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Footnotes / Blog

Toenail Fungus

Friday, September 3rd, 2010 Kenneth Donovan

There is a whole host of treatment modalities out there for Toenail Fungus. Unfortunately, none has a success rate approaching even 90%. Which makes this one of the more difficult podiatric problems to treat.

Toenail fungus is usually caused by the organism Trichophyton rubrum. The fungus is everywhere in the environment, although most cases in young females seem to come from nail salons. In the elderly or immuno-compromised (ie Diabetes, HIV, Chemotherapy, etc) it is fairly common to see this condition. In it’s mild form, most people experience slight yellowing of the nail corners of the big toenail. In its most severe form it causes thick, discolored, flaking, malformed, painful nails. Obviously the more mild the case, the easier to treat, while some of the most severe cases require removal of the nail.

Treatment varies from patient to patient, case to case. It usually starts with an office visit, where we use a variety of sanders and burrs’s to remove and thin the affected nail, so that the recommend treatment has the best chance of working. The universally accepted best treatment out there right now is Lamisel. It’s an oral tablet that you take once a day for 3 months. Its success rate is close to 70-80% of the time. The downside of this product is that there is some risk to the liver. While the risk is minimal (has the same risk as taking Lipitor or other cholesterol lowering agents), we still like to monitor a patients liver function w/ lab work during the course of the treatment. The other oral therapy drug on the market is Gris-Peg, while not as effective at Lamisel, it is more likely to be covered by insurance plans.

For whatever reason, some patients can’t take the oral Lamisel or Grispeg (albeit it they don’t want to…or can’t accept the minimal risks to the liver). Which means the only option to them are varying topical’s. The most famous one being Penlac. Since Penlac is now generic it is accepted by most insurance plans. However, it is labor intensive treatment and only works 10-15% of the time. It’s a nail lacquer that the patient needs to apply every morning, and remove w/ alcohol every night for 48 weeks.

In our office we sell Formula 3, another nail lacquer which is oil based. It is a non-prescription medicine that requires application 1-2 times a day. Cost’s about $40 dollars, but it comes w/ a no questions asked money back guarantee if you don’t see results. We are also in the process of marketing Fungisel anti-fungal lacquer (topical form of Lamisel), which would cost roughly the same as Formula 3 with the same money back guarantee.

The new thing in treating toenail fungus is Laser. No conclusive scientific studies have been published proving the efficacy of this form of treatment. Therefore, insurance companies won’t pay or approve of this sort of therapy. Which means the out of pocket cost to the patient and can be as high as $800 per foot. Until there is more scientific proof of Laser therapy, we’ll continue to instead peruse the above therapies w/ patients.

Last line of defense are the home remedies. There are several home remedies that can be tried, most of which involve drying out the nail. Fungus likes dark moist areas to live, and the inside of your shoes is the perfect environment. The home remedy I recommend is to apply rubbing alcohol or apple cider vinegar on the affected toenail after showering, and spraying the inside of your shoes w/ Lysol to kill any fungus hiding there, and applying foot powder daily. I’ve also heard of patients success w Vicks Vapor Rub, Listerine (old school kind), and bleach. Most of these at home remedies require up to a year, and strict daily use to work.