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Interviewer: They're ugly, and, for some, nail fungus can be painful and also very tough to get rid of. Dermatologist, Dr. Christopher Hull, what's the first thing you do when a patient comes in with nail fungus?

Dr. Hull: Well, first, I like to make sure that it actually is nail fungus, because there are other nail conditions that can look very similar to and mimic nail fungus. So first that usually involves assessment of the nails. Sometimes we'll do some confirmatory testing with clippings and cultures and scrapings. And then, once we're comfortable that it's a fungal infection and not another condition of the nail that looks like nail fungus, then we talk about how it's affecting them and what they're hoping to achieve as far as treatment.

Interviewer: Got it. So if it's something else, the treatment options would be different. That's why you really want to find out, what . . . it is fungus, right?

Dr. Hull: Right. And treating nail fungus is notoriously very challenging, often with failures along the way. And so it's important to be sure that before you start going down the path of treatment, that you've actually got a correct diagnosis.

Interviewer: And it can take a long time to treat. So you wouldn't want to go down this path of treatment and then . . . yeah.

Dr. Hull: Right. And some of the treatments require monitoring and have some risks associated with them.

Interviewer: Got it. So you find out it's a nail fungus. At that point, what are the treatment options?

Dr. Hull: There are a number of treatments. There are many things that are you know, available over the counter. You go to the internet and Google "nail fungus treatment," you'll come up with 10,000 hits, I bet.

Interviewer: Yeah, pills, polishes, creams?

Dr. Hull: Right.

Interviewer: Yeah, all sorts of things. What do you tend to like to use?

Dr. Hull: Most of those have not been investigated with really good clinical trials. But I think there's things that people have used and have found to be helpful. One common thing that comes up are products that contain menthol. So Vicks VapoRub is a common nail remedy for nail fungus. It probably won't help. But it won't hurt anything either.

Most of my conversation is usually discussing medical therapy, so things that are available by prescription only. And those come in two main forms, which are topical antifungal medications, and then oral antifungal medications. There are other surgical or procedural options, so you can remove nails as well. And then there's starting to be more interest in technologies like lasers for nail fungus.

Interviewer: So you would said at one point that you have a conversation with the patient, what is it you're trying to accomplish. I understand for some people it can be very painful. So it might be to alleviate the thickness of the nail and the pain.

Dr. Hull: Right. And it gets difficult to clip, trim, and groom nails when they get very thick. It can be associated with pain because of ingrown nails. And in some cases, it can also predispose people to infection, so cellulitis and so forth. So there are medically important reasons to treat them. Some people just don't like the appearance of the nails.

Interviewer: Yeah. Because doesn't look good in your flip-flops, does it?

Dr. Hull: Right. Wearing sandals in the summer time with thick, yellow nails is something that a lot of people would like to not have to do.

Interviewer: So if it isn't necessarily painful, do you recommend treatment? Do you really leave that up to the patient at the point?

Dr. Hull: Yeah. My personal philosophy is to leave it up to the patient. So I give them the different options, talk about the length of treatments, the monitoring, the likelihood of success, and then have a conversation with them about whether they want to move forward with those treatments. And a lot of people like not to do anything and many people are very motivated to treat their nails.

Interviewer: Sure. What about the oral drugs? I understand that some people are concerned about the side effects those can cause. So are the oral drugs, generally, better than the topical or . . .

Dr. Hull: Yeah. The oral medications are more effective than topical treatments.

Interviewer: Sure.

Dr. Hull: The good news though is that the safety of most of these oral medications is very good. And the treatments are also much less expensive. So there's quite a bit of cost benefit from using the oral medications.

Interviewer: What are some of the concerns with the oral medication side effects?

Dr. Hull: The primary concern is liver toxicity, because these medications are metabolized by the liver. Looking at cost effectiveness of oral versus a topical medication, I'm really sort of arguing for the oral medication because it's so much less expensive. But then, also, looking at a lot of the safety information about the medication and the risk of serious liver adverse event is very low in that medication. That said, I still will recommend appropriate monitoring. And that's laboratory testing, usually a baseline and then midway through the treatment.

Interviewer: Are they antibiotic based?

Dr. Hull: They're antifungal, so they're specific towards fungus. So they have no effect on bacterial like an antibiotic would.

Interviewer: So people that are afraid of antibiotics for whatever stomach reasons they might have.

Dr. Hull: Yeah. It won't have any effect on the flora of the gut. And actually, interesting, they don't . . . this particular one, terbinafine, doesn't have an effect on the natural yeast that we see in the intestine called candida. So it shouldn't have any effect on that. Some people can get rashes, and there's, you know, other less common side effects. But for the most part, I find them to be well tolerated.

Interviewer: Some of the home remedies that I saw, you mentioned Vicks VapoRub, snake root extract, tea tree oil . . .

Dr. Hull: I haven't come across snake root extract yet. But it sounds like it might eat away a nail pretty well.

Interviewer: Sure.

Dr. Hull: Yeah. There's a lot of those things out there. A lot of people use vinegar, tea tree oil. The hard part with any of these topical medicines is they don't penetrate the nail unit very well. So getting them, actually, to the fungus in the nail unit is very difficult. And that's why a lot of the prescription topical medicines have such limited effects.

Interviewer: What about do-it-yourself at home trying to thin that nail out like, you know, by coating it with . . . what do people coat it with?

Dr. Hull: Well, I think doing debridement at home is, actually, helpful. So a lot of times, I'll have people file their nails down, clip the nails back, because that helps to kind of trim away some of the infected nail as well.

Interviewer: Would your recommendation, generally, be for somebody to use the oral pills if possible just because it's such a shorter treatment time?

Dr. Hull: Well, I think it just depends on the person. There are some people who have other risk factors, who have a history of liver disease or something where I wouldn't be comfortable putting them on that medication. So I use both medications, and sometimes I use them in combination. So I'll have them do a first course with an oral antifungal and then follow up with a topical. And that may help prevent reinfection, too, down the road.

Interviewer: Which is pretty common from what I understood.

Dr. Hull: Yeah. So it's common. You can get the nail clear, and then people are just exposed to the fungus in their environment, in their shoes and so forth, and they can get reinfected easily.

Interviewer: So it sounds like that if somebody does have nail fungus, for the most part, does it bother you because it's ugly? If there's pain involved, then for sure, you would recommend some treatment. For some people, there could be other medical reasons to treat it.

Dr. Hull: Right, yeah. Somebody with, you know, for example, diabetes who's at risk of ulcerations on the feet, cellulitis infections, they are people that may be . . . they may be more proactive about treating to help reduce their risk of infections.

Interviewer: But for the most part, it sounds like if you don't really have many symptoms, it's just kind of a personal choice?

Dr. Hull: That's true.

updated: August 26, 2020
originally published: July 19, 2017