FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

NAIL INFECTION TREATMENT EFFECTIVE BUT EXPENSIVE

Question: I've had trouble with fungus infection in my toenails for years. Several years ago my doctor told me that the medicine available then wasn't very effective. I've recently seen advertisements for a new product that is suppose to cure the condition. Does this new medicine really work?

Answer: Upwards of 5 percent of the U.S. population suffer from fungal infections of the nails. This condition is called onychomycosis, and it can be quite annoying. It can occur in only one nail or occasionally in all 20 of them at the same time. When fingernails rather than toenails are involved there is usually less discomfort but more concern about appearance.

When a nail is infected it becomes thickened, rough and irregularly shaped. Further, it is often broken, discolored and can become unattached from the nail bed. Not only is this unattractive, but it can also cause discomfort, particularly if the nail on the big toe is involved.

Simultaneous infection of the surrounding skin is almost always present and produces symptoms of athlete's foot mild to extreme redness and scaling as well as itching and irritation. An over-the-counter athlete's foot remedy may clear this skin infection, but it can't penetrate into the nail's growing area, the source of infection in onychomycosis.

The new medication you saw advertised was probably either itraconazole, brand name Sporanox, or terbinafine, marketed as Lamisil. Both of these drugs are taken by mouth. The bloodstream then carries the active ingredients into the growing part of the nails the location of the infection where it kills the fungus. This simplified discussion makes it seem that anyone with a fungal nail infection should get one of these wonderful, new products immediately. Unfortunately, the real story is a bit more complicated.

The nail on the big toe requires 12 to 18 months to totally grow anew, while a fingernail may take only six to nine months. To be effective, an antifungal medication must be present until an entire new, healthy nail has grown in, otherwise the fungus left in the old nail will just reestablish the infection. Older oral medications had to be taken on a daily basis for the entire time required to grow a new nail. This is because they only killed fungi in the "growth plate" area where the body is producing new nail. The newer drugs, the ones for which you've seen advertisements, kill fungi in this area but also are effectively incorporated into the existing nail. This shortens the treatment time for toenail infections to three to four months, but the nail continues to look ugly until it has been replaced by healthy new growth that same 12 to 18 months.

When nails are judged nine months after starting treatment, the newer medications have a 70 to 80 percent cure rate. The older medications are significantly less effective, usually in the 20 to 50 percent range, and that is why your doctor suggested that they probably weren't a good choice for you several years ago.

There are several other important factors to consider in making a decision about treatment. One of them is cost. The newer medications are more expensive than the older ones, but they are taken for a shorter period. Consequently, with either approach, the total cost for medication alone is usually $600 to $1000. Add to this the cost of doctor visits as well as tests to be sure the infection is actually a fungus instead of several other conditions that can cause nails to look much the same. Once treatment is begun, regular blood tests are necessary to be sure the drug is not causing any liver damage. In addition, these antifungal medications cause interaction with several other common medications. So, taking medication for onychomycosis also requires adjustment of dose or elimination of other medications.

Certainly, I'd recommend you talk to your doctor again about your nails, but you shouldn't expect a quick or inexpensive cure.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701.