The sun is out – and that means feet are out too.
The heavy boots and thick socks of winter have been swapped for sandals and flip flops, and suddenly toenails are on display.
And for many of my patients, that’s a problem. They look down, feel embarrassed, and come to my surgery asking what on earth can be done about their thickened, crusty, yellowing nails.
If that’s you, you are far from alone. About one in ten of us has a fungal toenail infection – and by the age of 70, it’s roughly half of all adults.
The culprit is usually a family of fungi called dermatophytes, the same bugs behind athlete’s foot. They invade the nail and the skin underneath it, and left untreated the nail becomes thickened, discoloured – often yellow, white or brown – brittle and, in some cases, painful.
So why do so many of us get it? Fungal nail infections become more common with age, as nails grow more slowly.
You’re also more at risk if you have a weakened immune system, poor circulation – perhaps due to diabetes – or a nail that’s been damaged in the past. And walking barefoot in communal areas such as gym changing rooms and swimming pools increases your exposure to the fungi in the first place.
But here’s the surprising bit: it’s often your footwear that triggers the problem.
About one in ten of us has a fungal toenail infection – and by the age of 70, it’s roughly half of all adults
Fungi thrive in warm, dark, moist environments – which makes the inside of your shoe the perfect breeding ground.
Synthetic trainers worn for hours on end, rubber-soled boots and tight shoes with no ventilation all trap the heat and sweat that fungi love. This is why Crocs – the plastic sandals – or other sandals are some of the best anti-fungi shoes, as they have holes that circulate air and evaporate sweat, so moisture doesn’t build up.
Your socks matter too. Synthetic sports fibres or merino wool pull sweat away from the skin so it can evaporate.
Cotton, on the other hand, acts like a sponge – absorbing moisture and holding on to it, leaving your feet constantly damp.
Change your socks daily (and no, that isn’t obvious advice to everyone), and try alternating your shoes so each pair gets 24 hours to dry out fully.
However, this advice only helps those who haven’t got the infection yet. So what do you do once your nails are crusty and yellow?
The good news is that antifungal nail lacquers, such as amorolfine, are available over the counter. But this is where most people go wrong – and I see the same mistakes again and again.
Take my patient Lucy. She noticed athlete’s foot – a scaly, itchy rash – between her toes a few months ago and didn’t treat it. A while later, her pharmacist diagnosed a fungal toenail infection and recommended an antifungal lacquer. She used it for a month, then came to see me complaining she’d wasted her money because it hadn’t worked.
Do you have any of these conditions?
The problem is that a month is not nearly enough time for the lacquer to take effect.
And it’s the most common reason I see for these treatments ‘failing’: people simply haven’t given them long enough.
The reason it takes so long to work is because toenails grow slowly – very slowly in fact.
Depending on the nail, it can take 12 to 18 months to grow out fully.
Amorolfine needs to be applied once or twice a week for at least nine to 12 months. The infected part of the nail may never look better – instead, crucially, treatment has worked if new, healthy nail grows in from the base.
There is a second mistake I also see. Patients not filing the nail first.
The lacquer has to penetrate the nail to reach the fungus underneath, and if the infection has made your nail thicker, the medicine simply can’t get through.
That’s why the packs come with disposable nail files. Patients are supposed to file the nail down every time before they apply the lacquer, or the treatment is far less likely to work.
The third mistake is Lucy’s original one: ignoring athlete’s foot. If you have a fungal infection on the skin of your feet, the same fungi may be causing both problems.
Treat the nail without treating the skin and you’ll simply reinfect yourself. Athlete’s foot creams are also available over-the-counter and should be used alongside the nail treatment.
If you’ve done all of this properly, for long enough, and it still hasn’t worked, see your GP.
We can send nail clippings to the lab to identify the fungus, and if appropriate prescribe potent terbinafine tablets.
These are more effective and work faster, but they can cause liver side effects, need monitoring, and aren’t suitable for everyone.
Laser therapy to burn away the fungus is also offered by some private podiatrists, but it can be expensive and have mixed results.
There are also alternative – and potentially effective – treatments that many patients might not have heard of.
There is some evidence that tea tree oil, applied undiluted to the affected nail twice daily after filing, might help – especially if the infection is caught early.
Again, it takes time, and it’s less likely to work on a longstanding or severe infection, though it can be used alongside antifungal nail lacquer.
GP, author and broadcaster Dr Philippa Kaye advises patients to act quickly if they spot a fungal toenail
Apple cider vinegar, on the other hand, is often promoted as a toenail fungus cure but has no good evidence to support it – save it for your salad.
One thing I’d urge you not to do is reach for the nail varnish. I understand the temptation to paint over the problem, but varnish traps moisture, stops antifungal treatments from penetrating the nail – and hides what’s going on underneath, which all may well be getting worse.
Instead, keep it simple. Dry your feet thoroughly after washing, including between the toes. Keep your toenails trimmed straight across. Don’t share towels, nail clippers or footwear as this can spread the infection.
And if you spot athlete’s foot, treat it promptly with an over-the-counter cream before it spreads to the nails.
And if you’ve only just spotted a fungal toenail? Start treatment now. The honest truth is that you probably won’t see the results this summer – but, if you follow these steps, you could well do by the time next year’s heatwaves roll around.
