obvious reason for a suppressed immune system, the treating physician may suggest a test to check for HIV. If you are seeking treatment for a fungal infection of the fingernail or toenail that has started at the cuticle side of the nail, be prepared to be asked to have an HIV test. This test can only be performed with your consent. Also keep in mind that a diagnosis of proximal subungual onychomycosis does not necessarily mean that you have a diagnosis of HIV.

Unlike some other onychomycoses, proximal subungual onychomycosis simply must be treated with an oral antifungal medicine in order to eradicate the problem. There are a number of possible oral onychomycosis treatments, however they are only available by prescription in United States. Topical medications are completely ineffective in treating proximal subungual onychomycosis.

If the proximal subungual onychomycosis is known to be caused by Trichophyton rubrum or Trichophyton mentagrophytes, then a good treatment choice is terbinafine, also known as Lamisil. Terbinafine is given as a 250 mg pill once a day for six weeks if treating fingernails and twelve weeks if treating toenails. Lamisil has no effect on Candida infections and should not be used to treat cases of proximal subungual onychomycosis caused by this organism. Lamisil has the advantage of being less expensive than the other new generation of onychomycosis treatments.

Itraconazole (Sporanox) is a good option for proximal subungual onychomycosis when the cause of the disease is known to be fungal but may or may not be a dermatophyte. Sporanox has some activity against Candida, too. This treatment is usually more expensive than other onychomycosis treatments, including Lamisil.

Fluconazole (Diflucan) can be used to treat proximal subungual onychomycosis, but this is not a first line drug for this disease. This medication halts the growth and spread of the disease rather than killing the fungus outright. In medical terms, fluconazole is fungistatic (fungus stopping) rather than fungicidal (fugus killing).

This means that the drug helps the immune system get a handle on the fungus by slowing down its growth. Since many cases of proximal subungual onychomycosis occur in people that already have depressed immune systems, this approach may not be terribly effective. When used, fluconazole (Diflucan) treatment usually continues until symptoms resolve.

References
Hainer BL. Dermatophyte infections. Am Fam Physician 2003;67:101-108.
Jaffe R. Onychomycosis: recognition, diagnosis, and management. Arch Fam Med 1998;7:587-592.

The short answer is that no one really knows for sure. There hasn’t been much research on removing some or all of the nail to treat fungal nail infection. This treatment isn’t used very often, but your doctor might suggest it if your infection is severe or keeps coming back. If you are experiencing recurring nail fungus infestation then this might be a bigger issue with your immune system and your overall general health.  You might want to discuss with your doctor doing a cleanse and changing your diet to include more organic live foods and stay away from cooked foods.

What is it?

You can have your nail completely removed (this is called avulsion) or partially removed (this is called debridement). This can be done either with minor surgery or with an ointment that softens the nail so that it can be removed easily.

Surgery: Your doctor will first numb the skin around and under your nail with a shot of a local anesthetic. He or she will then use a tool to separate your nail from the surrounding skin and nail bed (this is the area under your nail). Once the nail is removed, your skin underneath should heal in a few weeks.

Removal with an ointment: Your doctor will cover the skin around your nail to protect it and then put an ointment on the infected part of your nail. Your nail will then be covered with a plastic dressing, which you’ll need to keep dry. After a week to 10 days, your nail should be softened enough for your doctor to remove it. The skin that was under your nail should heal in a couple weeks.
After your nail is removed, your doctor will probably recommend putting an antifungal cream on the nail bed or taking antifungal pills. This is because the fungus lives on the skin under your nail, rather than on the nail itself.

If you have a fingernail removed, it should grow back in about six months. If you have a toenail removed, it may take 12 to 18 months to grow back.

If you keep getting infections, your doctor might recommend completely removing the nail and then putting a chemical on the thin layer of skin at the base of your nail (your cuticle) to stop your nail from growing back.
How can it help?

We don’t know. There hasn’t been much good-quality research on whether removing all or part of the nail can get rid of fungal nail infections.

We found one study that compared antifungal pills (terbinafine, itraconazole and fluconazole) with other types of treatments, including removing part of the nail and putting antifungal medicine directly on the nail.1 It found that people who used antifungal pills were more satisfied with their treatment than people who had part of their nail removed or put medicine on their nail.

What are the Side Effects

Once your nail is removed, there’s a chance the skin underneath could become infected while it heals. To prevent this, doctors recommend keeping the skin clean and dry, and putting on an antibiotic cream.

If all or part of your toenail is removed, it’s possible that the corner or side of the nail could regrow into the skin on that toe. This is called an ingrown toenail. A mild ingrown toenail can be treated with remedies at home, such as soaking your foot in warm salt water and then putting cotton underneath the ingrown part to help it grow above the skin. A more severe ingrown toenail, however, will need to be treated by your doctor.