Topical Treatments for Toenail Fungus

Chris Vincent, MD, is a licensed physician, surgeon, and board-certified doctor of family medicine.

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Onychomycosis (toenail fungus) is a problem that affects millions of people worldwide. Onychomycosis can be mild, causing only cosmetic concerns. For some people, however, changes in the nail structure can cause pain and even lead to a secondary bacterial infection.

Onychomycosis is notoriously difficult to treat, mostly because the fungus resides throughout the nail, including the nail bed. Moreover, the structure of the nail is not easily penetrated by topical medications.

This article explores the different topical medications and procedures that can help treat onychomycosis, either on their own or with aid of oral antifungal drugs.

Diagnosing Onychomycosis

If you have toenail fungus, it is always a good idea to see a foot specialist known as a podiatrist to have your nails evaluated. This can help identify the most effective treatments.

The diagnosis typically involves a nail clipping or a biopsy of the nail and nail bed. The nail sample is then sent to the lab to be cultured, examined under the microscope, and/or exposed to potassium hydroxide (known as a KOH test) to determine if the cause is fungal.

One of the main reasons why nail treatments fail is that people treat a bacterial nail infection as a fungal one. By working with a podiatrist, you will not only be able to confirm that the cause is fungal but identify which strain of fungus you have.

Onychomycosis is diagnosed by obtaining a sample of nail and evaluating it in the lab. This may involve a microscopic examination of the nail, a KOH test, or a fungal culture.

Prescription Antifungals

One of the more frequently prescribed topical antifungals is Penlac (ciclopirox). This is a brush-on lacquer applied to the nail, usually over the course of months. Penlac is recommended for mild to moderate cases of onychomycosis in which the infection has not spread to the nail’s growth center (known as the matrix).

It is important to note that Penlac only targets certain types of fungi (including the main form known as Trichophyton rubrum). It is less effective in controlling drug-resistant fungal strains.

Research has shown that fewer than 12% of Penlac users have partial or complete clearance of symptoms. Because of this, most doctors will combine Penlac with other forms of antifungal therapy, including oral antifungals like Diflucan (fluconazole) or Lamisil (terbinafine),

Another topical antifungal called Jublia (efinaconazole) was approved by the Food and Drug Administration in 2014. Studies have shown that Jublia is two to three times more effective in curing nail fungus than Penlac but is nearly nine times more costly ($750 vs. $85, respectively).

Children tend to respond to topical nail treatments better than adults because their nails are thinner and more porous.

Penlac (ciclopirox) and Jublia (efinaconazole) are two topical antifungals available by prescription that can help treat onychomycosis. Jublia has proven more effective than Penlac but costs considerably more.

Topical Treatments for Toenail Fungus

Nail Debridement

If you decide to use a topical agent, monthly debridement (the removal of affected nail tissue) will help the medication penetrate deeper. This is typically performed by a podiatrist with the aid of a topical urea cream to help thin the nail.

Studies have shown that debridement with a urea-based topical agent can significantly improve the symptoms of onychomycosis after one to two weeks.

While applying urea, you will need to keep the nail covered with a water-tight bandage (known as an occlusion dressing). This helps ensure that the urea penetrates the nail and doesn’t rub off.

Available by prescription in a 40% formulation (under the brand name Cerovel), the urea ointment retails for around $20. An extra-strength 45% formulation (marketed under the brand name Uramaxin GT) costs around $250.

Monthly nail debridement helps topical medications penetrate the nail more deeply. The procedure often includes a topical urea cream that helps thin the nail plate.

Over-the-Counter Treatments

There are plenty of over-the-counter (OTC) topical antifungals on drugstore shelves, most of which promise more than they deliver. If you have especially thick nails or advanced signs of fungal infection (such as discoloration and texture changes), these drugs are unlikely to be beneficial no matter how long you use them.

However, if you have mild onychomycosis limited to the ends of the nail, OTC products like Lamisil (terbinafine) cream may provide relief in conjunction with regular debridement. The cost of generic Lamisil cream is around $12 for a 0.46-ounce tube.

Over-the-counter topical antifungals like Lamisil (terbinafine) may be useful for treating mild cases of onychomycosis limited to the nail ends. OTC products are unlikely to help moderate to severe cases involving the nail plate or bed.

Home Remedies

Several home remedies have been popularized as nail fungus cures. These include tea tree oil, coconut oil, and Vicks VapoRub. Each has antifungal properties and an oily texture which promotes easy absorption.

While clinical evidence remains sparse, a small study concluded that 100% Melaleuca alternifolia (tea tree) oil was as effective in treating nail fungus as 1% clotrimazole antifungal ointment. Around 50% of the tea tree oil users reported improvement, although the rate of recurrence was high.

Coconut oil contains caprylic acid and capric acid which some people claim can clear all types of nail fungus. While there is little evidence to support the claims, research shown has shown that capric acid can suppress Candida albicans (the fungus linked to yeast infections) in the test tube.

Whether it can do the same with an especially hearty fungus such as Trichophyton rubrum is doubtful.

A small study involving Vicks VapoRub showed promising results in people with onychomycosis. After 48 weeks, 10 of the 18 participants achieved partial clearance of their symptoms, while five achieved complete clearance.

A 2016 study echoed these results in people with HIV. However, the results were typically short-lived, with most experiencing recurrence within a year.

Keep in mind that home remedies lack rigorous testing. Further trials are needed before any can be recommended.

Tea tree oil. coconut oil, and Vicks VapoRub are three home remedies popularly used to treat onychomycosis. At present, the clinical evidence supporting their use is limited.


Onychomycosis is a fungal nail infection. The infection is notoriously difficult to treat and typically requires a podiatrist to select the best treatment options. Topical medicines are one such option, particularly if you are averse to pills.

These include over-the-counter topical antifungals like Lamisil, prescription topical antifungals like Jublia and Penlac, and home remedies like tea tree oil. coconut oil, and Vicks VapoRub. To aid with treatment, your doctor may recommend monthly nail debridement to thin the nail and allow for deeper penetration of the medicine.

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