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

Using antifungal pills (oral medicine) gives you the best chance of curing a severe fungal nail infection. But 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.

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. You can also get an infection by direct contact with an infected person or through contact with floors, shoes, or other personal items, such as nail clippers or nail files, that have fungi on them. Long-standing athlete's foot also can result in fungal toenail infection. Shoes that are moist, tight, and do not allow moisture to escape contribute to fungal infections.

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

A fungal nail infection does not go away on its own and tends to slowly get worse 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. After this happens, it is difficult to cure a fungal infection, even with oral medicines.

Your doctor 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 medicine?

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 medicine is expensive. There is no guarantee that oral medicine 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 medicine 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 medicines available to treat fungal nail infections?

Terbinafine (Lamisil) is a first-line medicine 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 medicine 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. But 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 (Grifulvin V) are rarely used. Griseofulvin has low cure rates and is no longer considered standard treatment for fungal toenail infections.7

What are the side effects of these medicines?

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

What are the risks of not taking these medicines?

If you are healthy, no serious medical risks are linked to ongoing fungal infection. But 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 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 medicine takes into account your personal feelings and the medical facts.

Deciding about taking an oral antifungal medicine
Reasons to take medicine for a fungal nail infection Reasons not to take medicine for a fungal nail infection
  • Oral medicines can be effective. Cure rates range from about 40% to 90%.5, 6
  • Topical medicines are not as effective.
  • Topical medicines 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 gets worse.

Are there other reasons why you might use an oral antifungal medicine?

  • 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 medicines may be effective.
  • Blood testing for liver damage may be required every 4 to 6 weeks during treatment.
  • This treatment is expensive. Costs include medicine, laboratory tests, nail-related procedures, and office visits.

Are there other reasons why you might not use an oral antifungal medicine?

These personal stories may help you make your 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 medicine. 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 medicine 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

         

Citations

  1. 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.

  2. 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.

  3. Roberts DT, et al. (2003). Guidelines for treatment of onychomycosis. British Journal of Dermatology, 148(3): 402–410.

  4. 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.

  5. Rodgers P, Bassler M (2001). Treating onychomycosis. American Family Physician, 63(4): 663–672.

  6. Darkes MJM, et al. (2003). Terbinafine, a review of its use in onychomycosis in adults. American Journal of Clinical Dermatology, 4(1): 39–65.

  7. Verma S, Heffernan MP (2008). Superficial fungal infection: Dermatophytosis, onychomycosis, tinea nigra, piedra. In K Wolff et al., eds., Fitzpatrick's Dermatology in General Medicine, 7th ed., vol 2, pp. 1807–1821. New York: McGraw Hill.

Author Maria G. Essig, MS, ELS
Editor Susan Van Houten, RN, BSN, MBA
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer Alexander H. Murray, MD, FRCPC - Dermatology
Last Updated July 24, 2008

WebMD Medical Reference from Healthwise

Last Updated: July 24, 2008
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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