Nail Fungus

Dr. Greene's Answer

Dear Lesley, Last night I had bad dreams about nail fungus. Your story reminded me of the seemingly interminable battle I have had with them. Mine began when I was in college and rowed on the crew team. I had athlete’s foot that eventually spread into the toenails.

The nails of our fingers and toes are tremendously effective barriers. This barrier makes it quite difficult for a superficial infection to invade the nail. Once an infection has set up residence, the same barrier that was so effective in protecting us against infection now works against us, making it difficult to treat the infection.

Fungus rarely invades an intact nail. Usually, there is some kind of trauma such as that experienced by your son. Prolonged wetness can also allow the barrier to be breached. Sometimes a prolonged athlete’s foot condition can even breach an intact nail. Usually, it is some combination of these methods. Fungal infections can also be a problem for people wearing acrylic nails. This happens because the fungus becomes trapped next to the natural nail in a warm, dark, moist environment for a prolonged period of time. Long-term bandages over the nails can have the same effect.

Fungal nails usually begin with an opaque white or silvery area at the distal (outside) edge of a nail. The fungus gradually works its way inward. As the fungus grows, the nail thickens and can become quite painful.

My Own Story (I) – Frustration

When I first noticed that I had a fungal nail, I began treating myself with over-the-counter athlete’s foot medicines — one after another. It soon became evident that while they were effective in treating the athlete’s foot, they were of no value in helping the nail condition. I went to see a physician and eventually went through a large number of more potent anti-fungal creams, including Nizoral, which you’ve used so liberally. Sometimes this seemed to slow the progression of the fungal infection, but the onward march across the nail was relentless. I later learned that the treatment was a little more effective if I gently filed the outer surface of the nail, thus making the barrier less complete, and immediately applied the Nizoral. This was much more work, and resulted in a small improvement in efficacy. Later, I learned from a podiatrist that this could be enhanced further by using an electric tool, called a dremel drill, to gently buff the outermost layer off the nail before applying the Nizoral. I tried this, but was also disappointed with the results. I have, however, known people who have had success with this method.

In the beginning, I was told that two oral agents were available for treatment of fungal nails. One of them is called griseofulvin. It requires daily treatment — 6 months for fingernails and 12 to 18 months for toenails. Even prolonged therapy does not always lead to a cure. With griseofulvin, recurrences are quite frequent. I eventually tried this medication, but was not able to tolerate it due to nausea. I also tried the other oral medication that had been suggested, ketoconazole (Nizoral), the oral form of the same medicine you have been trying as a cream. Oral Nizoral is another long-term, daily treatment. This is more effective in treating fungal nails, but it can have even more side effects than griseofulvin. I needed to stop taking this medicine because of the effect on my liver. Both of these oral agents are available for children.

My Own Story (II) – If At First You Don’t Succeed…

After a long and painful struggle, I became frustrated with all of the conventional medicine approaches and looked at alternative medicines. A promising solution was a natural remedy called Australian Tea Tree Oil. It is a naturally occurring anti-fungal compound that can penetrate the nails. Full of hope, I began gently filing my nails and applying the Australian Tea Tree Oil two times daily. I found this to be about as effective as the Nizoral cream. It did slow the progression of the fungal nail, but it did not reverse the condition.

I finally accepted the fact that the fungus would never go away.

My Own Story (III) – Success At Last!

A few years after that, a pharmacist friend suggested I try a newer oral medication called fluconazole (Diflucan). This is taken once a week until all the infected nail grows out. Fluconazole is far safer and more effective than any of the previous oral preparations. I took the oral Diflucan as suggested and was giddy to see the fungal nails heal almost effortlessly! As the nail grew out, it was replaced by a perfect-looking nail. Fluconazole was developed as a result of AIDS research and is now available in a pleasant-tasting liquid for children. It is also being marketed as a single-dose medication for yeast infections in women.

Current Treatment

Two newer, more effective oral medications have now become the standards. Itraconazole (Sporanox) and terbinafine (Lamisil) are both FDA approved for the treatment of nail fungus. The most frequent side effects include nausea, diarrhea, and rash. As with other medications used to treat nail fungus, liver enzyme abnormalities can occur and should be monitored. The medicines work even better if part of the fungus-filled nail is filed away.

Effective Prevention

I have since learned that, unfortunately, I am prone to fungal problems. If I fail to keep up a preventive regimen, and my feet get moist for a prolonged period, then the fungal infection starts up again (for which I use Sporanox). Because your son’s infection was precipitated by an abrupt injury, we don’t know how prone to fungal infections he is. I would still recommend — at least while he has this infection — keeping his fingers as dry as possible. When his fingers do become wet, they should be dried thoroughly, perhaps with a hair dryer.

I have found an effective preventive routine for my feet: shoes that breathe, cotton socks, athlete’s foot powder (any brand) in my shoes, Fungoid Tincture on the nails before bed, and Lamisil cream to the whole foot once a week. The latter two may be useful for your son’s hands.

You have had a long battle with an annoying problem. I wish you the best in days to come.