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Medical Author:

Allison Harvey, MD, FACEP

Medical Editor:

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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In this Article

• What other conditions can be mistaken for fungal nails?
• What causes fungal nails, and what are some of the risk factors?
• Is nail fungus contagious?
• What are the symptoms and signs of fungal nails?
• How are fungal nails diagnosed?
• How is nail fungus treated?
• Are oral medications for nail fungus toxic?
• What about the cost of oral medications?
• How do you prevent fungal nails?
• What is the prognosis of fungal nails?
• Conclusion
• Patient Comments: Fungal Nails - Treatments
• Find a local Dermatologist in your town
• Fungal Nails Index

Physical exam alone has been shown to be an unreliable method of diagnosing fungal nails. There are so many conditions that can make nails look damaged, that even doctors have a difficult time. Therefore, laboratory testing is almost always indicated. A nail sample is obtained either by clipping the toenail or by drilling a hole in the nail. That piece of nail is sent to a lab where it can by stained, cultured, or tested by PCR (the best test but new and not widely available) to identify the presence of fungus. Staining and culturing can take up to four weeks to get a result, but PCR, if available, can be done in about one day. Most of the medications used to treat nail fungus have side effects, so you want to make sure of what you are treating.

Keeping nails trimmed and filed can help to reduce that amount of fungus in the nails and is highly recommended. A podiatrist or dermatologist may shave the top layer of the nail off or even remove part of the nail.

Creams and other topical medications are usually not effective against nail fungus. This is because nails are too hard for external applications to penetrate. However, a new medicated nail lacquer, ciclopirox (Penlac) topical solution 8%, has been approved to treat finger or toenail fungus that does not involve the white portion of the nail (lunula) in people with normal immune systems. It only works about 7% of the time. There is some evidence that using an antifungal nail lacquer containing amorlfine can prevent reinfection after a cure, with a success rate of about 70%.

Oral antifungal therapy works about 50%-75% of the time. It can take nine to 12 months to see if it has worked or not, because that is how long it takes for the nail to grow out. Even when therapy works, the fungus may come back about 20%-50% of the time.

Oral medications that are effective against nail fungus include:

• Griseofulvin (Fulvicin, Gifulvin, Gris-Peg): This drug has been the mainstay of oral antifungal therapy for many years. Although this drug is safe, it is not very effective against toenail fungus. Newer agents have largely supplanted it.
• Terbinafine (Lamisil): This drug is taken daily for six to eight weeks for fingernail fungus and for 12 weeks for toenail fungus. The drug is safe, effective, and produces few side effects. However, it must be used with caution in patients with liver disease. It can also be prescribed as a "pulse regimen," which seems to cause fewer liver problems that the usual daily dosing.
• Itraconazole (Sporanox): This is often prescribed in "pulse doses" -- one week per month for two or three months. It can interact with some commonly used drugs such as the antibiotic erythromycin or certain asthma medications.
• Fluconazole (Diflucan): This drug may be given once a week for several months. The dosing of this drug may need to be modified if the patient has impaired kidney function or is taking it simultaneously with certain other medications. It is not as effective as Lamisil or Sporanox and should be used cautiously in patients with liver disease.

There are several innovative treatments that are still being tested, but show good results so far:

• Photodynamic therapy uses application of light-activated agents onto the nail followed by shining light of a proper wavelength on the nail.
• Use of electrical current to help absorption of topical antifungal medications into the nail
• Use of a special nail lacquer that changes the micro-climate of the nail to make it inhospitable for the fungus to grow. If this works, it may be an inexpensive way to treat this problem in the future.

Vinegar is a commonly recommended home remedy. Its effectiveness has not been proven or disproven in a medical study. Some people apply various oils and other tonics to their nails as well.