Toenail Fungus: A Stubborn Infection Affecting 1 in 10 People–Signs to Watch For

What Are the Symptoms and Early Signs of Toenail Fungus?

The infection progresses gradually, typically beginning at the edge of the nail and then spreading across the entire nail. Its symptoms may affect one or more toenails and can include:

Nail Discoloration: The first sign is usually a color change in part of the nail, often yellow, brown, or white, and sometimes orange, greenish-black, or black. It typically starts at the tip of the nail and spreads toward the cuticle. Affected nails often feel soft, dry, and powdery.
Brittle Nail: Infected nails become fragile and may split, crack, or develop crumbling edges.
Thickened Nail: Affected nails can become thick and lose their natural shine or luster.
Spots and Pits: Flaky white spots and small pits can develop on the surface of the nail plate.
Pain: Nail fungus is typically painless, but in severe cases, it can damage the nail and cause pain. Poorly fitting shoes can worsen the pain.
Foul Smell: Fungi living under or around the nail can cause toenail odor. Cutting or filing the nail can release trapped compounds, making the smell more noticeable.
Nail Detachment: If left untreated, the fungus may penetrate deeper under the nail, changing its shape and potentially causing the nail to lift or separate, which can lead to debris buildup beneath it. Detachment may make the skin around the nail bed swollen and painful.

Nail fungus often doesn’t require medical attention. However, you may consider seeing a doctor if:

There is bleeding, swelling, or pain around the affected nail or nails.
The fungus has extended beyond the original nail.
You have trouble walking.
The infection has not responded to treatment.
You have diabetes, as foot infections can become more serious and lead to complications in people with this condition.
You have a weakened immune system and are more vulnerable to fungal infections.

What Causes Toenail Fungus?

Toenail fungal infection is caused by three types of fungi: dermatophytes—which account for 90 percent of cases—molds, and yeasts. They grow in warm, moist places, including nails, and everyday items like unwashed bathroom floors, towels, or nail clippers, making it contagious. Over time, fungi can reach the nail matrix, the part of the nail that produces new nail growth.

1. Dermatophytes

A dermatophyte is a type of fungus that requires keratin—a tough structural protein that makes up nails— for growth. It thrives on skin, hair, and nails, where keratinized tissues are found. Dermatophytes spread through fungal spores, which are tiny, highly resistant reproductive units that can survive for long periods in the environment, allowing the infection to spread through direct contact with infected people, animals, or contaminated surfaces.

2. Nondermatophyte Molds

This type accounts for about 8 percent to 10 percent of cases. These molds are usually harmless fungi that live in the environment, but they can sometimes cause infections if they get into the nails.

3. Yeast

Candida albicans is the main cause of this type of fungal infection.

Other common fungal infections, such as athlete’s foot, jock itch, and ringworm on the body or scalp, can spread to the toenails, leading to toenail fungal infection.

How Nail Fungus Transmits

Nail fungus enters through tiny openings in the toenails or the skin around them, usually from contact with an infected person or item. You may get infected by:

Touching someone’s nail fungus or athlete’s foot
Walking barefoot in warm, damp places like pool decks, locker rooms, or public showers
Sharing unwashed towels, shoes, or nail tools used by an infected person
Having athlete’s foot, as fungi can spread from the skin to the nails

Risk Factors

Anyone can develop toenail fungus, but certain habits, health conditions, and daily exposures can make it more likely.

Long Nails: Long nails or nails trimmed incorrectly can make it easier for fungi to enter.
Tight Shoes: Shoes that are tight or make the feet damp create a perfect environment for fungi.
Heavy Toenail Polish: Nail polish forms a sealed layer on the nails, creating an ideal environment for fungi to thrive.
Nail Injury: Nail fungus is more likely if you’ve injured a nail, have a bunion—a painful bump on the side of a big toe—or have had a fungal nail infection in the past.
Exposure to Infections: Using shared personal items or having contact with people with toenail fungal infections may lead to the infection.
Walking Barefoot: Walking barefoot in public, damp places increases the risk of picking up fungi.
Playing Sports: Toenail damage can happen from repeated rubbing during sports like running or from a sports-related injury. Athletes also often share bathroom facilities with teammates, increasing the risk of getting infected.
Family History: Nail fungus can run in families, and living with relatives who have it increases your risk of getting infected.
Age: Nail fungus is uncommon in children but becomes more likely with age; about half of people over 70 get it because slower nail growth and weaker infection defenses make older people more vulnerable.
Smoking: A 2020 meta-analysis of 25 studies involving over 18,000 people found that smokers had a higher risk of developing invasive fungal diseases, possibly because long-term smoking affects circulation and weakens the immune system.
Skin and Medical Conditions: Having hyperhidrosis—excessive sweating—psoriasis, cancer, diabetes, poor circulation, peripheral artery disease, obesity, inflammatory bowel disease, or a weakened immune system from an HIV infection can make nail fungus more likely.

How Is Toenail Fungus Diagnosed?

Early and accurate diagnosis improves the chances of curing nail fungus. A doctor can often diagnose toenail fungus by performing a physical examination of the nails, but may confirm it with lab tests and other procedures, such as:

Dermoscopy: A close-up imaging test that shows patterns such as white or yellow streaks, nail thickening, and changes in color or texture. It can also help identify the specific type of fungal infection based on where the fungus has invaded the nail.
Mycology Specimens: A test that involves taking nail clippings or scrapings—usually from the most damaged part of the nail—to look for fungus under a microscope.
Fungal Culture Testing: A lab test that grows the fungus from a nail sample to identify the exact organism causing the infection. It’s considered the standard test, but it can take several weeks for results.
Polymerase Chain Reaction (PCR) Testing: A test that detects fungal DNA directly from the nail sample. It’s very accurate and provides results much faster than a culture test, but it’s also more expensive and not available everywhere.

What Are the Treatments for Toenail Fungus?

Treatment works slowly because nails are made of keratin, which doesn’t easily absorb medication or have a blood supply. Results may take up to one year.

1. Oral Therapies

The most effective treatment for toenail fungus infection, especially moderate to severe cases or in people with diabetes, is oral antifungal therapy such as itraconazole or terbinafine, which can clear the infection in 55 percent to 70 percent of patients within 10 months, although 15 percent to 20 percent may experience a recurrence.

These medications can affect the liver and interact with other drugs, so liver function monitoring and precautions like avoiding alcohol and sun exposure are necessary.

2. Prescription Topical Medications

For patients who cannot or prefer not to use oral antifungals, topical treatments like efinaconazole, tavaborole, and ciclopirox offer an alternative, particularly for early or superficial infections. Some of them are applied like nail polish and require regular application for up to one year, with a cure rate of about 35 percent. Filing the nail surface helps the medication penetrate better.

3. Over-the-Counter Medications

Over-the-counter antifungal nail products may improve nail appearance but are generally ineffective at fully curing the infection.

4. Chemical Nail Avulsion

This is a nonsurgical method for removing an entire damaged or infected nail by applying a chemical agent, typically a 40 percent urea ointment, which softens the nail over the course of several days. The urea penetrates the nail keratin, breaking down its structure until the nail becomes soft, pliable, and easily separable from the underlying nail bed.

5. Combination Therapy

Using a combination approach—such as applying prescription topical antifungals alongside oral medication, regularly trimming or filing the affected nail, or removing the nail chemically—can improve treatment outcomes as it targets the fungus from multiple angles and allows medications to penetrate more effectively than systemic therapy alone.

6. Nail Removal

If a yellow streak appears in the nail, surgical removal of the affected portion may be necessary. In extreme cases where toenail fungus does not respond to treatment, complete surgical removal of the nail may be required.

7. Advanced Therapies

A range of advanced, technology-driven therapies has emerged, providing effective and often curative options for persistent or chronic nail fungus.

Laser Therapy: Dual-wavelength infrared and fractional carbon dioxide laser therapy can temporarily improve nail appearance, and combining it with topical treatments enhances overall effectiveness.
Plasma Therapy: A treatment that uses electric pulses to create antifungal compounds. Studies show 70 percent to 90 percent cure rates when combined with nail filing or medication.
Photodynamic Therapy: A noninvasive treatment that uses a combination of a special light and a photosensitizing agent—a substance that becomes activated when exposed to light—to target and destroy fungal cells in the nails without harming surrounding tissue. A meta-analysis published in August reports a 30 percent to 90 percent improvement and up to 100 percent cure rates when combined with laser treatment.
Iontophoresis: A safe, effective, and inexpensive procedure that uses a mild electrical current to drive ionized particles—such as drugs or anticholinergics—through the skin. It reduces sweating and enhances drug delivery.

8. Snakeroot

Snakeroot is a poisonous perennial herb. In a 2020 study, among patients with Type 2 diabetes and onychomycosis, treatment with a snakeroot extract in a medicated nail polish achieved about 78.5 percent clinical efficacy, outperforming the commonly used medicine ciclopirox. In a 2009 study, a 16.8 percent snakeroot extract demonstrated an effectiveness rate of 79 percent.

9. Ozonized Sunflower Oil

This oil is created by infusing sunflower oil with ozone gas, which has antimicrobial and therapeutic properties. In a 2011 study involving 400 participants, 90.5 percent of patients treated with ozonized sunflower oil were cured, and 9.5 percent showed improvement.

10. Natural Coniferous Resin Lacquer

Natural coniferous resin from the Norway spruce has been used topically in Finland and Sweden for centuries to treat infections and wounds. In a 9-month observational study, some patients using spruce-resin lacquer daily tested clear of the fungus by the end.

11. Vicks VapoRub

Vicks VapoRub, a topical cough suppressant, has shown potential as an alternative treatment for toenail fungus, likely due to its ingredients thymol and camphor, both of which have antifungal properties. In a 2011 study, daily application for one year led to significant improvement in 83 percent of participants, with complete fungal eradication in 28 percent.

However, despite seeking treatment for toenail fungus infection, recurrence is common, occurring in 5 percent to 50 percent of cases.

What Are the Natural and Lifestyle Approaches to Toenail Fungus?

Natural interventions—such as lifestyle modifications and foot soaks—can inhibit fungal growth, reduce the risk of cross-infection, and complement the efficacy of standard topical or oral antifungal therapies, while others—such as bee propolis—may be as effective as some prescription medicines in treating toenail fungus.

1. Nail Care

Simple daily nail care habits can make a meaningful difference in managing toenail fungus.

Trim nails after bathing when soft, following their natural shape. File the nail plate gently with an emery board and discard the used section
Avoid picking at the skin around the nails
Avoid using nail polish and artificial nails on infected toenails
Seek periodic nail debridement to help manage severe toenail fungal infection and reduce complications in patients who cannot or choose not to use systemic or topical antifungal treatments

Besides the above tips, always keep your nails and hands, feet, socks, and shoes clean and dry. Wash your hands after touching your feet. Make sure to dry your feet completely after bathing and before putting on shoes and socks. Change your socks frequently, and choose dry, moisture-absorbing socks. Avoid going barefoot in public areas, and use antifungal sprays or powders on your feet and inside your shoes.

2. Foot Baths

Several household items can be used to create foot soaks for toenail fungal infections.

Listerine: Mouthwashes possess antifungal activity. Listerine contains beneficial essential oils such as menthol, thymol, methyl salicylate, and eucalyptol, along with alcohol, so it can act as a disinfectant for treating mild cases of toenail fungus. Soaking the feet in a 1:1 mixture of Listerine and water for about 45 to 60 minutes can be a home remedy for the infection.
Epsom Salt: An Epsom salt foot bath—using one cup of Epsom salts in warm to hot water and soaking for about 20 minutes—can help draw out moisture, making the environment less favorable for fungus while also soothing itching and burning.
White Vinegar: White vinegar has natural antifungal and antibacterial properties that can help eliminate fungi. To use, mix vinegar and warm water in a 1:2 ratio, stir well, and soak the affected foot or feet in the solution.
Baking Soda: A 2013 study found that sodium bicarbonate—commonly known as baking soda—showed strong antifungal activity, completely inhibiting fungal growth in 79 percent of infected nail and skin samples and reducing it in 17 percent. A mixture can be prepared by adding 1/4 cup of baking soda to a small tub of warm water, and the feet should be soaked in the solution for 20 to 30 minutes.

3. Bee Propolis

In a 2018 study, 16 people with toenail fungus who hadn’t used antifungal medicines before applied two drops of a 10 percent bee propolis solution to the affected nails twice daily for six months. About 56 percent were completely cured, and about 31 percent showed some improvement. Propolis not only fights fungus but also penetrates deep into the nail. Its sticky nature helps it stay on the nail longer, allowing better absorption.

4. Certain Foods and Beverages

Maintaining a healthy gut can help prevent toenail fungus by supporting the immune system. Eating fermented foods like yogurt, kefir, and sauerkraut, along with other healthy whole foods, promotes gut health. Staying well hydrated is important. Limiting sugar, refined carbohydrates, and alcohol can prevent yeast overgrowth that may contribute to fungal infections.

How Does Mindset Affect Toenail Fungus?

Mindset itself doesn’t directly cure toenail fungus, as it’s a biological infection caused by fungi. However, one’s mental attitude can indirectly affect the course of the infection in several ways:

Treatment Adherence: People with a positive, proactive mindset are more likely to adhere to long-term treatment regimens, which is critical because toenail fungus often takes months to resolve.
Stress and Immune Function: Chronic stress can weaken the immune system, potentially making it harder for the body to fight off fungal infections. A calm, optimistic mindset may help the immune system function more effectively.

How Can I Prevent Toenail Fungus?

Since toenail fungal infections are difficult to eradicate, prevention is the most effective strategy. In addition to the self-care tips, the following measures can also help you prevent toenail fungus and its recurrence:

Keep Skin and Nails Dry: Dry skin and nails are less prone to infection, and using skin care powder after bathing can help.
Choose Breathable Footwear: Wear sandals or roomy, breathable shoes and let them air out 24 hours before reusing. Wear shoes made of natural materials or mesh to allow air circulation. Spray shoes with disinfectant and let them dry completely before wearing.
Use Clean Socks: Always wear socks and change them if your feet become damp or sweaty.
Protect Feet in Public Wet Areas: Wear shower sandals in locker rooms, and let them dry between uses.
Seek Professional Pedicures Safely: If you receive a professional pedicure, ensure the tools are properly sterilized.

What Are the Possible Complications of Toenail Fungus?

Fungal toenail infections are often dismissed as a cosmetic issue, but they can lead to serious health problems:

Sepsis: If the infection spreads to the bloodstream, it can trigger sepsis, a life-threatening body-wide response.

Social Stigma: Toenail fungus can be embarrassing and make people feel self-conscious in social situations.

Foot Ulcers: Toenail fungus may cause foot ulcers in people with diabetes.

Damaged Nails: If left untreated, the infection may cause the nails to become deformed or completely damaged.

Severe Pain: Severe pain can impair mobility.

Paronychia: Toenail fungus can cause paronychia—an infection of the skin around the nail.

Cellulitis: Cellulitis is a serious bacterial infection that affects the deeper layers of the skin. It may occur when damaged skin around the nail lets bacteria enter and cause infection, especially in older people.

Osteomyelitis: The infection can reach the bone beneath the nail, leading to osteomyelitis.

By Mercura Wang

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