Toenail Fungus Treatments

Over the Counter Nail Fungus Treatments – Are There Any That Might Work?

In the world of microorganisms, fungi are a pretty hardy bunch. There are generally harder to kill than bacteria and viruses. Dermatophytes, yeasts, and molds invade nails and dig themselves deep within the nail itself. Thus an already resilient organism is even further protected by layers and layers of keratin. Because of these reasons, treating onychomycoses has been difficult, historically. Even powerful oral antimycotic medications are not 100% effective. In light of this, can any over-the-counter nail fungus treatment be effective?

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.

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