What topical (external) treatments are there?

Are topical treatments effective?

Only a few studies have looked into topical nail fungus treatments with nail polishes or creams. 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.

But even if the fungus had gone away, the cosmetic result wasn’t always satisfying – for instance because the nails no longer looked like they used to.

Treatment with sets combining the application of urea cream and then putting on bifonazole cream was tested in one study. That study compared that with a treatment in which only urea cream was applied and the nail was removed. Three months after treatment was completed, it was found that:

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

But there was no difference between the two groups six months after treatment. Also, the fungal infection returned in many participants,

What oral medications are available?

The tablets for treating nail fungus are prescription-only, so they have to be prescribed by a doctor. The main options for treating nail fungus are the drugs terbinafine and itracionazole.

• Terbinafine is preferred if the nail fungus is caused by skin fungal infections (called dermatophytes), which 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. It is best to talk to your doctor about which type of use is right for you. The treatment – whether it is done with or without breaks – takes at most 3 months with itraconazole and about 3 to 4 months with terbinafine.

Fluconazole is another medication taken in tablet form. It is only used if other treatments didn’t work well enough or aren’t an option for other reasons. Fluconazole is taken once a week for about six to twelve months.

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. The studies showed that both terbinafine and itraconazole are effective in treating nail fungus.

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.

One year after treatment with itraconazole:

• About 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 didn’t have this treatment no longer had a detectable fungal nail infection.

Some studies directly compared itraconazole and terbinafine with each other. They found evidence suggesting 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.

How well are tablets for treating nail fungus tolerated?

The studies on the tablets provided very little information about how commonly certain side effects occurred. But most people apparently tolerated the medications well. Only a few participants in the studies stopped treatment because of side effects.

Itraconazole may cause 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.

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Tell your doctor about any other medications you may be taking in order to prevent drug interactions.

Itraconazole should not be taken by people with heart failure. 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 home remedies like 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?

How you feel about the pros and cons of the different treatment options is a personal matter. Factors like how far the fungus has spread or how often you have already had nail fungus in the past might play a role. You can also discuss the options with your doctor.

Most doctors recommend 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.

If the fungal nail infection is severe, tablets can be used in combination with nail polish or cream. For example, if the nail is very thick, urea cream can be used (in addition to taking tablets) to gradually remove or partially file off the affected nail. Combining these treatments may also be an option if there are large collections of fungi beneath the nail.

What other options are there?

It is also possible to see a podiatrist (foot care specialist) to deal with a severe fungal nail infection. Then your nails will be treated professionally and thick nails can be filed off, for instance. The podiatrist can also advise you on what you can do yourself and on the best ways to maintain hygiene and disinfect your nails. That is important because the nail material that is removed may contain infectious spores. In Germany, public health insurance will cover the costs if the treatment has been prescribed by a doctor.

Sometimes laser treatment is offered. This involves shining infrared or ultraviolet (UV) light on the nail in order to kill the fungus. Laser treatments haven’t been proven to work in good quality studies. Because public health insurers in Germany don’t cover the costs of this treatment, you have to pay for it yourself.

How long does treatment last?

A fungal nail infection is unpleasant, but it is not a serious illness. Many people find discolored or thickened nails unpleasant to look at, though, and want to get rid of the fungus as soon as possible. Fungal nail infections can also spread and destroy the nails, and they may infect other people. Whichever treatment you choose, it will take a while until your nail looks normal again. So you need to be patient, especially if the fungus is on your big toe. It can take up to one year for it to grow back and be healthy again.

Nail fungus can sometimes be very persistent despite treatment, and can also come back again even after successful treatment.

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). S1-Leitlinie Onychomykose. AWMF- Registernr.: 013-003. 2022.
• 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.