Fungal nail infection is a common condition, which usually affects toenails. The main products used for toenail fungus treatment are available in most pharmacies, supermarkets and perhaps with the best range of products found online. Topical products, which are applied directly to the infected area, are the main products used as toenail fungus treatment. I will review the best toenail fungus treatment options available over the counter in the UK. I will also look at the national guide on toenail infections (treatment approach in the NHS) and summarise the recommended treatment. Summary of the post:
- symptoms of fungal toenail infection
- toenail fungus – predisposing factors
- overview of the fungal nail treatment according to national guide (NICE)
- best toenail fungus treatment
- new drugs is the treatment of fungal nail infections
Symptoms of fungal toenail infection
Fungal nail infection (also known as onychomycosis) is usually caused by prolonged moisture present around the feet and toes. A fungus which causes the infection thrives in a dampened and warm environment. The most common symptoms of toenail fungus are:
- yellow discolouration of the nail
- toenail becomes brittle and often breaks
- thickening of the nail
Toenail fungal infection is not a dangerous condition; however, the treatment is usually slow and may take up to 12 months.
It is recommended that a particular group of people; for example, diabetic patients seek advice from a podiatrist or diabetic nurse as any infections in diabetes may lead to complications.
Individuals who have more than two nails infected should speak to their GP about the treatment.
Toenail fungus – predisposing factors
The following factors make people more susceptible to fungal nail infections ()Gupta et al., 2017:
- human immunodeficiency virus
- older age
- athlete’s foot
Toenail fungus treatment – ‘official’ guide
Treatment recommendation from the guide on fungal nail infections (NICE, 2018) depends on the severity of the infection, symptoms and any other conditions that a person may have.
Antifungal treatment is not always recommended, mainly when a person experiencing the infection is not worried about the appearance of the nail and/or infection is without symptoms.
If, however, an individual is affected psychologically or have other conditions, antifungal treatment may be recommended.
The NICE guide recommends only one product for toenail fungus treatment. If topical treatment is appropriate, a GP will recommend using amorolfine 5% nail lacquer. GP may ask patients to buy amorolfine nail lacquer over the counter, rather than produce a prescription.
Amorolfine 5% nail lacquer (brand name: Curanail 5% w/v Medicated Nail Lacquer) is available as general-sale medication, which can be purchased in most supermarkets and pharmacies.
Amorolfine 5% nail lacquer is usually applied once or twice weekly. Toenail fungus treatment may last six months for fingernails and 9–12 months for toenails.
When is ora treatment recommended for toenail fungal infections?
Oral treatment for toenail fungus may be offered to patients who failed to achieve results by implementing self-care measures and trying the topical treatment.
Terbinafine is recommended as the first-line oral antifungal drug. The advantage of the treatment is shorter treatment period as compared to topical products, lasting between 6 weeks and 3 months for fingernails, and 3–6 months for toenails (NICE, 2018).
Topical products for toenail fungus treatment are recommended as the first option due to a better safety profile as compared to treatment with oral antifungal drugs. Of particular concern is hepatotoxicity (damage to the liver), which may affect patients with and without the pre-existing hepatic disease. Pre-treatment liver function test is recommended with a follow-up review after 4-6 weeks of treatment. Additionally, oral antifungal tablets are not licensed for use in children.
Overall, oral treatment with drugs cure toenail infections more quickly and effectively than topical treatments (Cochrane, 2017).
Best toenail fungus treatment
As mentioned before, a national guide on management of toenail fungal infection recommends mainly one topical product. There is an overwhelming number of products sold for the treatment of toenail fungus. Products listed below are the best rated and most popular on Amazon.co.uk.
Curanail Once Weekly 5% Fungal Nail Treatment
Curanail Once Weekly Fungal Nail treatment contains 5% of amorolfine hydrochloride as an active ingredient. Amorolfine is the main topical treatment recommended for toenail fungus by NICE guide; therefore, a GP would usually suggest it, when seeking advice for the treatment.
Curanail is limited for treatment of fungal nail infections up to two nails in adults and elderly only.
Amorolfine is classified as antimycotics drugs, which kills the fungus. When tested in the lab, amorolfine found to be a very active substance against a variety of yeasts, fungi and moulds.
- An effective treatment for mild fungal nail infection
- Penetrates the nail, kills the fungus and prevents further infection spreading
- Works underneath nail varnish
How is Curanail used in toenail fungus treatment?
Firstly, the infected nail is filed down (nail file supplied) and cleaned with an alcohol pad provided. The applicator is submerged into the lacquer and applied evenly to the infected nail (entire surface).
The applicator can be used more than once during treatment but needs to be cleaned. Nail lacquer needs to be applied once a week until the infection is gone. The process or removing the lacquer and filing down the nail needs to be repeated weekly also. It takes around 6 months to treat fingernails and 9-12 month to treat toenails.
Read product information leaflet for more detailed application tips and safety information.
Amorolfine nail lacquer is sold under different brands, for example, Schollmed Once Weekly Fungal Nail Treatment.
Excilor Nail Fungus Treatment Solution
Excilor Nail Fungus Treatment Solution is another popular choice for the treatment of toenail fungus. It is advertised as effectively and clinically proven product with easy daily applications which last less than one minute. Excilor is advertised as a product which gives visible results from two weeks on. Similarly to other products, Excilor should be applied until a healthy nail has re-grown.
- An effective, clinically proven treatment against fungal infections inside or underneath the nail. Easy to apply. Takes 1 minute a day. No filing needed.
- Penetrates the nail without filing and acts fast to block the progression of the fungal nail infection.
- Visible results from two weeks on.
Excilor – review of clinical effectiveness
Sleven et al. (2016) evaluated the topical antifungal product in a lab. In their experiment, the effectiveness of Excilor together with other six products was compared to Loceryl (known as Curanail – contains amorolfine) against one specific fungus – trichophyton interdigital, which causes fungal nail infections.
All products were applied daily. Please note that Loceryl (amorolfine) is used once a week usually. Boots Fungal Nail Treatment pen and Scholl Fungal Nail Treatment (reviewed in the next paragraph) were also included in the experiment.
What was the outcome of the experiment?
Out of seven commercial products, only two showed activity against fungus: Excilor and Nailner:
- Daily applications of Excilor and Nailner were much less effective than everyday applications of Loceryl (Curanail).
- Everyday applications of Excilor showed similar effectiveness to the weekly application of Loceryl (Curanail).
- Nailner was less effective as Excilor against trichophyton interdigital.
- Loceryl (Curanail) has proven to be of ‘superior’ effectiveness to all other products when applied daily.
- The experiment confirmed the claim that some products can penetrate the nail and have an antifungal effect.
Authors of the paper suggested that organic acids have a role as antifungal ingredients. Excilor contains acetic acid and ethyl lactate, whereas Nailner contains lactic acid, citric acid, ethyl lactate.
Products which were found inactive in the experiment did not contain any organic acids.
Conflict of interest: the above study was partly funded by producers of Excilor Nail Fungus Treatment Solution.
Nailner Brush 2 in 1
Nailner is another toenail fungus treatment option which has proven to be effective against fungal infection, possibly to leaser extend than previously reviewed Excilor Nail Fungus Treatment Solution.
As suggested, Nailner takes advantage of a combination of different organic acids, ethyl lactate, lactic acid and citric acid, which penetrate the toenail and display an antifungal activity.
As advertised, Nailner may give promising visible results in just seven days.
How is Nailner used?
Initially, Nailner used twice a day for four weeks, and daily after that, until a healthy nail is re-grown.
Canespro Fungal Nail Treatment for Toenails
Canespro product comes from the producer of a well-known range of Canesten products (antifungal products). The approach to the treatment of toenail infection is different from previously reviewed products. The treatment aims to remove the infected part of the nail over 2-3 weeks.
Canespro Ointment softens the nail, which can be removed with a plastic nail scraper provided in the set. Removed nail exposes the area under the nail plate where most infections happen. Following the removal of the infected part of the nail, it is recommended to use an antifungal cream.
How is Canespro used in the treatment of toenails?
In summary, the urea ointment is applied daily, and the toe is covered with a plaster provided. The next day (24hrs) after the removal of plaster and soaking of the toe in the water, soften part of the nail is removed with the plastic scraper provided. This process is repeated daily for 2-3 weeks.
Canespro Fungal Nail Treatment contains 40% urea ointment. Some evidence exists which support the increased effectiveness of fungal nail treatment when urea is used alongside topical or oral regiments (Dars et al., 2019).
Scholl Fungal Nail Treatment
Scholl Fungal Nail Treatment is one of the most reviewed products for fungal nail infection on Amazon.co.uk. Schooll’s toenail fungus treatment product advertises visible results from 2-4 weeks from the start of the treatment. Scholl Fungal Nail Treatment is clinically proven, although not reference or access to any clinical data is given.
Treatment is divided into two phases:
- Treatment phase (4 weeks): the surface of the infected nail is nailed once a week with daily application of the liquid. This process is repeated weekly for four weeks.
- Protection phase (9 months): liquid is applied to the infected nail once a week for nine months or until signs of infection is gone (discolourisation)
Similarly to other product for fungal nail infection, the treatment process is slow. Overall this product has good reviews on Amazon.co.uk
Is Scholl Fungal Nail Treatment effective in toenail fungus treatment?
With reference to the previously discussed experiment, no activity was found for Scholl product against trichophyton interdigital. The manufacturer provides no information on the composition of the product, which made it impossible for authors of the experiment to make any further comments on the product.
Nevertheless, Scholl Fungal Nail Treatment is one of the best selling products and Amazon’s choice for fungal nail treatment (well-priced and highly rated product).
New drugs for toenail fungal treatment
There are a couple of newly approved drugs currently not available in the UK for the treatment of fungal nail infection, which show promising results as confirmed by a systemic review (review of several clinical trials).
- Efinaconazole 10% topical solution – approved in the USA in 2014, but also available in Canada and Japan (brand names Jublia and Clenafin) showed promising results in clinical trials. Efinaconazole penetrates the nail allowing for an effective treatment under the nail.
- Tavaborole 5% solution (brand name: Kerydin 5% solution), was also approved in 2014 in the USA. Similarly to efinaconazole, tavaborole can penetrate the nail. Tavaborole is effective against a range of fungal species. Studies have shown that tavaborole can remain in the nail for up to three months after the treatment is stopped (Kawa et al., 2019).
Is Vicks VapoRub effective for toenail fungus treatment?
The myth about the effectiveness of Vicks VapoRub in the treatment of toenail fungus has been spreading since the publication of a research paper Novel Treatment of Onychomycosis using Over-the-Counter Mentholated Ointment: A Clinical Case Series in JABMF science journal (Derby et al., 2011). Rumours about the use of Vicks VapoRub for the treatment of fungal toenail infection became some kind of ‘fashion’ rather than proven fact.
The above article describes a small study of 18 participants who applied Vicks VapoRub as a treatment for fungal toenail infection for up to 48 weeks. The primary outcome of this study was to measure the cure rate at the end of this study.
Supposedly 15 out of 18 participants showed a positive treatment effect.
Overall the above study is very questionable. In particular, the main weaknesses of this study are as follows:
- a small number of participants (18)
- no control group (treatment compared with no treatment – standard feature of clinical trials)
- presence of different organisms which cause the infection, with even smaller number of participants infected with a fungus that commonly causes toenail infections
- no control set for the degree of toenail infection
- Only 6 out of 18 participants were positively tested for T. rubrum (a common pathogen to cause fungal nail infection). In this subgroup 5 had a partial cure and 1 had no change.
Overall above study very weakly (and badly) demonstrated that Vicks VapoRub is useful for the treatment of toenail fungus. The use of Vicks VapoRub in fungal toenail infections should be discouraged as there is no good evidence to suggest its effectiveness against toenail fungus infection.
Treatment of toenail fungus with over the counter topical products is a slow and challenging process. The slow growth of the nail, nail bed out of reach and lack of topical drugs with penetrating power are some of the main challenges of the treatment (Dhamoon et al., 2019). Oral treatment with antifungal drugs seems to be superior to topical options; however, at the moment, it is not a recommended first-line treatment.
Toenail fungus is a difficult infection to eradicate. A large proportion of people (20-25%) will not respond to the treatment. Many patients will relapse after the initial improvement in symptoms (Lipner et al., 2015).
There are plenty of options for toenail fungal infections; however, it can be concluded that limited products are effective. Out of all reviewed product amorolfine medicated nail lacquer (Curanail) has the most robust evidence for its effectiveness, and it is a first-line choice as a topical product by national guide on management of toenail infections by NICE. Canespro has a different approach to treatment. It may provide faster results since treatment relies on the removal of the infected part of the nail.
Customers are reminded that products which rely on regrowth of the nail usually require a lengthy treatment.
Seemingly, the prevention of toenail fungus infections is an approach rather than the treatment.
What is your experience with fungal nail products? Please leave comments below.
Cochrane (2017). Kreijkamp-Kaspers S, Hawke K, Guo L, Kerin G, Bell-Syer SEM, Magin P, Bell-Syer SV, van Driel ML. What is the best medication for a fungal infection of the toenail? Available at: https://www.cochrane.org/CD010031/SKIN_what-best-medication-fungal-infection-toenail Accessed on 20/10/2020
Dars, S., Banwell, H.A. & Matricciani, L. The use of urea for the treatment of onychomycosis: a systematic review. J Foot Ankle Res 12, 22 (2019). Available at: https://doi.org/10.1186/s13047-019-0332-3 Accessed on 20/10/2020
Derby R, Rohal P, Jackson C, Beutler A, Olsen C. Novel treatment of onychomycosis using over-the-counter mentholated ointment: a clinical case series. J Am Board Fam Med. 2011 Jan-Feb;24(1):69-74. doi: 10.3122/jabfm.2011.01.100124. PMID: 21209346. Available at: https://doi.org/10.3122/jabfm.2011.01.100124 Accessed on 21/10/2020
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Kawa N, Lee KC, Anderson RR, Garibyan L. ONYCHOMYCOSIS: A Review of New and Emerging Topical and Device-based Treatments. J Clin Aesthet Dermatol. 2019;12(10):29-34. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937150/ Accessed on 21/10/2020
NICE (2018). Fungal nail infection. Available at: https://cks.nice.org.uk/topics/fungal-nail-infection/ Accessed on 17/10/2020
Lipner SR, Scher RK. Efinaconazole in the treatment of onychomycosis. Infect Drug Resist. 2015;8:163-172. Published 2015 Jun 1. doi:10.2147/IDR.S69596 Available at: https://dx.doi.org/10.2147%2FIDR.S69596 Accessed on 21/10/2020
Sleven R, Lanckacker E, Delputte P, Maes L, Cos P. Evaluation of topical antifungal products in an in vitro onychomycosis model. Mycoses. 2016 May;59(5):327-30. doi: 10.1111/myc.12475. Epub 2016 Feb 9. PMID: 26857689. Available at: https://doi.org/10.1111/myc.12475 Accessed on 20/10/2020