THREE NEW MEDICATIONS
FOR FUNGUS NAILS
(Revised 12-7-2012)
Fungal nails could possibly be the most common foot problem
in the world. It is also one of the least talked about. People who have no problem talking
about their bunions or heel pain sometimes cringe to even think about their thick,
brownish-yellow nails. What these people need is a perfect drug: a medicine taken for a
very short time, with nearly no side effects, interacts with few medications, causes no
damage to their bodies and works for a very long time. To the relief of those suffering
with fungal nails, such medication may finally exist.
TOPICAL TREATMENT
In the past, treating fungus nails with anything less than
an oral medication was less than successful. All that was
supposed to change with PENLAC, a formerly new
prescription topical medication. PENLAC is applied once a day using a fingernail
polish-type brush. It builds up a slightly yellow tinge to the nail. Used on nails
partially infected with a superficial fungus the medicine provides success between 10% and
35% of the time. [This is , of course, pretty minimal] Thoroughly infected nails are less successful. A little (3.3 ml.) bottle
provides 400 applications and costs about $60. PENLAC probably increases the effectiveness
of the oral medications.
GRISEOFULVIN AND KETOCONAZOLE
In the recent past the only two oral medications available
for fungus nails were Griseofulvin (also called Fulvicin or Gris-peg) and Ketoconazole
(Nizoral.) The former worked only 20% of the time. Ketoconazole had a 60-80% effectiveness
but had an unacceptable risk of kidney and liver damage. Both had to be taken daily for
12-18 months and both required frequent liver function tests. Unfortunately, the moment
the medication was stopped the fungus often returned.
SPORANOX
Sporanox was the first of the new medications to hit the
market. The European pulsed method involves taking 4 tablets a day for a single
week (28 tablets) repeated for two more consecutive months at a cost of about $600 for 84
tablets. This method cures about 70% to 80% of fungus nail infections. A temporary
nail removal or aggressive trimming the nail will increase the effectiveness of the
treatment. unfortunately Sporanox now has a black box
warning that it may cause heart issues so it is rarely used for fungus nails.
Not only is Sporanox costly,
it interacts with a variety of other medications such as blood thinners and oral
anti-diabetes medications.
As of 2012 Sporanox is nearly never
used for fungus nails.
LAMISIL
Lamisil is taken one tablet a day for three months (cost:
it used to be about $550 for 90 tablets
but now it is generic and much less expensive..) Cure rates are reported in excess of 70%. Again, temporary
nail removal or trimming can increase the cure rate. Lamisil does not interact with other
drugs. Its only drawback is a report that it does not kill certain uncommon types of
fungus and has rare but real effects on the liver. There is
more than one report in the literature that Lamisil has caused liver failure.
.
DIFLUCAN
Diflucan has not been approved for oral treatment of fungal
nails but it is sometimes used anyway. The dosage is one tablet a week until the nail
looks better, usually six or seven months. The cost is $20-30 a pill!
As of this 2012 update I have not heard of anyone using Diflucan for fungus nail
in many years.
LAMISIL OR SPORANOX
In 2000 I said: Both medications effectively treat most cases of fungus
nails. Certainly Lamisil is the cheaper of the two with no real drug interactions. If the
infection is one of the common fungi (and most are) Lamisil is your drug. If a culture of
your fungus shows it to be an unusual “saprophyte” and you are not taking one of
the interacting drugs, then Sporanox is suggested. If you are on a medication that
interacts with Sporanox but have a saprophyte fungus, you should probably take Lamisil and
hope for the best.
Now, in 2012, I will tell you that the
only real oral medication for fungus nails is oral Lamisil therapy. I prescribe
it once or twice a week as do the majority of podiatrists and dermatologists for
fungus nails. it is save and reliable and works at least 80% of the time.
Because it does have the potential for serious side effects most podiatrists,
(like, me,. for example) require that we have laboratory proof that you have a
fungus in your nail and pre- and during-treatment liver function tests to shoe
that the medicine is not hurting your liver. I will only write for 30 days
without a second liver function test.
AM I CURED?
If you take oral Lamisil
therapy you stand a 70+% chance of clearing
your nails of the fungus. I do not believe this will be a permanent correction,
however. There must be some underlying condition that caused the nails to be
invaded by the fungus organisms. This condition is probably not changed by
taking the medication so I expect that the nail fungus will recur.
MINI-DOSE LAMISIL
A report from 2004 is starting to make the rounds of
professional circles. It stated that once a full dose of either the Laser or
oral Lamisil therapy has gotten your nails clear enough to make you happy, you
need to keep it clear and clean by taking 1 week of the pills every 3 months for
a total of 28 tablets a year. This dose of medicine probably does not require
liver function tests, except before you start the first time. I understand your
reluctance to take the medicine quarterly for a lifetime, It worries me, as
well. But fungus is so difficult to keep under your thumb (toe?). I think the
laser might be safer. In our office we are treating people every three months
with the laser for $100 to keep them clean. this is a modest cost compared to
dealing with liver damage.
CONSIDER YOURSELF LUCKY IF YOUR NAILS STAY CLEAR AND FREE
OF FUNGUS FOR THREE
YEARS!
LABORATORY CULTURES FOR FUNGUS
Before taking an oral medication you probably should have a
fungus culture that proves your problem is due to a fungus. Certain conditions
(like psoriasis) can make your nails look like they have a fungus when, in reality, they
do not.
BLOOD TESTS
Lamisil has been used for many years and
appear to be very safe. Still, most authorities recommend that blood test be made to
assess liver function prior to starting treatment and after the first third of the
treatment is completed.
INSURANCE APPROVAL
Many insurance companies will cover the approved oral
medication for fungus without a hitch. Some, like the Blues in California, want to call
this a cosmetic condition and refuse to cover the medication costs. I beg to differ,
however. A fungus nail infection is an infectious disease and deserves treatment. A
cosmetic procedure is designed to take something that is normal and try to improve on it.
Bringing an abnormal part back to normal is a RESTORATIVE procedure and deserves to be
reimbursed by those insurance companies that reimburse for medications. I use the example
of a breast augmentation as a cosmetic procedure but a post-surgical reconstruction after
mastectomy as a restorative procedure. Now I do not mean to equate the severity of fungus
nails with breast cancer, but it does point out the differences between restorative and
cosmetic.
TEMPORARY NAIL REMOVAL
There is no question that the effectiveness of any fungus
treatment is increased if the contaminated part of the nail is removed. Usually this is
done with an office visit. Occasionally it may require local anesthesia. Alternatively, a
urea cream applied to the nails for two days can easily and painlessly remove most of the
bad nail.
PERMANENT NAIL REMOVAL
Believe it or not sometimes people choose to have a thick
toe nail permanently removed. These people are sick of dealing with thick, discolored and
painful nails. The procedure is done under local anesthesia in the office and takes just a
few minutes. The nail is removed and the nail root is treated with a chemical to kill the
nail root. The result is not all that bad. I do not advocate this for everybody, but for
those who do not mind the look of such a nail, it is a very acceptable alternative.
George is a retired
photographer who was sick and tired of his fungal nails, especially on his big toes. He
asked to have both of them removed permanently. I talked him into doing just he left one
first. It took longer than expected to heal fully, about 4 months. Now he is happy. This
photo is of his nails about 5 months after the procedure. Note that you can make an
argument that the thick right big toe nail is actually less attractive then the left
(on the right, of course) one
with the nail removed permanently.
LASER TREATMENT
There is no question that laser treatment for fungus nails
can produce some remarkable results. But once is never enough. Repeated
treatments cause most nails to look better and better. In our office, after
paying for the initial treatment, we charge a modest fee of $100 to treat all 10
nails with the laser on a 3-minth basis. Please see the laser treatment page for
more information. -->
