Fungal toenail infections, also known as onychomycosis, are notoriously stubborn and can be difficult to treat. While prescription treatments are available and often effective, there are cases where fungal toenails do not respond as expected despite our best efforts. As a podiatrist, I frequently see patients frustrated by the persistence of their infection even after following prescribed treatments. In this blog post, I will explore the reasons why some fungal toenails do not improve with treatment and what can be done in these challenging situations.
Understanding Onychomycosis
Onychomycosis is caused by fungi that infect the nail bed, leading to thickened, discolored, and brittle nails. Common treatments include oral antifungals, topical medications, and, in some cases, laser therapy. While many patients experience improvement, some do not see the results they hoped for. Here are some of the key reasons why this occurs:
1. Inadequate Penetration of Topical Treatments
One of the most common reasons for treatment failure is the difficulty topical medications face in penetrating the thick, hard nail plate. The fungal infection often resides deep in the nail bed, beneath the protective surface of the toenail. Even with daily application, many topical antifungal treatments struggle to reach the infection's source.
Solution:
Combination Therapy: Combining topical treatments with oral medications can help improve the effectiveness of the treatment by targeting the infection from both inside and outside.
Nail Debridement: Regular debridement (trimming and thinning of the nail) by a podiatrist can allow the medication to penetrate more effectively.
2. Incomplete Treatment Course
Fungal toenail infections take time to resolve, and treatment can be a long-term commitment. Oral antifungals typically require a course of 12 weeks, while topical treatments may need to be applied daily for up to a year. However, patients often stop treatment early once symptoms improve, allowing the fungus to persist and re-grow.
Solution:
Consistency: It’s crucial to complete the entire course of treatment, even if the nail starts to look better. Stopping too soon can lead to a relapse.
Regular Monitoring: Follow-up appointments with a podiatrist can help ensure the infection is fully eradicated and adjustments to treatment can be made if necessary.
3. Resistant Fungal Strains
Not all fungal infections are created equal. Some fungal strains are more resistant to treatment than others, making them harder to eliminate with standard antifungal medications. In these cases, the infection may persist or worsen despite treatment.
Solution:
Culture and Sensitivity Testing: If the infection is not responding, it may be helpful to take a sample of the infected nail to identify the specific strain of fungus. This allows for a more targeted treatment approach.
Alternative Therapies: In cases of resistant fungi, alternative treatments such as laser therapy or non-standard antifungals may be recommended.
4. Reinfection and Environmental Factors
Even with successful treatment, reinfection is common. Fungi thrive in warm, moist environments such as showers, locker rooms, and even inside shoes. If patients are re-exposed to fungal spores in these environments, the infection can return.
Solution:
Environmental Control: Disinfecting shoes, changing socks regularly, and avoiding walking barefoot in communal areas can help reduce the risk of reinfection.
Foot Hygiene: Maintaining good foot hygiene, including keeping feet clean and dry, is essential to preventing recurrence.
5. Underlying Health Conditions
Certain health conditions, such as diabetes, thyroid dysfunction, poor circulation, and immune system disorders, can make it more difficult for the body to fight off infections, including fungal toenails. Patients with these conditions often struggle with persistent infections and slower healing times.
Solution:
Comprehensive Management: For patients with underlying health issues, it’s important to manage these conditions alongside fungal treatment. In some cases, a multidisciplinary approach may be necessary to address the root causes of the persistence.
Regular Podiatric Care: Ongoing care with a podiatrist can help monitor the condition and adjust treatments as needed to account for the impact of underlying health problems.
6. Nail Damage or Trauma
Toenail trauma or repeated pressure on the nail can weaken the nail bed and create an environment conducive to fungal growth. If the nail has been damaged, it can make it harder for treatments to fully clear the infection, and the infection may return once treatment stops. Previous nail trauma with loss of a toenail is especially challenging to treat especially when the nail bed has been damaged.
Solution:
Protect the Toenail: Wearing proper footwear that reduces pressure on the toenails and prevents further trauma is important for successful treatment. Orthotics or padding may be recommended.
Treat the Underlying Trauma: If trauma or damage is contributing to the infection, addressing these issues alongside the infection may improve outcomes.
7. Age and Nail Growth Rate
Nail growth slows as we age, and since the new healthy nail must replace the infected portion for complete healing, slow-growing nails can prolong the treatment process. It may take over a year to fully regenerate a new big toenail! Additionally, older adults often have thicker, more brittle nails, which can further complicate treatment.
Solution:
Patience: Treating fungal toenails in older adults may simply take more time. Expect 12 to 18 months of treatment. Regular follow-up care and consistent treatment application are critical for success.
Nail Trimming and Care: Regular trimming and thinning of the affected nail can promote better results and help treatments penetrate more effectively.
Fungal toenail infections can be persistent and frustrating, especially when they do not respond to topical treatments. However, understanding the reasons behind treatment failure can help guide more effective care. Whether it’s due to resistant fungi, reinfection, or underlying health issues, there are often ways to adjust the approach to improve outcomes.
If you are struggling with a fungal toenail infection despite your best efforts and prescription treatments, it’s important to consult a podiatrist. Together, we can explore alternative treatments, adjust your care plan, and take proactive steps to help you achieve healthy, clear nails.