Nail fungus is pretty stubborn. Topical treatment with polish for nails can take up to a year. Nail fungus tablets are usually taken for a longer time. After several weeks or months they are significantly more effective than topical treatments, but have more side effects.
A nail fungus can usually be recognized by brittle and whitish-yellowish to brownish discolored nails. The nails can also thicken and change shape. The affected part of the nail may become detached from the nail bed. For the treatment of nail fungus, nail polishes and creams for application as well as tablets for oral use are possible. Lacquers and creams are available from pharmacies without a prescription.
What External Treatments are there?
- Sets with creams and spatulas: For the external treatment of nail fungus, there are also treatment sets that contain two creams and a spatula: A cream contains urea (urea) and dissolves the nail so that it can be removed. The other cream contains bifonazole, which works against fungi. In this treatment, the affected toe or finger is first soaked in warm water for ten minutes and then dried. The urea-containing cream is then applied to the nail and protected with a plaster. After 24 hours, the patch is removed and the toe or finger is put back into warm water. Then the softened layer of the nail is scraped off with a spatula, the nail is reapplied with cream and bandaged over. This treatment is continued for 14 days. When the part of the nail infected with nail fungus is completely scraped away, the underlying skin is treated with a bifonazole cream for another four weeks.
- Lacquers: Many people try to treat nail fungus with a colorless nail polish first. Before applying the varnish, the affected nail is cut and filed down as much as possible. Nail polishes contain one of the growth-inhibiting and fungicidal ingredients amorolfine or ciclopirox.
The products differ in how often they are used: Amorolfine is applied once or twice a week. Ciclopirox is usually applied every other day for the first month, at least twice a week for the second month and once a week from the third month. In both treatments, the old paint film is removed with an alcohol swab before the paint is applied again. Normal nail polish can be applied over the lacquer film. Newer Ciclopirox lacquers are water-soluble. They are applied daily and the paint residue is washed off with water before each new application.
How Effective are Topical Treatments?
External nail fungus treatments with varnish or creams have so far only been investigated in a few studies. Because these studies had weaknesses, the results must be interpreted with caution. Amorolfine has not yet been well studied. Ciclopirox varnish and treatment sets with urea and bifonazole cream were tested in individual studies. Studies on the effect of nail polish with ciclopirox show after one year:
- Without Ciclopirox varnish, about 10 out of 100 people could no longer detect any nail fungus.
- With ciclopirox varnish, nail fungus was no longer detectable in about 32 out of 100 people.
- Treatment with ciclopirox made the fungal infection disappear in about 22 out of 100 people.
But even if no more fungus was detected, the cosmetic result was not always satisfactory. Only 7 out of 100 people had healthy nails after the treatment. Treatment with urea and bifonazole cream was investigated in one study. It was compared to treatment where only urea cream was applied and the nail removed, but no bifonazole cream afterwards. Three months after completing the treatment, the following was found:
- With urea alone, no more fungus was visible or detectable in about 41 out of 100 participants.
- With urea and bifonazole, no fungus was visible or detectable in about 51 out of 100 participants.
The combination of urea and bifonazole was able to free about 10 more participants from the nail fungus. Six months after the end of treatment, however, there was no longer any difference between the two treatment groups. In addition, the nail fungus returned in many. Therefore, neither treatment is likely to increase the chances of a long-term cure. People who had more than half of the nail surface or who had the disease originating from the nail root did not participate in the studies.
What Are the Oral Products?
For the internal treatment of nail fungus, tablets are used, which also inhibit the growth of the fungi or kill them. All require a prescription. Terbinafine and itraconazole are particularly suitable for the treatment of nail fungus:
- Terbinafine is preferred when skin fungi (dermatophytes) are the cause of the nail fungus. This is mostly the case.
- Itraconazole is usually used when a yeast or mold infection caused the nail fungus.
- Both terbinafine and itraconazole tablets can be taken continuously or with breaks in treatment.
Apart from that, they are used differently:
- Terbinafine: With continuous treatment, the drug is usually taken once a day for three months (dosage: 250 mg). When taking with a break in treatment, the drug can be used as follows: 500 mg terbinafine (2 tablets) daily for one week, then a three-week break. Or: 250 mg terbinafine (1 tablet) daily for four weeks, then a four-week break. Even with this form of administration, the treatment usually lasts no longer than three to four months.
- Itraconazole: With continuous treatment, itraconazole is taken once a day for a maximum of three months. The dosage is 200 mg per day (two tablets with 100 mg itraconazole each). When taking with breaks in treatment, take 400 mg itraconazole daily for one week (two tablets with 100 mg itraconazole in the morning and two in the evening). This is followed by a three-week break in treatment. Here, too, the treatment lasts a maximum of three months.
- Fluconazole: This medication is only used when other treatments have not worked or are not possible for other reasons. It is taken once a week (dosage: 150 mg). However, fluconazole must be used for about 6 to 12 months to be effective.
How Effective Are Tablets Against Nail Fungus?
Nail fungus tablets have been investigated in several studies. All study participants had an infection on their toenails caused by skin fungus. Overall, the study results showed that tablets are significantly more effective than paints or creams. One year after three months of treatment with terbinafine:
- Without treatment, nail fungus was no longer detectable in around 17 out of 100 people.
- After treatment, about 76 out of 100 people no longer found any nail fungus.
- Treatment with terbinafine cured the infection in about 59 out of 100 people.
Itraconazole was also found to be effective:
- Without treatment, after one year, 7 out of 100 people could no longer detect any nail fungus.
- After one year of treatment, about 43 out of 100 people could no longer detect nail fungus.
- Treatment with itraconazole cured the infection in an estimated 36 out of 100 people.
Some studies have compared itraconazole and terbinafine directly. They confirm that terbinafine is slightly more effective than itraconazole. Taking it with a break in treatment is probably as effective as continuous treatment. However, this has only been investigated in individual studies.
What Side Effects and Interactions do Tablets Have?
Possible side effects of itraconazole include headache, dizziness, gastrointestinal problems, and skin rashes. Itraconazole can also interact with a number of other active substances. These include cholesterol-lowering and blood sugar-lowering drugs, as well as certain sleep aids. It is therefore important to inform the doctor about which medication you are taking. Itraconazole is not an option for people with a weak heart. The drug is also not suitable for women who are pregnant or breastfeeding.
Terbinafine can cause gastrointestinal problems and lead to a temporary loss of taste and smell. There may also be interactions with certain antidepressants and heart medication. Overall, terbinafine has significantly fewer interactions than itraconazole. However, it is important to inform your doctor about other medications you are taking. As a precaution, the product should not be taken during pregnancy or breastfeeding.
The frequency of the individual side effects was rarely reported in the studies. Most people tolerate the drugs used against nail fungus, but apparently well: only a few stopped the treatment because of side effects. However, when taking itraconazole or terbinafine, there is a risk, albeit a very small one, of liver damage. In people with liver disease, these drugs are therefore only used if absolutely necessary.
What About Remedies Like Tea Tree Oil?
Home remedies, such as applying tea tree oil or vinegar, are sometimes recommended to treat nail fungus. Whether this and other remedies help against nail fungus has not yet been tested in good studies.
When are Which Treatments Possible?
Topical treatment for nail fungus with varnish or cream is considered by most professionals:
- At most half of the nail is affected by the fungal infection.
- The nail root is not infected.
- Only individual nails are affected.
External treatment is also recommended for children. For one thing, most drugs are not approved for children. On the other hand, children have thinner nails that grow faster. It is therefore assumed that treatment with varnish or cream has a better chance of success with them than with adults. A white, superficial nail fungus is also often treated with varnish or cream. If several nails are affected by the fungus or the infection is extensive, it is usually necessary to take medication. Even if the infection originates from the root of the nail, only tablets will most likely help.
If the nail is badly affected, tablets can also be combined with varnish or cream. For example, if the nail is very thick, it can be slowly removed or partially abraded using urea cream in addition to the tablet treatment. A combination treatment can also be considered if there are large clusters of fungus under the nail. Professional medical foot care is also an option for severe nail fungus. When the nail is abraded, it is important to maintain good hygiene and disinfection as the material ablated may contain contagious fungal spores.
Sometimes people with nail fungus are offered laser treatment. For example, the nail is irradiated with infrared light or ultraviolet light (UV light), which is supposed to kill the fungi. The effectiveness of laser treatments has not been proven by good studies. Since they are not a service provided by the statutory health insurance funds, you have to pay for them yourself.
What is The Right Treatment for Me?
Nail fungus is usually harmless. But many people find discolored or thickened nails unsightly and want to get rid of the fungus as quickly as possible. In addition, a fungal nail infection can spread and also lead to other people becoming infected. Regardless of the treatment chosen, it will take a while for the nail to look normal again. Patience is especially important when it comes to a toenail. It can take a year for the nail on the big toe to grow back healthily. In some people, nail fungus is very persistent despite treatment. It can recur even after successful treatment.
The chances of permanently curing nail fungus with external treatment are rather slim. Treatment with tablets is much more effective and less tedious. However, because of the very rare but serious risks, it is not an option for all people. How you assess the advantages and disadvantages of the various treatment options for yourself is a matter of personal consideration. The doctor can advise you.
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