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Options for Thick and
Fungal Nails.
By:
Michael Zapf, DPM, MPH, FACFAS, FACFAOM
April 7, 2009
THERE ARE FOUR MAIN OPTIONS
TO TREAT YOUR FUNGUS NAILS:
1. DO NOTHING
Fungus in a nail rarely goes away without treatment. The normal course is for
the nail to get fully involved with the fungus growing from the tip to the root
and then get thicker and thicker. It is not unusual to see some of out senior
patients with nails that can approach an inch thick.
2. TOPICAL MEDICINES:
Most people start
their treatment with the use of a topical medication or a home remedy. People
have tried topical Lamisil, Lotrimin, Micatin, Vicks Vapo-Rub, tea tree oil,
white vinegar, rubbing alcohol, bleach and the prescription product Penlac. All
of these need to be used twice a day for up to a year to see results. Our
current favorite is a topical Fungal Free Nails product that we sell for $38 a
bottle (available from the internet at the same price). All three doctors have
seen this remarkable product work on many (but not most) occasions. The probable
effectiveness rate is less than 20% when used twice a day for a year.
3. ORAL MEDICINE. Currently the only oral medicine is terbinafine, also called Lamisil.
This medicine is taken one tablet a day for 90 days and achieves a 75% rate of
improvement. There is a rare and slight but very real risk to the liver, kidney
and blood cells. The people who have been seriously injured probably already had
some organ damage and there is no proof that Lamisil did the damage all by
itself. To check on potential damage we require a pre-treatment
and during-treatment levels of your liver function and your blood
cells (liver function tests and complete blood count). Because of the risks of
Lamisil, we want laboratory proof that you have fungus in your
nails before we prescribe this medication. This requires a laboratory
examination of a sample of your nails. It takes us about 2 weeks to get results
back from the laboratory. Non-generic Lamisil costs more than $400 but generic
forms are available.
  4.
PINPOINTE LASER THERAPY This is a new
treatment available for fungus nail treatment. The laser treatment is done at
one visit where a laser light is passed over and through your nails to kill the
fungus without damage to any of your skin or nails. The light literally passes
right through your skin without any damage at all. It has been used thousands of
times without any side effects. With the laser there are no injections, no
pills, no lab tests and no risks of any kind. The effectiveness is running at
88% (no fungus can be resistant to this wavelength of light). Failures are
likely due to damage to the nail plates, either through injury, severe long
standing fungus infection, poor circulation or genetics. The laser treatment
with 1 year of follow-up exams costs $950 and is not covered by any insurance
companies. You can pay for your treatment with a credit card, cash or check and
you can also use your flexible spending account or health savings account. We
have even made arrangements with an interest free health credit card for your
convenience.
Example of Pinpointe Laser Result
The Pinpointe Laser Machine
Additional treatment
recommendations to avoid reinfection:
q
Use of a topical antifungal medicine daily or at least once
or twice a week. Topical Lamisil is probably your best bet. We ask that you
apply this to the tops of your toes, including the nails, between the nails and
across the bottoms of your feet in the so-called moccasin distribution. Doing
this right after your shower and before putting on your socks and shoes is a
convenient and effective time to do this. You can purchase a very helpful
topical antifungal medicine in our office or from the Footstore link on
our website:
www.conejofeet.com.
q
Antifungal Foot Spray. We recommend that you spray the
inside of your shoes with an antifungal foot Spray when you are finished wearing
your shoes for the day. For real shoe sterilization we recommend the use of an
ultraviolet shoes sterilizer. A good antifungal foot spray is available in our
office and many brands can be found from the Footstore link on our
website:
www.conejofeet.com.
 q
SteriShoe. The sweat and dead skin cells from our feet accumulate on the
inside of our shoes and it becomes the perfect breeding ground for athlete’s
foot fungus, bacteria and other unpleasant critters. Spraying the inside of your
shoes with an antifungal spray does achieve some good but it is nowhere near
100% effective. Ultraviolet light, however, is 100% effective in killing all
pathogens from the inside of your shoes. We sell a set of two ultraviolet light
containing shoe trees that will kill all organisms from the inside of your shoes
in 45 minutes. They have an automatic shut off so all you have to do is place
the shoe trees in your shoes, turn it on and forget about it. If you want to be
free of fungus on your skin and nails we strongly recommend that you use the
SteriShoe. You can purchase the pair of SteriShoe shoe trees from us for $130 or
you can purchase it from the SteriShoe website:
www.SteriShoe.com.
q
If you want to get pedicures we ask that you take the proper precautions.
Make sure that the pan in which you soak your feet has a disposable liner so
that you don't soak your feet in the same water used by other clients. Make sure
that the facility sterilizes any instruments used on your feet such as clippers,
files, probes and scissors. Autoclaving (sterilizing under high pressure using
hot steam) .is the only sure way to sterilize instruments. Typically these
instruments are placed in an autoclave bag that has a colored marker that
changes color when the autoclaving is successful. In our office our autoclave
bags have a pink square that turns brown with successful autoclaving. Soaking
instruments in a disinfectant is not a guaranteed way to kill nail fungus. You
will notice that our office opens a sterile bag of instruments for every patient
every time right in front of you, the patient. Your nail salon should do the
same thing if they are interested in your foot health. Unfortunately, very few
nail salons take this level of precaution. For this reason you should purchase
your own reusable metal instruments and cleaned them yourself between visits.
You can purchase these instruments from a beauty supply house or we sometimes
have an extra supply of some instruments that you could purchase. Some
instruments are also on sale from the Footstore link on our website
www.conejofeet.com .From time to time we even have a pedicure kit for sale.
Once you have your own metal stainless steel instruments, you can run them
through your dishwasher as a reasonably effective way to keep them clean. If you
are real serious about your foot health, we will offer to place your instruments
in one of our autoclave bags and sterilize them for you. Ask about this service
next time you are in our office.
q
Fingernail and toenail polish: we have five colors
of fingernail polish available for purchase in our office. They cost $17 a
bottle and they have tea tree oil as an antifungal agent. These are not meant to
treat fungus nails but they can help you keep your new beautiful nails fungal
free. Please polishes also are free of two agents that tend to yell over the
nails after the polish has been removed. You can apply this polish your self or
you can ask your pedicurist or manicurist to use it when you receive your
pedicure or manicure. Please polishes are also available from the Footstore
link on our website
www.conejofeet.com.
q
Nonyx-Nail Gel. This product is only modestly helpful in
treating fungus nails but it has an excellent bleaching agent to lighten the
color of a discolored nail. We sell Nonyx nail gel for $25 a bottle in our
office. It is also available online at
www.drugstore.com and other sources.
q
Biotin is a vitamin pill that may help treat or prevent split and
cracking nails. Biotin stimulates epidermal cells and affects the protein
structure called keratin found in skin, nails and hair. Biotin is directly
involved in the production of keratin cells and is believed to increase the
quantity of keratin-matrix proteins in the nails. Thus, this B. vitamin is
likely to improve nails strength, and dust resistance to fungus, by influencing
keratin structure. One clinical trial of Biotin use in nails used a high tech
scanning electron microscope to carefully measure fingernail thickness and
splitting. The study used a daily dose of 2.5 mg of Biotin and found that
fingernail thickness increased by 25% and splitting decreased after biotin
supplementation. This study appeared in the respected dermatology journal,
Cutis. (Hochman LG, Scher RK, Meyerson MS.
Brittle nails: response to daily biotin supplementation. Cutis.
1993;51(4):303-305) Appearex is a
commercial product recommended and sold by many dermatologists and contains 2.5
mg of Biotin per capsule and sells for $32 for 84 tablets at
www.drugstore.com. We sell a more cost effective Biotin made by a high
quality vitamin manufacturer at $8 for 60 8 mg tablets. Probably only two or
three tablets a week are needed to improve the strength of your nails.
q
Gelatin: gelatin capsules are available at your drugstore or health food
store, Knox or other gelatin powder that you can mix in your fruit juice or even
eating Jell-O can improve the thickness and strength of your nails and make them
more resistant to attack by fungus.
q
Moisture wicking and moisture repelling
socks athletes foot fungus , like any good mushroom , prefers dark , moist
and warm environments to grow. The sweat from your feet can create a wonderfully
hospitable environment for athletes’ foot fungus. Traditional cotton socks will
absorb moisture until they are saturated and then maintain themselves as a wet
layer of cotton against your skin for the rest of the day. There are two better
alternatives for you then cotton socks. The first is exemplified by Thor-lo
brand (www.thorlo.com)
which readily transfers the sweat from your skin to the stock and allows for
more rapid evaporation than cotton. Thor-lo socks are available at all sporting
goods stores and athletic shoe stores for 31 different sports. A better
alternative is exemplified by Drymax sports socks (www.drymaxsocks.com
) which is composed of two layers of material the inner layer of which quickly
transfers moisture to the absorb an outer layer much like a disposable diaper.
In both cases the skin, and in the Drymax case, the nails, stay extremely dry.
Drymax socks were recently featured in Diabetes Educator Magazine as being very
helpful for diabetics in preventing infection. In our area Drymax socks are
Available at Road Runner Sports in Newbury Park.
q
Rotate your shoes – unless your shoes are made of all
plastic, they will, undoubtedly, absorb a lot of the moisture that your feet
produce each day. Unless you use the sterilizing shoe tree discussed above it
will take about two full days for your shoes to completely dry out and be ready
to absorb moisture again. If you wear your shoes in the rain, or get them wet
some other way, it made take a full three or four days for them to fully dry
out. Please place them in a well ventilated area so that air circulation can get
to them.
q
Avoid bare feet in public places.
q
Treat athlete’s feet of all family
members. One of the most common sources of reinfection are the athletes feet
fungus spores left on the carpet, in the shower and in the bed sheets of family
members who also have the condition. If you really want to be free of
reinfection consider having your family members treated at the same time.
q
Corynebacterium although it is not a fungus, there is a bacteria called
corynebacteria that can grow on your feet and between your toes that can cause
an athletes foot type itch, irritation and, especially, a pungent and
disagreeable odor. This bacteria produces a coral red fluorescence which can be
detected using a special wavelength of ultraviolet light. We have a special
“Wood’s Lamp” in both offices that can detect the presence of this bacteria. If
you are positive for coral red fluorescence this bacteria can easily be treated
with topical erythromycin.
q
Green nails: sometimes we will find a distinct color growth under
the nail plate. This is often confused with a fungus but it is caused by a
bacteria called Pseudomonas. Pseudomonas infections will are surprisingly common
and are usually caused by foot soaking. The bacteria can sometimes be found in
faucets used to fill a foot soak bowl. If we think you have a Pseudomonas
infection under your nail we will treat it with either Ciprofloxacin ear drops
placed under your toenail or with white vinegar. Pseudomonas is thought to be
killed by acetic acid.
Random trivia about nails
·
The longer the toe or finger, the faster the fingernail grows
·
Nails grow faster in warm climates and fastest in the summer.
·
Nails grow 20 percent faster when a body is fighting off the flu
·
Extreme
dieting slows nail growth
·
The nail on the pinkie finger and toes grows the slowest, followed
by the thumb/big toe nail.
·
Fingernails grow twice as fast as toenails.
·
Men's nails grow faster than women's
·
Nails grow fastest between the ages of 10 and 14.
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Below are two old articles on Fungus Nails that are
presented here for historic interest. The article above contains the most
current data on Fungus Nails
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TWO ARTICLES ON FUNGUS NAILS
ACORN May 1993
The Fungus Among Us
By: Michael Zapf, D.P.M., M.P.H., F.A.C.F.O.
All right my dear Acorn readers, this is a column I didn't want to write. I can write
about bunions, ingrown nails and heel pain with great dignity. But how do you do justice
to that age old scourge of mankind: fungus nails. Due to popular demand, here goes.
Fungus in the nails is a wide spread problem. I have seen it in all age groups but is
rare in children and common in seniors. It attacks the nails and makes them thick, yellow
and almost impossible to cut. I would tell you about the stuff that grows under them, but
there may be children reading.
The fungus that causes the problem is found everywhere in nature. It is rare that any
of us goes a week without coming in contact with the fungus. So why is it that we all
don't have the fungus in the nails? This is an excellent question and we do not have good
answers. What we do know is that strong, healthy, fast growing nails are relatively immune
to the fungus. (This is why it is rare in children.) As we go through life our nails start
to grow slower and get thicker and even start to discolor a little. Eventually the nails
can grow slow enough, and be think enough as to become susceptible to invasion by fungus.
damage to the nail either by an accident or through such innocuous methods as tight shoes,
seems to make hem even more susceptible. Therefore it is axiomatic that if there is fungus
in the nail then the nail is not healthy to begin with. This is why it is so difficult to
eliminate the fungus and even more difficult to keep it away
One more bit of confusion, not every "fungus nail" has fungus. Enough damage
to the nail can make the nail look for all the world like it has fungus. A nail thick and
yellow due to damage is not treatable by any method. For this reason I culture every
suspected fungus nail to make sure it actually has fungus. It is very discouraging for a
patient to find out that a nail fungus he has been treating for years is not due to
fungus.
Proven nail fungus is treated by a variety of methods. The most common treatment is
with topical medicines, either by prescription or over-the-counter. Without help from a
podiatrist, these almost always fail. The fungus is buried deep under the nail. Usually
topical medicine cannot reach the fungus. My analogy is going through a drive through car
wash. The water and soap is attacking your car but you are sitting safely inside. In the
nail I imagine the fungus being mildly amused by all the effort but being relatively
unaffected.
For topical medicine to be effective, the nail needs to be trimmed back. For bad nails
I use a urea preparation to painlessly "melt away" the infected part of the
nail. For worse nails, I sometimes remove them temporarily under local anesthesia. Using a
comprehensive treatment program an improvement is seen a majority of the time.
Oral medications have also proved to be effective. There are two types depending on the
type of fungus found in the nail culture. Both have very slight but definite risks,
especially if there is any kidney or liver disease present. i a healthy patient decided to
try the oral medication, I perform blood tests after 30 days of treatment and then every
60 days to spot potential trouble before it starts.
There I did it. Now to more pleasurable topics. In a few days my son Christopher will
celebrate his first birthday and I will use the occasion to talk about children's foot
problems.
Dr. Michael Zapf is a board certified podiatrist in practice in Agoura Hills and
Thousand Oaks. For more information please call his office at (181) 707-3668
ACORN NEWSPAPER ARTICLE August 1996
New Treatments for Fungal Nails
By: Michael Zapf, D.P.M., M.P.H., F.A.C.F.O.
If you have fungal nails you probably noticed those four page inserts in your favorite
magazines touting a new oral antifungal medication. You presumably wondered, can these
medications really be that good? Well I have good news and bad news for you. They are that
good. They are also very costly.
It is not exactly clear why a nail becomes eligible for a fungus infection. Clearly a
damaged nail, either from nutrition, trauma or disease, is at greeter risk for a fungus
infection. But apparently healthy looking nails can also get the disease. It is caused by
a microscopic plant-like creature that takes up residence in the nail plate.
Topical creams and lotions, even when applied twice a day, are rarely effective. Only
if you temporarily remove infected nails and apply the medicines, can you boost the
success rate to 20% or more. Luckily there is now a method to remove infected nails that
uses a cream and not needles, injections and pain. Choosing a course of a topical cream is
a reasonable choice if a patient cannot take an oral medication.
The older oral medications, griseofulvin (also called Fulvicin) and ketoconazole have
been all but abandoned. One was very ineffective and the other hazardous.
The first of the new medications is called Sporanox, A full course of two tablets a day
for three months costs well over $1000. The European "pulsed" method uses four
tablets a day for a week repeated each month for four months. These 112 tablets coast
about $800. Sporanox is useful against both the common and uncommon forms of the fungus.
Its only drawback, except for the cost, is that in interferes with some drugs that pass
through the liver. Many patients on these medications cannot take Sporanox.
The second new medication is Lamisil. A full course of one tablet a day for 90 days
costs almost $600. Lamisil does not interfere with medications and is very effective
against the common fungus types. Since there is a question about its efficacy against the
uncommon fungus forms, a culture should be taken to identify the fungus before taking
Lamisil.
Both Sporanox and Lamisil are extremely effective. Many reports put the effectiveness
at 80% or higher, especially if you use the cream to dissolve infected nails. The medicine
gets into the nail plate quickly and stays there for a god long time afterwards. Lamisil
reports an 80% success after two years.
Dr. Michael Zapf is a board certified podiatrist with offices in Agoura and Thousand
Oaks. He has been using the oral antifungal medications for three years. For more
information you can call his office at (818) 707-3668.
# # #
Finally here is an article from February 2,
1994 on Fungus nails including the use of urea and topical Mycocide. Just double
click the article and it will pop up.
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