So you think toenail fungus is a joke. Not even a blip on the radar screen. Of interest only to your pedicurist, if that.
Well, try telling that to Gertrude Patenaude, a 57-year-old teacher-librarian from Portsmouth, R.I. who had the fungus on every toe. “It was brutal,” she says. “I couldn’t put my feet in shoes because of the pain.”
Okay, so toenail fungus, or onychomycosis, isn’t exactly the biggest threat to public health since The Plague. But it affects, by some estimates, more than 10 million Americans, including about 20 percent of older people.
It’s ugly – it makes toenails (and, to a lesser extent, fingernails) thick and discolored. It can be painful, because the thickened nails press into the delicate nail bed, especially in tight shoes.
And if you have diabetes, or poor circulation for other reasons, it can lead to ulceration underneath the nail and, ultimately, bacterial infections of the skin and bones, potentially necessitating amputation.
Got your attention? Great, because contrary to the reality a just a few years ago, there are now some pretty good remedies for toenail fungus.
The problem is caused by microorganisms called dermatyophytes – little critters that live on dead skin tissue and cause athlete’s foot. The whole process gets a toehold, as it were, when you contract athlete’s foot, which often happens when people who have a genetic predisposition to it walk barefoot in moist, germy places like locker rooms.
Athlete’s foot is treatable with over-the-counter topical creams, says Harvey Lemont, head of podiatric medicine at Temple University School of Podiatric Medicine in Philadelphia. The creams contain ingredients such as clotrimazole, tolnaftate and miconazole.
But if you don’t treat it, the fungi can creep deep into the nail matrix from where the nail grows, says Michael Hass, immediate past president of the Massachusetts Podiatric Society.
They love it there, because, unlike your fingernails, your toenails are swathed in (sweaty) socks and shoes, where it’s warm, dark and moist – in other words, perfect for fungi. And the food supply – keratin, the protein that nails are made of – is plentiful.
As the fungi grow, the nail gets thicker and may become foul smelling, according to the American Podiatric Medical Association. Debris – which can be white, green, yellow or black – can build up under the nail, discoloring the bed and giving the nail above a ghastly cast, adds the American Academy of Dermatology.
Once you’ve progressed from athlete’s foot to fungal nail infection, over-the-counter topical creams don’t help much because they can’t penetrate deeply enough, says James Chrzan, a podiatrist at Beth Israel Deaconess Medical Center. Even prescription creams may help only about 20 percent of people.
But two years ago, the outlook brightened for those with serious nail fungal infections – the arrival on the market of two oral prescriptions drugs, Lamisil and Sporanox. Both remedies must be taken for about three months, and it often takes another few months – and sometimes, repeated treatment – before the infection truly clears up, says Lemont of Philadelphia.
Both treatments work about 50 to 60 percent of the time, podiatrists say. Lamisil is typically taken every day for up to 12 weeks, while Sporanox is taken for a week, then skipped for three weeks, with this pattern repeated for three months.
The drugs are “far more efficacious and safer than the prior agents we had,” notes Dr. Robert Stern, a Beth Israel dermatologist, though they can cost $500 for a full course and may not be appropriate for people with minor problems. After all, he asks, “Does everyone really need to have beautiful toenails?”
In a small percent of people, both drugs can also elevate liver enzymes, although this rarely translates into liver disease. Still, many specialists advise blood tests of liver function before, during and after treatment. The drugs can also interfere with the metabolism of other medications in the liver, so it pays to tell your doctor about all medications you take.
In addition to the pills, some specialists recommend reducing the thickness of the nails with electric burring, a procedure normally done by podiatrists. This helps decrease the pressure on the nail bed, which can reduce the risk of ulceration. Once ulcers develop, bacteria can invade the skin and underlying tissue, potentially causing wider infection in people who have weakened immune systems because of disease or advancing age.
In healthy, young people, the pain caused by thickening nails often prompts a visit to the doctor – and treatment. But in many older people, particularly those with diabetes who lose sensation in the feet due to neuropathy, the pain of fungal nail infections can go unnoticed until the problem is severe, notes Lemont.
For Gertrude Patenaude, relief finally came with Lamisil – and throwing out all her old shoes. It took 12 weeks of treatment, and a year for healthy, new nails to grow.
But she’s fine now, and says, “I would never want to get it again.”