Toenail fungus, otherwise known as onychomycosis, is an extremely common and persistent problem.  Certain people seem to have a unique pre-disposition to this toenail infection which makes it difficult to achieve a permanent cure.  Permanently curing this condition requires determination, persistence and know-how.  Often, a more realistic approach is palliative treatment instead of permanent cure.

Treatment of Toenail Fungus

The gold standard for the treatment of onychomycosis is systemic terbinafine.  This treatment usually requires at least 3 to 4 months of ongoing daily medication.  Care must be taken for individuals who have certain pre-existing conditions or who are taking other medications that may interact with this drug.  After approximately 6 to 12 months, the majority of individuals will improve.  However, without some type of ongoing maintenance, relapse is almost certain.

There are numerous recommendations floating around for the topical treatment of onychomycosis.  These range from various formulations of vinegar to the use of Vicks VapoRub.  Topical antifungal creams, sprays and powders fail because of lack of penetration into the nail tissue.  Even complete removal of the affected nail usually results in relapse.

Prescription Options

There are three topical prescription products available in the United States specifically for the treatment of nail fungus.  Listed below are their names, approximate effectiveness and approximate cost.

  1. Ciclopirox 8% nail lacquer, in one large study was shown to clear about 40% of cases.  In my clinical experience, the number is significantly less.  The price of this medication is approximately $60 for 6.6 ml of the generic.  As a point of reference, a teaspoon holds 5 ml.
  2. Jublia, in studies provided by the drug manufacturer, gave 20 to 30% clearance rates after 48 weeks of treatment.  This medication costs approximately $645 for 4 ml.
  3. Kerydin, in company provided information, gave response rates of a little below 20% at one year.  This drug is also priced at approximately $645 for 4 ml.

Over the Counter Treatment Options and Plan

Due to the lack of cost effectiveness of current prescription topical treatments, my preferred topical treatment for onychomycosis is the following:

  1. Apply over the counter terbinafine cream ($15.99/30 gm) to both feet, toes, web spaces and nails once daily.  Most people will have coexisting athlete’s foot and this strategy will help contain infection.
  2. Apply 47% urea gel (KERA Nail Gel $30/30 ml) thoroughly over and under the affected nails nightly.  If possible, work some of the terbinafine cream under the nail while applying the urea gel.  This concentration of urea will help dissolve away the infected nail, thus allowing the terbinafine to penetrate more effectively.

This treatment should be continued for 3 to 6 months and then reassessed.  While I do not have any research data on the effectiveness of this treatment, it is my clinical experience that many patients show improvement comparable to the much higher priced prescription topical medications.

Prescription Treatment Plan

For those highly motivated individuals in good health and not taking any other medications, I recommend the following approach for a complete and permanent cure:

  1. Systemic prescription terbinafine daily for 3 to 4 months.
  2. 47% urea gel nightly for 3 to 4 months.

Upon completion of this treatment program, it is essential to continue preventative maintenance indefinitely.  This is best accomplished with terbinafine cream applied to the feet, toes and nails daily after bathing.

It continues to surprise me how many people don’t realize that they have athlete’s foot.  This common fungal infection, known as tinea pedis, is frequently mistaken simply as “dry skin.”   The name “athlete’s foot” is a misnomer as the problem is not limited to athletes.  It is reported to affect between 30% to 70% of the population.  There are a variety of responsible fungi, but trichophyton rubrum is the most common.  These fungi are common in the environment and grow in the dead “keratinized” layer of the skin, known as the stratum corneum.  Genetics, climate and occlusive footwear predispose individuals to tinea pedis and it is much more common in adults than children.

Signs of Athlete’s Foot

Tinea pedis is frequently asymptomatic but the signs may include dry, scaly skin with or without tiny bubbles around the sides and along the bottom of the feet.  The skin between the toes may have a white, pasty appearance and often there is an accompanying toenail fungus.  Other common or more serious conditions such as psoriasis, eczema, allergic skin reactions, cellulitis and callused skin could be confused with tinea pedis.  A physician should be consulted if there is any redness, swelling, bleeding, inflammation, pain or if there are open sores or other complicating factors such as diabetes, vascular insufficiency, advanced age, cancer or immunosuppression.

Topical Antifungals

There are many effective antifungal topical products available for treating tinea pedis.  In recent years, prescription antifungal creams have undergone substantial price increases, but economical and excellent over the counter products are available such as generic terbinafine cream or butenafine cream (Lotrimin Ultra).  I do not recommend antifungal powders or sprays.  For maximum benefit, it is just as important to use the medicine properly as it is to choose the right medicine.  Apply the cream to both feet in a thin layer from the ankle down covering the entire foot surface.  It should be applied every morning after showering for two to four weeks.  Recurrences are likely, so be prepared to start treatment early for any signs of flare-ups.  While all medications may have the potential for adverse reactions, problems with over the counter topical antifungal medications are unusual.  The most likely problem would be an allergic rash, in which case the medication should be stopped immediately.  If your problem is not improving within two weeks (or certainly if it is worsening), see your physician for evaluation.


In addition to using a topical antifungal cream in the mornings, applying a “keratolytic” exfoliating cream or lotion at bedtime will increase the effectiveness of the antifungal cream.  These products work by helping to remove the dead keratinized layer of skin inhabited by the fungus.  They also by allowing better penetration of the antifungal cream.  Keratolytic products contain various concentrations of urea (10%-20%), salicylic acid (3%), or alpha hydroxy acids (12%).  They may be used indefinitely to keep the feet smoother, softer and to prevent recurrences.  A warning, keratolytics should not be applied to sensitive, irritated, inflamed or open skin.