Toenail fungus is the bane of every podiatrist’s existence. The reasons are plentiful. First, there is not one treatment that is guaranteed to work on everyone. Secondly, even if the patient experiences a clinical cure, there is a good chance they will contract the infection again in the future. Thirdly, most insurance companies are considering this a cosmetic issue and they are choosing not to pay for treatment or antifungal medications.
Toenail infections can be caused by fungus, yeast or mold. The most common infectors of the skin and nails are Trichophyton mentagrophytes and T. Rubrum, which are types of fungus and are the most treatable. Most topical and oral medications are geared toward these organisms as well as yeast. When choosing a treatment option it is important to submit a sample of the affected toenails for culture to pin point the causative organism so the correct medication can be selected. Because oral antifungals can harm the liver, it is important not to prescribe them for an organism that they are not able to treat.
Toenail infections are caused by some type of trauma to the nail such as stubbing a toe or dropping a heavy object on the foot. In addition, ill fitting shoes and toenails that are too long are contributing factors. These can cause a separation between the toenail and the nail bed and allow water to become trapped. Warmth + moisture= fungus. Fungal and yeast cells are naturally occurring on the skin just the same as bacteria. Under the right conditions it can overgrow and infect. Once a fungal infection is firmly entrenched in one toenail it has the possibility to spreading to other nails on the same or opposite foot.
Treatment options include daily application of a topical antifungal, taking an antifungal pill, treatment with High Power Laser Therapy (HPLT), or benign neglect. Topical treatments are reserved for mild cases of fungus that are near the tip of the toenail and have a 15-20% success rate by themselves. Oral medications treat the fungal infection from the inside out, but can cause liver damage in some people and require a blood test prior to the start of treatment to ensure the patient has a healthy functioning liver. Treatment with a laser (HPLT) has the highest success rate without unnecessary risks or side effects. In addition, the laser can eradicate all causative organisms and does not require a culture to determine the source or sources of the infection. HPLT heats the nail plate, nail bed, and surrounding skin to a temperature that causes the cell wall of the infecting organism to burst effectively neutralizing it.
Removing the toenail is not a viable treatment option because it constitutes trauma to the nail in and of itself. Removing the toenail in conjunction with treatment of the nail and surrounding skin has been shown to have better results than just treating the affected nail alone. This combination treatment has been used when there are only one or two nails affected, but is not feasible for 3 or more infected toenails.
It is also a viable treatment option not to treat the infection at all. As long as the nails can be trimmed and thinned and do not cause pain or problems, one can choose to live with it. However, the same organisms that infect the toenails also infect the skin, the continued presence of a nail infection can spread to the surrounding skin to cause Athletes’ foot which should be treated aggressively to prevent bacterial superinfection especially in diabetics and those with immune suppression.
For the vast majority of patients, the best combination treatment has been High Power Laser Therapy in conjunction with a topical antifungal. It is the one-two punch with the best chance of curing the infection. In addition, we give our patients the tools and knowledge they need to prevent re-infection in the future. Below are photographs of 2 patients successfully treated with High Power Laser Therapy (HPLT) and topical treatment. HPLT is the optimal method because it can kill fungus, yeast, and mold infections without serious side effects that can be caused by oral antifungals. There is no “quick cure” for toenail fungus, but for those who are willing to make treatment a part of their daily routine, the reward can be very satisfying.
Here is a good example of before and after treatment
