Toenail Fungus

Overview

What is toenail fungus?

Toenail fungus is a widespread fungal infection that affects the toenails. Less commonly, nail fungus infects the fingernails. Nail fungus is also called onychomycosis.

Toenail fungus happens when fungi get between the toenail and the toenail bed (tissue right underneath the toenail). This usually happens through a crack or cut in your toe.

How common is toenail fungus?

Toenail fungus is very common, especially as people get older. Medical experts estimate that onychomycosis affects 1 in 10 people overall. That number jumps to 1 in 2 (50%) for people older than 70.

Symptoms and Causes

What causes toenail fungus?

More than one type of fungi can affect the toenails. Dermatophytes (a type of mold) cause most toenail fungal infections.

Dermatophytes are fungal microorganisms (too tiny to see with the naked eye). They feed off of keratin, a protein found in your fingernails and toenails. Keratin makes nails hard.

Is toenail fungus contagious?

Yes, many types of toenail fungi are quite contagious. An infected person can spread the fungus to someone else through direct contact. You can also get toenail fungus by touching an infected surface.

What are common ways you can get toenail fungus?

Nail fungi like warm, moist, dark places. Many people get toenail fungus by:

  • Walking around the perimeters of swimming pools.
  • Using a public locker room or shower.
  • Walking barefoot in a public area.

Can toenail fungus spread to other areas of the body?

Yes. But toenail fungus usually doesn’t spread beyond the toe.

Some dermatophyte fungi spread easily to the skin. (Your skin and scalp also contain keratin.) When dermatophyte fungi affect the skin, it’s called ringworm.

Toenail fungus may spread to:

  • Other toenails.
  • Skin between your toes (called athlete’s foot).
  • Groin area (called jock itch).
  • Scalp (skin on top of your head).

Who is likely to get toenail fungus?

Anyone can get toenail fungus. It often affects older adults, especially people over 60.

You may have a higher risk of getting toenail fungus if you have:

What does toenail fungus look like?

Toenail fungus can change your toenail’s appearance in more than one way. Your toenail may:

  • Change color, looking white, yellow or brown.
  • Look chalky or cloudy in some spots.
  • Thicken and possibly look misshapen.
  • Separate from the nail bed (leaving space between the nail and the skin underneath).
  • Crack or break in one or more spots.

Is toenail fungus painful?

Not typically. Toenail fungus can be unsightly to look at, but it usually isn’t painful.

Diagnosis and Tests

How is toenail fungus diagnosed?

Your healthcare provider will first look closely at the affected toenail to evaluate your symptoms. Many providers can identify toenail fungus simply by looking at an infected toe. However, tests need to be done to confirm the fungal infection.

What tests might I have for toenail fungus?

Your provider will probably take a small sample from underneath your nail to further analyze it. Viewing the cells under a microscope can confirm a toenail fungus diagnosis. If the initial test is negative, a scraping can be sent to see if the fungus grows out in a culture. It also helps your provider identify the type of fungus.

Management and Treatment

How is toenail fungus treated?

Toenail fungus is notoriously tricky to treat. You may need to treat the condition for several months to get rid of the fungus. Still, toenail fungus often comes back.

A dermatologist (skin specialist) or podiatrist (foot doctor) can explain your treatment options. If you have a mild case that doesn’t bother you, your provider may recommend no treatment.

Toenail fungus treatment options include:

  • Oral antifungal medication: You take prescribed medication, such terbinafine (Lamisil®), itraconazole (Sporanox®) and fluconazole (Diflucan®), to treat the fungi. You will need to take this medication every day for several months (or longer). Your provider may use blood tests to check for potential medication side effects. These medications can affect the liver and interact with other medications, so oral antifungals are not for everyone.
  • Topical medication: You regularly apply a medication right on the nail. The medication treats the fungi over time. Topical medications are most effective when paired with oral medications.
  • Laser treatments: Your provider directs a high-tech laser beam and special lights at the toenail to treat the fungus. Lasers are FDA approved for “temporary increase of clear nail” in nail fungus but is not a cure. Cure rates for laser treatment are lower than oral and topical mediations so they are not typically used as first line treatments for nail fungus.
  • Surgery: (In dermatology, we do not utilize surgical removal of a nail at all. The fungus can come back even after the nail has been surgically removed. Not sure if this is more widely used in podiatry)

What is the most effective treatment for toenail fungus?

The most effective toenail fungus treatment for you will largely depend on your symptoms and situation. Your provider will consider several factors before recommending a treatment plan that’s customized to you.

Overall, oral antifungal medications may offer the most treatment potential. Pairing oral drugs with topical antifungal medication may make treatment more effective.

Prevention

How can I prevent toenail fungus?

There’s no way to guarantee that you won’t get toenail fungus. But you can take several steps to help prevent it:

  • Avoid going barefoot in communal areas such as hotel rooms / showers, public showers, locker rooms and swimming pools. Most people pick up fungus in these situations. It helps to wear flip flops in these public areas.
  • If you have a family member with foot fungus or nail fungus, try to use different shower or wear flip flops in the shower to avoid coming in contact with it.
  • Trauma due to accidental or aggressive clipping of the nails can turn into portals of entry for the fungus.
  • Clean your nail trimmer before using it.
  • Do not tear or rip your toenails on purpose.
  • If you have diabetes, follow all foot care recommendations from your healthcare provider.
  • Keep your feet dry. Make sure to fully dry your feet after a shower.
  • Soak toenails in warm water before cutting them. Or you can cut your nails after a shower or bath.
  • Trim toenails straight across (don’t round the edges).
  • Wear shoes that fit correctly. They should not be too loose or tight around the toes.

Outlook / Prognosis

What is the outlook for someone with toenail fungus?

While toenail fungus is common, it’s usually not harmful. Symptoms mostly affect the look of your toenail.

Toenail fungus may spread to the skin between your toes or other areas of your body. When getting dressed, put your socks on first to reduce the chance of spread.

Treating toenail fungus takes a long time, and it doesn’t always work. Even then, toenail fungus often returns. Discuss the pros and cons of treating toenail fungus with your provider to determine what’s best for you.

Practicing good hygiene and foot care reduces the chance toenail fungus will come back. If you have diabetes, getting regular foot exams may help you address foot problems before they get serious.

Living With

Can I wear nail polish if I have toenail fungus?

You may feel tempted to cover up a discolored toenail with nail polish. If you are using a topical antifungal, you probably should not use polish. Some providers may tell you not to wear it in any case. Polish traps in moisture from the nailbed (tissue below the toenail). Because fungi thrive in moist environments, wearing nail polish may make a fungal infection worse. However, the nail continues to grow with or without polish.

When should I call the doctor?

In rare cases, toenail fungus can cause an infection called cellulitis. Without prompt treatment, cellulitis may pose a serious danger to your health.

You should seek treatment guidance from a trusted healthcare provider if you have:

  • Circulation problems.
  • Diabetes.
  • Redness, pain or pus near the toenail.
  • Weakened immune system.

What should I ask my healthcare provider about toenail fungus?

If you have toenail fungus, you may find it helpful to ask your provider:

  • What type of infection do I have?
  • Do you recommend I treat it? Why or why not?
  • How long will I need treatment?
  • What steps can I take to stop it from coming back?
  • Should I be aware of any potentially serious complications or treatment side effects?

A note from Cleveland Clinic

Toenail fungus is an incredibly common infection that can be difficult to treat. The condition usually isn’t painful, but it may make you feel self-conscious about how your foot looks. If it bothers you, talk to your provider about your treatment options. A trained specialist (such as a dermatologist or podiatrist) can provide guidance on what’s most likely to address your concerns while protecting your overall health.

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