Welcome everyone to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. This week I’d like to address the feet. We don’t talk much about the feet and we should! Here’s why: 

The average person is going to walk 150,000 miles during their lifetime. That’s like walking around the globe 6 times. If you have problems with your feet, you’re going to suffer. The number one thing with longevity is movement. If your feet are hurting or they can’t perform, you’re not going to move. 

Your foot has 26 bones in it, making it one of the most intricate parts of your body. If something is off with your feet, you’re going to know it. My dad always said don’t skimp on two things, your shoes or your mattress, because you’re going to spend most of your life in one or the other. 

The structure of your feet is important, and it’s so different for everybody. You could have an arch that’s too high. You could have flat feet, which means you don’t have any arch. You could have bunions, hammer toes, plantar fasciitis, corns (calluses), heel spurs, claw toes, or metatarsalgia (very common among people my age). You could have diabetic neuropathy. If you have any one of these common conditions, it’s going to severely limit the way you’re able to promote your health. Foot problems can be painful, lead to infection, limit your movement, all of which are important for longevity. 

Today’s note will be centered on one particular foot problem that I see all the time in the office, fungal toenails. Although it isn’t a pressing health problem, fungal infection can ruin the appearance of your nails and cause infection and pain. It’s unpleasant and difficult to treat.   

Let’s get started. 


Fungal Toenails 


Fungal toenails are very common. According to the Centers for Disease Control and Prevention (CDC), there are 3 million new cases in the United States every year. Problems caused by fungal toenails can be purely cosmetic, or they can lead to infection and be very painful. If you have fungal nails, you probably need to get rid of them.

Nail fungal, also called onychomycosis, is caused by the dermatophyte fungus trichophyton rubrum, which causes the thickened, brittle, crumbly, ragged nails. It’s relatively easy to diagnose, but hard to treat, and it can last a lifetime. Note: Sometimes nail fungal can get confused with other conditions like psoriatic nails or damaged nails. Usually when the nail starts to get that thickened, yellowy appearance, you can tell what it is. If there’s any question, you can always do a biopsy by taking a nail clipping. 

Fungal toenails are more common in old age, rarely in kids. You are at an increased risk for fungal nails, if you: 

  • have had athlete’s foot in your lifetime (fungus of the skin caused by the same general fungus)
  • have cancer and are receiving chemotherapy
  • have had previous nail infections or injured nail 
  • have poor circulation (I see this a lot because I work with spider veins)
  • are immunocompromised 
  • have people in your family who have fungal infections
  • have psoriasis or a lot of skin conditions 

Fungal toenails are really common. Sometimes they can lead to infections and become painful. Plus, who wants to have toes that look like they’ve been invaded by fungus, of which could possibly affect your overall health? 


Cause of Fungal Toenails


Your lifestyle has a lot to do with it. A few things that make you more at risk are: 

  • your feet frequently wet
  • you smoke
  • you walk in your bare feet in humid places (pools, public showers, locker rooms)
  • you wear tight fitting, closed toed shoes (especially if your feet sweat a lot)

Most people get fungal toenails when they have skin contact with somebody who has a fungal infection (i.e., athlete’s foot). Note: You can also get it by sharing nail clippers or towels. Fungal nails are contagious, but there are other ways you can get it.  

Funguses are everywhere. It’s all about the right condition. You may have a crack in your nail, or in the skin beside your nail, even a small cut! This fungus can get into that area and cause infection. The area under your nail also provides a warm, moist place to grow. Infection can spread to other nails, or even the skin. Note: It’s weird how a lot of times it will spread to other nails, but not the other foot. I think this is probably because of poor circulation in the one foot. 

Sometimes you see fungus in just one nail and not the others, while other times it spreads to all the nails. It usually starts out as a discolored yellow spot on the nail, and then it slowly grows. You’re more prone to get fungal nails if you’re stressed, immunocompromised, or have had a lot of antibiotic treatments. 


Treatment of Fungal Nails 


This is the tough part. There are topicals, oral medications, and surgery. Topicals have a low cure rate. Oral medications are pretty effective, but can have side effects. With nail removal (surgery), you have to think about caring for the wound afterwards, and it can still return. Toenails can take from 12-18 months to grow out in their entirety. It’s a long process. It’s a stubborn infection. You have to be patient when treating fungal nails. 

The first topical that came out was called Penlac. Penlac has about a 12% cure rate. Jublia is the one you hear advertised all the time. It has a better cure rate, but it’s really expensive. Note: I have heard of some of the specialty pharmacies being able to get the generic for cheaper. Out of the topicals, this may be the best brand name one.   

Topicals work better if you do debridement first (either manually with a podiatrist, or use a urea product). Urea thins the nail out and makes it more penetrable for the topical. There’s a brand name of Urea called CeraVe. It’s a prescription medicine, but you have to keep it covered under a tight water occlusive bandage. It’s usually performed monthly by a podiatrist. In my opinion, not real practical. 

There’s a daily compounded medication, a combination of urea and a medicine called Clotrimazole, that’s probably the best topical. You can get it from a compounding pharmacy. It’s still not perfect, not as good as the orals, but an option. Note: There’s a lot of over the counter home remedies like tea tree oil, coconut oil, and Vicks VapoRub, that have antifungal properties, but in my opinion they’re not that effective. You usually get recurrence with the OTCs. The orals work better than the topicals, there’s no doubt about it. 

Lamisil (Terbinafine) is probably the best one. It’s got about a 76% cure rate. Sporanox  (Itraconazole) has just about a 63% cure rate. So, I think the oral Lamisil is better. Note: Diflucan, which we use more for yeast, does not work well for fungal nails. You would have to take these orals daily for 2-3 months. The downside is that it can affect your liver, so you need to get liver function tests before treatment and midway through your treatment. Then you have to worry about recurrence. This is why you have to do the things that will prevent it once you cure it!

Lasers? Right now the technology is only there for cosmetic reasons. It may thin it down and improve the appearance, but I don’t think it’s going to cure it. I haven’t found it to be effective. If a nail won’t respond to topicals or orals, you have to start thinking about surgical removal. Sometimes they even have to permanently remove the nail, if it’s recurrent. I’ve removed many nails for fungus, and unless you create the right conditions for it NOT to recur, it’s going to come back. At that point you have to permanently remove the nail, which is best done by the podiatrist. They can permanently remove the nail by using phenols at the base of the cuticle after they take it off. 

If they don’t permanently remove it, you’re going to need to use a topical as the nail grows back. It works at the base of the nail called the cuticle. These topicals penetrate, but it’s the action they take at the cuticle that will cure your nail as it grows out. Remember, you have to be patient. It’s going to take a long time for that new nail to grow out. It’s hard to treat. It’s stubborn, and it can recur. 

Note: There’s all kinds of toenail deformities that we see. A pincer deformity is where the edges of both nails are clawed in. It can be a very painful deformity and can lead to a lot of ingrown nails and other problems. They’re very curved. A lot of times the podiatrist will permanently take those corners out.


Practical Tips on Nail Care 


  1. Watch out for pedicures! I’m not saying you shouldn’t get them, but you need to look at where you’re getting them from. A lot of infections and fungus are spread this way. The tool needs to come out of the autoclave (sterilizing machine). Don’t let them mess with your cuticles or dig and try to get a nail out of the corner. Don’t let them dig on your nails! Just let them do the pedicure. If they get too deep, you’ll get an infection. That’s how fungus spreads.
  2. Be careful with toenail polish. I’m not against it, but if you have fungus don’t use toenail polish on top of it. .
  3. Cut your nails straight across. That’s what my dad would always say when I was a kid. When you cut your nails, cut them straight across. Do not curve them, and don’t try to dig them out by yourself. That’s when you get an infection. If you have a slight irritation that could lead to an ingrown toenail, let it grow out! Soak it, and let it grow out. Cut your nails straight across, and if you can’t cut them properly, get somebody like a podiatrist or another expert on nail care that can take care of this.

Bottom line, take care of your toenails. It’s kind of like taking care of your teeth. It’s very important for your overall health. 

Stay educated. Stay healthy.

Till next week.