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Tune in to hear from our doctors, Dr. Anthony Fedrigo and Dr. Oendrila Kamal about the latest and most up-to-date information about all things related to foot and ankle and sometimes life in general.  


By Foot and Ankle Specialists of Marin, Feb 17 2016 08:45PM

The second condition we see in winter is Onychomycosis, aka: Toe nail Fungus. While treating skin is relatively easy, treating toenails is much more difficult. When the skin is wet, fungal infections spread from the skin to the nails. Do you see a theme here? Fungal infections are moisture driven. The main reason we develop toenail fungus is trauma. Inside a shoe and sock all day is a very harsh environment. The trauma to our skin and toenails makes us susceptible to fungal infections. The toenails are particularly prone to fungal infections because of this. Shoe trauma to the nails causes the toenail plate to move and shift on top of the nail bed. What I mean by trauma, is just daily shoe wearing. Not acute trauma like dropping a frozen Thanksgiving turkey on your toe. As the trauma occurs the toenails lifts off the nail bed, and those pesky dermatophytes find their way under your toenail. At first you may just notice some thin white or yellow streaks at the tips of your toenails. Sometimes the streaks will be along the nail groove where the skin meets the side of the toenail. As it progresses, you start to see yellowing, thickening, and sub-ungual build up under the toenail. As you build up more dissolved skin, nail and fungal elements under the nail plate, the nail can start to change shape and the nail may take on a more curved appearance. I often have patients ask if they should try and clean this out from under their toenails. The answer is no. As you use an instrument to clean under your toenails, you not only lift the nail plate more, helping the fungus get further underneath, you also push these microscopic organisms further and further under the toenail plate. This is a common problem with patients that get regular pedicures. Watch for our summer time blog on how to avoid these common problems from pedicures.

The difficulty in treating toenails, unlike skin, is the slow growing nature of toenails. A toenails takes 9-12 months to grow from start to finish. Typically the fungus grows faster. So even though you produce perfectly sterile healthy toenails, as they grow out, the fungus in the toenail continues to reinfect the healthy toenail. As a result, there are very few topical treatments to clear your toenails of a fungal infection. All of the products over the counter may help, especially if treatment begins very early in the course of the infection, but for the most part, I tell my patients we are hoping for controlling the spread, not curing the condition when using an over the counter topical treatment. And I have heard of just about every topical home remedy from Clorox to Vics Vapor rub, to oregano oil, to grapefruit seed extract oil, and white vinegar to listerine to being applied on the nails. You name it, someone has tried it. That goes to show you how common onychomycosis is in the population.

Now this takes us to medical treatments. In my opinion there are only two options for cure. The first is a prescriptions topical that is relatively new on the market called Jublia (efinaconazole). The other is a prescription oral antifungal called Lamisil (terbinafine). Jublia is applied daily for 11 months. Remember how slow toenails grow. When applied daily, Jublia acts as an external barrier to prevent further fungal infections of the nail plate. Once a week I recommend patients cut and file away any loosely attached nail. The goal of Jublia is to apply it to the remaining healthy nail by removing the infected damaged toenail.

Lamisil is an oral antifungal medication available only by prescription. Lamisil is taken once daily for 90 days. Before you start the medication you need to get a blood test to check your liver enzymes. Even though the risk of liver involvement is very low, a baseline liver function test (LFT) is recommended. At the end of your 90 day course of Lamisil your toenails will not look any better =( . It takes another 6 to 9 months for your nails to clear up. Again the reason, slow growing toenails. On the other hand, fingernails grow almost twice as fast as toenails. So if you want to have great looking toenails by summer, Winter is the time to start treating your toenails

Dr. Fedrigo

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