Topical Treatments for Toenail Fungus

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Onychomycosis, or toenail fungus, is a problem that affects millions of people worldwide. Onychomycosis can be mild, causing only cosmetic concern. But, for some, the changes in the nail structure can cause pain and even lead to a secondary bacterial infection.

Onychomycosis is notoriously difficult to treat, mostly because the fungus resides throughout the nail, including the nail bed. Moreover, the structure of the nail itself is not easily penetrated by topical agents.1

While oral antifungals can often eliminate the fungus systemically, they are not right for everyone, either because of cost, side effects, or a personal aversion to pills. To this end, there are some topical remedies that may help.
Diagnosis

If you have a toenail fungus, it is always a good idea to see a podiatrist to have your nails evaluated and identify the most appropriate treatment. One of the main reasons why nail treatments fail is that people will typically self-diagnose and treat a bacterial infection as a fungal one. By working with a podiatrist, you will not only be able to confirm that the cause is fungal but identify which strain of fungus you have.
Prescription Antifungals

One of the more frequently prescribed topical antifungals is Penlac (ciclopirox), a brush-on lacquer applied directly to the nail, usually over the course of months. Penlac is recommended for mild to moderate cases of onychomycosis in which the infection has not yet spread to the nail's growth center (known as the matrix).

It is important to note the Penlac only targets certain types of fungi (including the main form known as Trichophyton rubrum) and is less able to control drug-resistant strains. In fact, research has shown that less than 12 percent of those treated with Penlac experience partial or complete clearance. To this end, most podiatrists will usually combine Penlac with other forms of antifungal therapy.

Another notable topical antifungal is Jublia (efinaconazole) approved for use by the U.S. Food and Drug Administration in 2014. Applied once daily for 48 weeks, Jublia is far more effective in clearing fungal infections is also comes at a heftier price ($500 for Jublia versus $20 for Penlac).

Children tend to be more receptive to topical nail fungus treatment, due in part to the fact that their nails are thinner and more porous than adults.
Nail Debridement

If you decide to use a topical agent, monthly debridement (the removal of affected nail tissue) by a podiatrist will help the medication better penetrate the affected tissues. This may include the use of a topical urea cream to thin the nail and clear remnants from the nail bed.

Studies have shown that debridement with a urea-based topical agent can significantly improve the symptoms of onychomycosis after only one to two weeks.

While undergoing treatment, you will need to keep the nail covered with a water-tight bandage known as an occlusion dressing. It is a procedure that some people find cumbersome but helps ensure the urea penetrates the nail and doesn't rub off.2

Available by prescription in a 40% formulation (under the brand name Cerovel), the ointment retails for around $20. An extra-strength 45% formulation (marketed under the brand name Uramaxin GT) costs around $250.
Over-the-Counter Treatments

There are plenty of over-the-counter (OTC) topical antifungals on drugstore shelves, most of which promise more than they deliver. If you have especially thick nails and/or advanced signs of fungal infection (such as discoloration and texture changes), these OTC agents are unlikely to be beneficial no matter how long you use them.

If you have mild onychomycosis restricted to the ends of the nail, OTC products like Lamisil (terbinafine) cream may provide relief in conjunction with regular debridement and consistent use over four to six months. The cost of generic Lamisil cream is around $12 for a 0.46-ounce tube.
Home Remedies

There are several home remedies that have been popularized as nail fungus cures. These include tea tree oil, coconut oil, and Vicks VapoRub. Each of these products has antifungal properties and an oily texture which facilitates easy absorption.

While clinical evidence remains sparse, a small study investigating the use of 100% Melaleuca alternifolia (tea tree) oil concluded that it was as effective in treating nail fungus as 1% clotrimazole antifungal ointment. All told, around 50 percent of tea tree oil users reported improvement, although rates of recurrence were high.

Coconut oil contains caprylic acid and capric acid, potent antimicrobial agents that some insist can entirely eliminate nail fungus. While there is little clinical evidence to support these claims, research has shown that capric acid can suppress Candida albicans(a type of fungus linked to yeast infections) in the test tube. Whether the 9% capric acid contained in coconut oil can achieve the same effect with an especially hearty fungus like Trichophyton rubrum remains doubtful.

On the other hand, a small study involving Vicks VapoRub showed promising results. After 48 weeks, ten of the 18 participants achieved partial clearance of their nail fungus symptoms, while five achieved complete clearance. A 2016 study published in the Journal of the Association of Nurses in AIDS Care echoed these results in people with HIV. However, the results were typically short-lived, with most experiencing recurrence within a year.