Should I take oral antifungal medication to treat a fungal nail infection?

Should I take oral antifungal medication to treat a fungal nail infection?
Introduction
Medical Information
Your Information
Wise Health Decision
References
Credits

Content provided by Healthwise

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

Using antifungal pills (oral medication) gives you the best chance of curing a severe fungal nail infection. However, antifungal pills can be dangerous, and they do not guarantee a lasting cure. Consider the following when making your decision:

If you have liver or heart problems, you should not take antifungal pills. They can also cause rare but dangerous side effects in healthy people, including heart and liver failure.¹
You may need testing every 4 to 6 weeks to check for liver, kidney, or heart damage, depending on the antifungal pills you use.
Even if your treatment is successful, the infection may return. Of people successfully treated with antifungal pills, 15% to 20% develop another infection in the next year.²
Having your nail removed, either nonsurgically or surgically, is a reasonable treatment option for a severely infected, thickened nail.

Medical Information

What is a fungal nail infection?

Fungal nail infections (onychomycosis) occur when fungi invade a fingernail or toenail (nail plate) and the skin underneath the nail (nail bed). Toenails are more commonly affected than fingernails, because they grow very slowly, allowing the fungi more time to develop. Toenails also require longer treatment time than fingernails do.

The infecting fungi may be a dermatophyte, yeast, or mold. Dermatophytes cause about 90% of all fungal nail infections.³ Dermatophyte and mold infections can cause discomfort but are usually not painful. Yeast infections, especially in the fingernails, can be painful.

You can get a fungal nail infection when you come in contact with the fungi and they begin to grow on or under your nail plate. Dermatophytes can be passed from person to person, either through direct contact or through contact with commonly used floors, shoes, or other personal items, such as nail clippers or nail files. Long-standing athlete's foot also can result in fungal toenail infection. Shoes that are moist, tight, and do not allow air to move around your feet contribute to fungal infections.

Why should I treat a fungal nail infection with oral medication?

A fungal nail infection does not go away on its own and tends to slowly worsen over time. An infection may spread into the nail root (matrix), where new nail growth begins, and may spread to other nails. The longer an infection is present and the worse it becomes, the harder it is to treat. Severe, extensive infections, especially in older people who have had the condition for many years, can cause very thick nails that are difficult to trim and may cause pain or discomfort when walking. Once this happens, it is difficult to cure a fungal infection, even with oral medications.

Your health professional may recommend treatment if you have a painful fungal nail infection or a medical condition, such as diabetes, that can lead to complications from foot infection.

Why wouldn't I treat a fungal nail infection with oral medication?

A fungal nail infection is not usually considered a "must treat" medical condition. Some people decide not to treat a fungal infection until it is uncomfortable or painful.

Fungal nail infections are difficult to treat, and the medication is expensive. There is no guarantee that oral medication will work or that the fungal infection will not come back. Of people successfully treated with antifungal pills, 15% to 20% develop another infection in the next year.² Advanced age (older than 60) decreases the likelihood of a cure to about 65%.⁴

The medication used for fungal nail infections can cause serious side effects, including liver damage and heart failure.

Other treatment methods are also available, such as using an antifungal cream or solution or removal of the nail, either surgically or nonsurgically.

How effective are the oral medications available to treat fungal nail infections?

Terbinafine (Lamisil) is a first-line medication for fungal nail infections caused by dermatophytes.⁵ Research on oral terbinafine reports that in people with an infection caused by dermatophytes, it:⁶

Killed fungi in 40% to 90% of the people using it.
Killed fungi and produced a normal-looking nail in 35% to 50% of the people using it.
Was more effective than itraconazole, griseofulvin, or fluconazole.

Itraconazole is a preferred medication for infections caused by molds and yeast (Candida).⁵ It can also be used for dermatophytes. Research reports that it killed fungi in 45% to 70% of people using it and produced a normal-looking nail in 35% to 80% of the people using it.⁵

Fluconazole (Diflucan) has not been well studied for fungal nail infections. However, research is promising, and it is considered a first-line therapy for infections caused by Candida.⁵ Oral fluconazole improved the appearance of more than 75% of a toenail in 72% to 89% of people using it.⁵ When taken in high doses once a week over 3 months for fingernail infection, oral fluconazole produced a normal-looking fingernail in 90% of people using it and killed the fungi in nearly all the people using it.⁵

Ketoconazole (Nizoral) and griseofulvin (Fulvicin U/F, Grifulvin V) are rarely used. Griseofulvin has low cure rates and is no longer considered standard treatment for fungal toenail infections.⁷ Ketoconazole has a lower cure rate (up to 50%) and a higher recurrence rate than itraconazole and fluconazole.⁸

What are the side effects of these medications?

Rare but serious risks of oral antifungals include serious drug interactions, liver damage, liver failure, and heart failure. Minor side effects of these medications include headache, stomach upset, diarrhea, rash, itch, and loss of taste sensation.

What are the risks of not taking these medications?

If you are healthy, no serious medical risks are linked to ongoing fungal infection. However, the nail may eventually become deformed and thickened, resulting in pain when wearing shoes or walking. You may consider your nail's appearance embarrassing.

If you have diabetes or a weakened immune system, a fungal infection can lead to a more serious bacterial infection.

If you need more information, see the topic Fungal Nail Infections.

Your Information

Your choices are:

Do not treat your fungal nail infection.
Take antifungal pills.
Try another treatment, such as an antifungal cream or solution or removal of the nail, either surgically or nonsurgically.

The decision about whether to take oral antifungal medication takes into account your personal feelings and the medical facts.

**Deciding about taking an oral antifungal medication**
Reasons to take medication for a fungal nail infection	Reasons not to take medication for a fungal nail infection
Oral medications can be effective. Cure rates range from about 40% to 90%.⁵ ⁶ Topical medications are not as effective. Topical medications are messy and need a longer treatment time. In people with diabetes or a weakened immune system, fungal infections can lead to a more serious bacterial infection. Wearing shoes is difficult because of pain or discomfort. The infection causes you embarrassment. Future treatment costs could be higher if the infection worsens. Are there other reasons why you might use an oral antifungal medication?	The infection may return; of people successfully treated with antifungal pills, 15% to 20% develop another infection in the next year.² In healthy people, no serious risks are linked to ongoing fungal infection, although the nail may eventually become deformed and thickened. Advanced age (older than 60) decreases the likelihood of a cure to about 65%.⁴ Heavily infected nails and those thickened by infection are less likely to be cured of fungal infection. Rare but serious risks of oral antifungals include serious drug interactions, liver damage, liver failure, and heart failure. Minor side effects include headache, stomach upset, diarrhea, rash, itch, and loss of taste sensation. Topical medications may be effective. Blood testing for liver damage may be required every 4 to 6 weeks during treatment. This treatment is expensive; costs include medication, laboratory tests, nail-related procedures, and office visits. Are there other reasons why you might not use an oral antifungal medication?

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about taking oral antifungal medication. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I'm concerned about this infection getting worse in the next few years.	Yes	No	Unsure
Keeping my feet clean, dry, and medicated with a topical antifungal has not cured my infection.	Yes	No	Unsure
I know that oral antifungals carry a risk of heart or liver damage, but I'm willing to take that risk to rid myself of this condition.	Yes	No	Unsure
I have a fungal nail infection that is uncomfortable, spreading, or unsightly.	Yes	No	NA*
I have a medical condition that can cause this fungal nail infection to become a complicated bacterial infection.	Yes	No	Unsure
I'm anxious to cure this infection before it gets any worse.	Yes	No	NA
I don't have liver, kidney, or heart problems.	Yes	No	Unsure
I am younger than 60 and have no significant circulatory problems involving my legs and feet.	Yes	No	Unsure
I'm willing to have blood tests every 4 to 6 weeks to make sure I'm not developing serious side effects from an oral antifungal.	Yes	No	NA
I'm willing to consider nail removal combined with topical antifungal cream to cure my severe fungal infection.	Yes	No	NA

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use oral antifungal medication for a fungal nail infection.

Check the box below that represents your overall impression about your decision.

Leaning toward taking antifungal pills

Leaning toward NOT taking antifungal pills

Return to the topic Fungal Nail Infections.

References

Citations
U.S. Food and Drug Administration (2001). FDA issues health advisory regarding the safety of Sporanox products and Lamisil tablets to treat fungal nail infections. FDA Talk Paper T01-22. Available online: http://www.fda.gov/bbs/topics/answers/2001/ans01083.html.
Habif TP, et al. (2005). Tinea of the nails (onychomycosis) section of Fungal infections. In Skin Disease: Diagnosis and Treatment, 2nd ed., pp. 234—237. Philadelphia: Elsevier Mosby.
Roberts DT, et al. (2003). Guidelines for treatment of onychomycosis. British Journal of Dermatology, 148(3): 402–410.
Gupta AK, et al. (2001). Single-blind, randomized, prospective study on terbinafine and itraconazole for treatment of dermatophyte toenail onychomycosis in the elderly. Journal of the American Academy of Dermatology, 44(3): 479–484.
Rodgers P, Bassler M (2001). Treating onychomycosis. American Family Physician, 63(4): 663–672.
Darkes MJM, et al. (2003). Terbinafine, a review of its use in onychomycosis in adults. American Journal of Clinical Dermatology, 4(1): 39–65.
Nelson NM, et al. (2003). Tinea pedis and tinea manuum subsection of Superficial fungal infection: Dermatophytosis, tinea nigra, piedra. In IM Freedberg et al., eds., Fitzpatrick's Dermatology in General Medicine, 6th ed., vol. 2, pp. 1999–2001. New York: McGraw-Hill.
Schlefman BS (1999). Onychomycosis: A compendium of facts and a clinical experience. Journal of Foot and Ankle Surgery, 38(4): 290–302.

Credits

Author	Sabra L. Katz-Wise
Editor	Susan Van Houten, RN, BSN, MBA
Associate Editor	Terrina Vail
Primary Medical Reviewer	Patrice Burgess, MD - Family Medicine
Specialist Medical Reviewer	Randall D. Burr, MD - Dermatology
Last Updated	August 23, 2006

Print This

Last updated:	August 23, 2006
Author:	Sabra L. Katz-Wise
Reviewed By:	Patrice Burgess, MD - Family Medicine, Randall D. Burr, MD - Dermatology
Editors:	Susan Van Houten, RN, BSN, MBA, Terrina Vail

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