Nail fungus.
It's one of the things I see every single day but is one of the hardest things to treat.
Today we're going to go through what nail fungus is, what treatments are available for
you, and what might be the best option for you.
The craziest thing to know about nail fungus is that it is pretty case specific.
Whether you have one toenail or you have five toenails or all ten, whether you have a little
bit of the nail involved or the whole nail is full of fungus, every case is different.
So what we're going to go through is what's the best treatment for every type/case of
nail fungus.
Think of nail fungus as a mold and it's living underneath the nail eating the nail itself.
The most common way that I find that nail fungus is picked up is through trauma.
Normally we have the nail that is nice and pink and attached to the nail bed.
This is a sealed environment.
But with trauma, and that could be tight shoes, dropping something on your toe, ill-fitting
footwear, someone playing around or getting a manicure or pedicure, lifting up the nail,
all these things allow an opening from the nail to the nail bed to appear and that can
allow fungus which is in all our environment to get into the nail.
That's why it is very common for the big toe and the baby toe to have fungus on them.
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It's very hard sometimes to test for fungus or to have a true result.
The most common ways we test for nail fungus is through nail clippings we would cut part
of the affected nail and send it off to the lab and see if it tested positive for fungus.
But the problem is sometimes we don't take a proper clipping we don't get enough of the
good stuff or just the technique isn't really accurate.
60% of the time it is a false negative meaning if you have a negative result there is a 60%
chance that it could actually be fungus and it just didn't show up.
A better way to test for nail fungus would be an actual fungal culture where you take
the nail and you try to grow an actual fungus from the sample.
It's a lot more expensive and time consuming.
So the best way to really go about deciding if you have nail fungus or not is just looking
at your toenails and seeing the clinical signs and symptoms.
We're looking for yellow, white, green kind of cloudy look.
Think of it as mold on bread.
That's the kind of thing that we are looking for underneath the toenail.
It's really tricky sometimes to determine if you have nail fungus or you have a damaged
lifted nail.
The moment the nail becomes lifted off the nail bed, it does look more yellow.
The thicker the nail is, that also makes it look more yellow.
So to me, we are always looking for that kind of cloudy irregular appearance on top of the
nail.
Determining what treatment is best for you really depends on three factors.
Number one, the severity of the nail fungus infection.
Is a portion of the nail affected?
Let's say one-third of the nail, just the very tip of the nail does that have nail fungus?
Does half of the nail have nail fungus?
Or does the whole nail have nail fungus?
The second factor is how many nails are affected?
It's much easier to treat one toenail than it is to treat all ten toenails.
The last factor is then nail integrity.
Is the nail still flat?
Has it become very destroyed and very thick?
Depending on the severity of the nail fungus, how many nails are affected, and the integrity
of the nail, that's going to kind of help to decide how we're going to treat the nail
fungus.
So like I said, it's very case specific and we have to pretty much come up with a decision
on the spot looking at the case what's going to be best for each patient.
The one thing to know about nail fungus there's only one way to see results.
As the new toenail grows in, the old nail with the fungus, grows out.
So we're hoping that as the new pink healthy nail is growing in, whatever damaged infected
nail is being pushed out.
So there is no secret, there's no fast way to just make fungus disappear it literally
has to grow out and that takes time.
It normally takes on average one year for a big toenail to grow from bottom to top.
So if you do have fungus that goes all the way to the bottom, you are looking at around
a year of treatment to really push everything out.
If it is half the nail, six months, and if it is the top third of the nail, you are looking
at around three to four months.
So time is going to really tell if treatment is working well.
There are four main treatments for nail fungus.
Number one, topical treatment.
This is the most standard treatment that's out there and that's applying some sort of
ointment or medicine to try to penetrate the nail, touch the fungus, kill the fungus, so
as the new nail grows in, the old nail grows out.
There's a lot of problems with topical treatments out there and the reason for that is penetration.
If the medicine or ointment cannot touch the fungus, there is no way that it's going to
work.
So, what's very very important with topical treatment is that you apply some sort of ointment,
whether it's prescription strength or over the counter, on a regular basis everyday or
twice a day and you have the nail filed down.
This is probably the key to topical treatment.
We call it nail debridement but you can call it nail filing.
You have the nails filed down on a regular basis.
This is going to remove a lot of the thickness of the nail or the damaged, infected nail
allowing more penetration of the medicine and a healthier looking nail.
This is going to definately increase your chances of success.
I always suggest to have some sort of prescription strenght topical that way we know that it's
been tested, it's been proven to kill fungus.
The problem with over the counter or let's say we have a natural products, we don't know
the percentage or the concentration of those substances.
You don't know how pure the substance you are receiving is actually going to kill the
nail fungus.
So to me in the office I normally suggest people use a prescription strenght topical
that they apply on the nail usually twice a day.
Every two months the come into the office to have the nail filed down and we watch that
new nail grow out.
The second option we have is laser treatment.
There are different types of lasers out there so in general how laser treatments work is
you're appling light at a certain wavelength to the toenail.
This wavelength is usually going to kill or inhibit fungal cells.
This is going to stop them from multiplying or producing or just outright kill them.
The goal is by applying that laser light that wavelength stops the fungus from growing or
kills it and as the new nail grows in the old nail with this destroyed or dead fungus
grows out.
Penetration always is an issue.
So even when we are using the laser, it is very important that we have the nail filed
down as much as possible.
The thinner the nail, the better the penetration of the laser.
The laser treatment that I use in this office, is called photodynamic therapy.
I file the nail down as thin as i can.
I try to get as much of the fungal debris off.
I stain the toenail with something called methylene blue which is a very common stain.
It stains fungus very well.
After the fungus has been stained or the nail had been stained, we apply a laser light.
This specific wavelength of light activates the dye and it causes a reaction that's toxic
for nail fungus but not for normal cells.
So we normally do two treatments, two to three months apart.
At the same time, I get patients to use topical anti-fungal nail polish and again we review
the case after the second nail treatment to see how much has really grown out.
Topical treatments and laser treatment are the most conservative treatments we have out
there.
The only problem with that is it only treats effectively the fungus we can see.
If the nail fungus goes all the way to the cuticle, it's possible that the fungus is
actually underneath the cuticle and its infecting the new nail that's underneath the skin.
This is something that the topical treatments and the laser light might not be effectively
reaching and that way we're not going to get the treatment of that fungus and as the new nail
is growing in, we're still going to see the fungal infection.
So this is why it depends on the certain case of nail fungus you have to determine which
treatment would be best for you.
The last two options we have are oral medication and surgical removal.
Oral medication consists of taking a pill every single day for usually three to six
months.
The medicine goes into your bloodstream, it feeds the nail matrix itself so the new nail
cells are being fed the antifungal medicine.
This is going to give new nail growth, a healthy nail growth, to show up and push everything
out.
It is very very effective and works really well at even aggressive cases of nail fungus.
The only issue is that it could be a little bit harsh on your liver, if you have a history
of liver issues or you're taking a lot of other medications.
So it's very important that if you do go this route, you get liver testing done by a family
doctor and at the end of every month of treatment.
That way you are making sure your liver is not being effected.
Sometimes they only give you three to six months worth of treatment but if your whole
nail is affected, sometimes it's best to go on a course of treatment for six to twelve months
to just to make sure everything good is pushed out.
If you stop the medication and the fungus hasn't fully grown out, it's possible that
it comes right back.
The last option that I offer is surgical removal of the toenail.
For severe cases or if it's one toenail that is really damaged, or you had it for a long
time, sometimes the best thing to do is just to surgically remove the toenail.
What I do is I numb the toe, remove the whole toenail, and we can do two things.
One, we allow a new toenail to grow in and it will grow in healthy and fresh and good
or if it's a very damaged thickened deformed nail, sometimes the best thing to do is stop
the nail from every growing again.
I apply an acid and no more nail grows ever again.
The reason we stop the nail from growing, if the nail grows back thickened, it might
be prone to fungus again and we have to do more treatment.
The worst part about nail fungus you can do all the treatment in the world and you get
rid of the fungus next month, it comes right back.
Fungus is an infection, like catching a cold.
It is very important that you work on eleminating the amount of fungus in your environment meaning
making sure your socks are dry, not wet or moist, you are spraying the insides of your shoes
with an antifungal or antibacterial spray, something that disinfects the shoes.
Sometimes there's UV shoe sterilizers or other biological products that kill fungus.
The insturments you are using are clean that they haven't been used on someone else that
has fungus.
All these things together will help try to reduce the amount of possible reinfection
of nail fungus.
The three factors kind of guide me on how we're going treat the nail fungus.
So we have really three categories.
You have mild to moderate case, you have moderate to severe, and then you have a severe case.
Within each of those groupings, you have the recommended treatments and then also based
on the number of nails, what treatment should be best for you.
So let's start with mild to moderate.
If you have a little bit of nail fungus one to three toenails are effected, the nail fungus
is at the very tip of the nail or maybe even half way up the nail, what I would recommend
is you start with topical treatment possibly laser treatment and of course nail debridement.
This does the job for most mild to moderate cases.
Something that's not really aggressive, something where the fungus has not reached the bottom
of the nail.
So anything like I said the distal or the very tip of the nail, half way of the nail
or one to three nails, this is something that could be definitely managed with laser treatment or topical treatment.
When we start dealing with moderate to severe cases, this is where we have two thirds of
the nail is affected or the whole nail is affected.
This is where the gets a little bit trickier.
If the nail fungus goes all the way to the end of the nail, it's possible for the nail
fungus to be underneath the skin and that is reinfecting the new nail that is coming
in.
This is much tougher to treat.
Also, if we have more than four nails affected, it gets trickier to treat all the toenails.
So when we have usually four nails or more that are affected, and we have more than half
of the nail affected with nail fungus, this is where we start considering oral medication
or surgical removal of the toenail.
At the same time, combination therapy seems to be working the best so you should think
about adding a topical aspect as well.
So a topical medication, an oral medication, and sometimes if it is one or two severe
nails out of the four or more, you do surgical removal.
At the same time, nail debridement is a must.
The last category we have is severe cases.
So these are cases that you know the whole nail is completely infected.
You've had it for multiple years.
The nail is extremely thick.
These are the cases that topical probably will not work even oral medicaiton might not
work.
This is where we start consdering just a surgical removal.
When we get rid of the nail, you know there is no more nail and we can probably stop the
nail from ever growing again.
That way we never have the chance of a reoccuring fungal nail.
But if we have more than three or four nails affected, that are severly affected, it's
a little bit unrealistic to remove all of these toenails.
So sometimes our only option again is oral medication mixed with a topical and routine
debridement.
The most important thing to stress during nail fungus treatment is that you need to
have the nail filed down.
You need to find a foot specialist near you who is able to safely debride the nail get
it down as thin as we can so whatever medicine you're applying as much as it can go into
the nail as possible.
If the nail isn't being filed down, no matter how good the topcial is, it just won't kill
the nail fungus.
There's something brand new that I just got a hold of that is actually very very exciting.
There's a chemist who's finally been able to bottle pure iodine in water.
So this is something that they weren't able to do.
They were'nt able to control iodine and mix it with water.
Usually it was a tincture or mixed with alcohol it was a very dark or brown liquid that everyone
remembers putting on cuts and it would sting like crazy.
But this is pure iodine in water and it's being controlled at a certain ph and this
is being used to actually treat nail fungus.
Iodine kills viruses, it kills bacteria, it kills fungus.
But the problem was how do we control it to get it into the nail.
So this is something I've just been introduced to and I've started to use with my patients
that might be a solution for people to use themselves at home.
It's called "One Minute Clear Nails" and it's a really interesting concept.
All we have to do is spray the affected toenails three times, so three pumps, twice a day.
So it's a clear liquid, nothing like that it's safe to use on the skin.
Because it is in water, an aqueous solution, it is able to treat the nail and touch that
nail fungus and kill it.
The second part of this treatment is that every other week, I'm getting them to soak their
affected toes in this pure iodine solution.
It's clear, it doesn't have a heavy odor, it doesn't have that same stain, like the
old tincture does, and this seems to be killing nail fungus.
We still have to debride the nail as much as possible.
We make the nails as thin as possible.
But now you have something at home that you can soak your toes in, kill the fungus in between treatments,
and hopefully give us a better shot.
That is something I am still introducing in the clinic, seeing how the results are,
but I thought I would bring it out and share with you guys because iodine is actually organic,
it's natural, it's something that we need in our diet every single day.
But in this formulation with the way it is mixed in water it is able to kill nail fungus.
So I'm hoping that this might be a real solution for all types of nail fungus.
So this is how I would suggest you guys tackle nail fungus.
How severe is the nail fungus?
Is is a portion of the nail or is the whole nail affected?
How many toenails are affected?
Do all ten toenails have this kind of discoloration or fungal look or is it just one?
And numer three is how damaged is your toenail?
Is it very thick or still flat?
If you have a very severe nail fungus where the whole nail is infected with nail fungus
all the way to the bottom, you've had it for a long time but it is just one toenail, you
can try you know the topical or laser treatment to see how it works.
But after four to six months if nothing is really improving, that's when you know you
have to go for the aggressive treatment.
If you have over four to five nails affected six or seven or all ten, usuallly it's better
to go toward more of an aggressive treatment such as oral medication coupled with a topical to try and treat it but again,
if you are under that three to four nail mark, something sometimes just starting with a topical
and laser might do your trick.
So based on those three factors, you can have to find your way what might be best for you.
At the end of the day, I have a simple equation that's going to improve your chances of success
with nail fungus.
You need a daily routine treatment whether it is a topical medicine or pill you have
to be doing somehting every single day with some sort of ointment or treatment applied
to the nails.
You need to have the nail reduced or filed down or debrided on a regular basis.
This gives the best opportunity for the medicine or treatment to get into the nail and remove
as much of the bad, dead nail fungus.
You need a lot of patience.
Patience and determination to really be applying the medicine and going to the routine
treatment and of course at the very end of it, time.
Time is the only thing that's going to tell if the treatment is working.
So if you are doing something every single day,
your daily treatment, you're having your nails filed regularly, you're having the patience
to continue to do this treatment for possibly six months a year, year and half, two years
and you're taking the time to watch the nail grow out, this is going to give you your highest
chance of success that's of clearing your nail fungus.
Hope this give you a little more of an insite into nail fungus.
It's not an easy game.
It's a complex situation that even with all the advancements in medical health, we're
still having problems with but I'm hoping that this gives you a little bit more information
and tools to kind of guide yourself to what might be the best treatment for you.