What topical (external) treatments are there?

How effective are topical treatments?

So far, only a few studies have looked into topical nail fungus treatments with nail polishes or creams. Because these studies had weaknesses, the results should be interpreted with caution. Amorolfine has not yet been well studied. Ciclopirox polish and treatment sets with urea and bifonazole cream were tested in a few studies.

Research on the effectiveness of nail polish containing ciclopirox showed that, after one year:

• About 10 out of 100 people who did not use ciclopirox no longer had a detectable fungal nail infection.
• About 30 out of 100 people who used ciclopirox no longer had a detectable fungal nail infection.

In other words, treatment with ciclopirox got rid of the fungal infection in about 22 out of 100 people. But even if the fungus had gone away, the cosmetic result wasn’t always satisfying. The nails only looked healthy after treatment in 7 out of 100 people.

Treatment with sets containing urea and bifonazole cream was tested in one study. It was compared with a treatment in which only urea cream was applied and the nail was removed, but without applying bifonazole cream afterwards. Three months after treatment was completed, it was found that:

• No fungus was visible or detectable in about 41 out of 100 people who only used urea cream.
• No fungus was visible or detectable in about 51 out of 100 people who used both urea and bifonazole cream.

In other words, the combination of urea and bifonazole got rid of nail fungus in an extra 10 participants. But there was no difference between the two groups six months after treatment. Also, the fungal infection returned in many participants, so it’s likely that neither of the two treatments can increase the chances of getting rid of the fungus in the long term.

People did not take part in the study if their fungal infection covered more than half of the affected nail area or if the infection started at the base of the nail.

What oral medications are available?

To treat fungal nail infections from inside the body, you can take tablets that inhibit the growth of fungi or kill them. They are all prescription-only. Terbinafine and itraconazole are typically used for this purpose.

• Terbinafine is preferred if the nail fungus is caused by a skin fungus (dermatophyte). This is usually the case.
• Itraconazole is generally used if the nail infection is caused by yeast or mold.

Itraconazole and terbinafine tablets can both be taken either continuously or with breaks between treatments. But they are used differently:

How effective are tablets in treating nail fungus?

Tablets for the treatment of nail fungus have been tested in several studies. All participants had an infection on their toenails caused by a skin fungus. Overall, the study results showed that tablets are considerably more effective than nail polishes or creams.

One year after a three-month treatment with terbinafine:

• About 17 out of 100 people who didn’t have this treatment no longer had a detectable fungal nail infection.
• About 76 out of 100 people who had this treatment no longer had a detectable fungal nail infection.

Itraconazole also proved to be effective. After one year,

• 7 out of 100 people who didn’t have this treatment no longer had a detectable fungal nail infection.
• About 43 out of 100 people who had this treatment no longer had a detectable fungal nail infection.

Some studies directly compared itraconazole and terbinafine with each other. They conclude that terbinafine is somewhat more effective than itraconazole.

Treatment with breaks is thought to be about as effective as continuous treatment. But that has only been looked into in a few studies.

What side effects and drug-drug interactions do the tablets have?

The possible side effects of itraconazole include headaches, dizziness, stomach and bowel problems, and rashes. Itraconazole can also interact with a number of other drugs. These include cholesterol-reducing and blood-sugar-lowering medications, as well as certain sleeping pills. It is therefore important to let your doctor know about any medication you take. Itraconazole is not an option for people with heart failure (cardiac insufficiency). It also isn’t suitable for women who are pregnant or breastfeeding.

Terbinafine can cause gastrointestinal (stomach and bowel) problems and a temporary loss of taste and smell. It can also interact with certain antidepressants and heart medications. Overall, terbinafine has far fewer drug-drug interactions than itraconazole. Nevertheless, it’s still important to tell your doctor if you are taking any other medication. As a precaution, this medication should not be taken during pregnancy or if you are breastfeeding.

The studies provide only very little information about how often the different side effects occurred. But most people apparently tolerated the medications well. Only a few people in the studies stopped treatment because of side effects.

But there is a very small risk of liver damage from taking itraconazole or terbinafine. For this reason, people with a liver disease are only given these medications if it’s absolutely necessary.

What can be expected of products such as tea tree oil?

Sometimes home remedies such as applying tea tree oil or vinegar are recommended for the treatment of nail fungus. But there aren’t any good quality studies on whether these or other products help to treat nail fungus.

When are the different treatments considered?

Most doctors consider treating nail fungus with nail polish or cream if

• not much more than half of the nail is affected by the fungus,
• the base of the nail is not infected, and
• only some nails are affected.

Topical treatment is also usually recommended for children. One reason for this is that most oral medications aren’t suitable for children. Another reason is that children have thinner nails that grow more quickly, so it’s assumed that treatment with nail polish or creams is more likely to work in children than in adults. White superficial onychomycosis is also often treated with a nail polish or cream.

If several nails are infected by the fungus, or if the infection has spread out more on the affected nails, it’s usually necessary to take oral medication. And if the infection started at the base of the nail, it’s highly likely that only tablets will help.

Which treatment is right for me?

Nail fungus is usually harmless. But many people find discolored or thickened nails unpleasant to look at and want to get rid of the fungus as soon as possible. Fungal nail infections can also spread, and may infect other people. Regardless of the treatment you choose, it will take a while until the nail looks normal again. It is especially important to be patient where toenails are concerned. It can take a year for a healthy big toenail to grow back. Nail fungus can sometimes be very persistent despite treatment. It can also come back after successful treatment.

Topical treatment (polish or cream) isn’t likely to get rid of a fungal nail infection. Treatment with tablets is considerably more effective and takes less time. But some people can’t take tablets because of the very rare, yet serious risks. How you feel about the pros and cons of the different treatment options is a personal matter. You can also discuss the options with your doctor.

Sources

• Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev 2007; (3): CD001434. [PMC free article: PMC7073424] [PubMed: 17636672]
• De Berker D. Clinical practice. Fungal nail disease. N Engl J Med 2009; 360(20): 2108-2116. [PubMed: 19439745]
• Deutsche Dermatologische Gesellschaft (DDG), Deutschsprachige Mykologische Gesellschaft (DMykG). Tinea der freien Haut (S1-Leitlinie, in Überarbeitung). AWMF-Registernr.: 013-002. 2008.
• Eisman S, Sinclair R. Fungal nail infection: diagnosis and management. BMJ 2014; 348: g1800. [PubMed: 24661991]
• Gupta AK, Daigle D, Foley KA. Topical therapy for toenail onychomycosis: an evidence-based review. Am J Clin Dermatol 2014; 15(6): 489-502. [PubMed: 25257931]
• Kreijkamp-Kaspers S, Hawke K, Guo L et al. Oral antifungal medication for toenail onychomycosis. Cochrane Database Syst Rev 2017; (7): CD010031. [PMC free article: PMC6483327] [PubMed: 28707751]
• Tietz HJ, Hay R, Querner S et al. Efficacy of 4 weeks topical bifonazole treatment for onychomycosis after nail ablation with 40% urea: a double-blind, randomized, placebo-controlled multicenter study. Mycoses 2013; 56(4): 414-421. [PubMed: 23586591]

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.