Toe nail fungus (also known as onychomycosis) is a common problem that is difficult to treat. It is difficult to treat for two reasons. 1) a toe nail is nearly impenetrable to creams and other topical medications, and 2) toe nails grow VERY slowly.
Many people present to our office with nails that are yellow and thickened and look “fungal”. The first thing we do is take a nail clipping and send it to the lab. When we find fungus, we have something to treat and we treat it (see below). When we do not find fungus, we are somewhat “stuck”. There are some products that can improve the appearance of these “fungal looking” nails that don’t have any fungus. For example, there are whitening agents to get rid of the yellow color, and urea products which decrease nail thickness. But these treatments are only cosmetic. On the other hand, when we do find fungus, then there is a chance for a “cure”.
The most effective way to treat toe nail fungus is with pills. And the most effective pill is terbinafine (Lamisil). But every patient seems to have heard from somewhere that Lamisil “kills your liver”. This is simply not true. There is a tremendous amount of data and experience with Lamisil to support its safety, or we simply would not use it. The biggest problem we have with Lamisil is cost (it is about $10 per pill) and getting it covered by insurance (many companies will not pay for it).
The patent for the very effective, but very expensive oral antifungal called Lamisil (generic name = terbinafine) just expired in June of 2007. Now that the drug is off patent, generics have started to appear. The cost difference is huge. A quick check at Costco.com pharmacy shows that 30 pills of the brand-name Lamisil cost $385 versus 30 pills of the generic at $21.
Lamisil is typically prescribed as a long course of continuous therapy: one pill a day for two months to treat finger nails; three months for toe nails. We treat nail fungus with a different approach called “pulse therapy”. Pulse therapy means that you take a one week “pulse” of the medicine every month or every two months. In other words you take Lamisil for seven days in a row (= one pulse) and then nothing for the rest of the month. There is data to support that pulse therapy is just as effective as “continuous therapy”, if not more so. The obvious appeal is that one can achieve the same results with less medicine. This means less potential for side effects and lower cost.
For those who can not or will not take pills, there are alternatives, but they are less effective. The treatment depends on what the nail looks like, but often consists of two parts. Part one, a topical anti-fungal agent. And part two, an agent to thin out the nail, making it appear more normal and allowing the anti-fungal medicine to penetrate better. We usually prescribe a compound so that both agents are applied as one medicine.
• Even with pills, only about 80% of patients can expect a “cure”
• When treatment is successful, it still takes 6 to 12 months for a toe nail to grow out completely and look normal again.
• The nail on the large toe grows at rate of approximately 1mm per month.
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