Bottom Line/HEALTH: You may think that gross, yellow, deformed nails mean only that you can’t wear your sandals. But the truth is, when you have nail fungus, that actually affects your entire body, not just your feet. So here’s what you need to know about toenail fungus.

I’m Sarah Hiner, president of Bottom Line Publications, and this is our Conversations With the Experts, where we get the answers to your tough questions from our leading expert.

Today I’m talking to leading podiatrist and foot surgeon Dr. Johanna Youner, who is in private practice in New York City and a regular contributor to Bottom Line Publications. So welcome, Dr. Youner.

Dr. Johanna Youner: Thank you, Sarah. It’s great to be here.
Bottom Line:  Foot fungus. There is such an array of toenail fungus, and I’m even hesitant to show many pictures, because they go from “Eh, not so bad” to pretty darn gross. Let’s have an overview of what’s going on with nail fungus, and then we’re going to look at a couple of examples.
Dr. Youner: Foot fungus is when—well, toenail fungus is when the nail gets injured, and fungal material invades the nail and makes it thickened, unsightly, sometimes malodorous and painful, and it can be actually dangerous in diabetics.
Bottom Line:  Is it inevitable?
Dr. Youner:  Sixty percent of the population over the age of 60 does have it.
Bottom Line: Let’s look—we have an example up here of a relatively benign one. How bad a case of nail fungus is this?
Dr. Youner: This is a very mild case of fungus, and cases that are this mild can be treated much more easily than they could in the old days. The fungus will just worsen without treatment, so it does need treatment.
Bottom Line: This has a little bit of yellow and a little bit of white. Is that the first symptom of nail fungus?
Dr. Youner: The first symptom can be some white crumbly stuff below the nail, noticing some pain or discomfort or thickening in the corner. And on this toe particularly, the nail—it’s right where the toe hits the shoe. So this may be from either damage from a shoe, damage from a pedicurist…but this is very mild. The reason you seek treatment is because of pain, of unsightliness—you don’t want this to get any worse.
Bottom Line:  So this toe has a little bit of yellow and a little bit of white. Is that how toenail fungus starts?
Dr. Youner: Yes. Toenail fungus starts with a little bit of yellow, little bit of white, sometimes white crumbly stuff below the nail; sometimes just some pain and a thickening, or a nail that looks very different. Or you take your nail polish off and the nail looks completely different than when you put it on a month ago.
Bottom Line: I never heard of nail fungus being painful, actually.
Dr. Youner: The nail can thicken, and a thick nail with a pair of shoes can press the nail into the toe and create a situation.
Bottom Line: Are there any other symptoms?
Dr. Youner: There can be some malodor. There can be some different coloring on the nails, including black, brown, green—a plethora of colors.
Bottom Line: Plethora of disgusting colors. How about when you bruise a nail, and then it seems to make it a little bit worse?
Dr. Youner: People come into the office thinking that they have a scary problem when they bruise their nail, because the area below the nail will bleed and it will be black. That’s just dried blood, and it can be fixed very easily. But that does need to be fixed easily and without any pain, because any bruising, any hurting of the nail, can lead to toenail fungus.
Bottom Line:  Let’s talk about causes. What causes it?
Dr. Youner: Trauma. Trauma, age, disease. Getting older—we don’t have enough circulation going to the toenails. It allows the body’s resistance to go down…the fungus gets in. Trauma—if you run a lot, the toenail is literally pistoning against the end of the shoe. It will open up the nail…fungus will get in. Disease—if you’re diabetic, your sugar is high, it will allow the fungus to invade.
Bottom Line: Besides diabetics, is anybody more vulnerable to fungus than others?
Dr. Youner: Anybody who’s immunosuppressed. That can be anybody on steroids, HIV, any sort of medication that would suppress your immune system, would be more vulnerable.
Bottom Line: Is it true about nail salons?
Dr. Youner: Nail salons are much cleaner than they used to be. But if a nail salon technician is digging under your nail with a tool, you should stop that right there, because they may create a situation that was not there. About giving it to you, I don’t see that much evidence anymore of things like that. But a situation can be created.
Bottom Line: And how about public showers?
Dr. Youner: I see a lot of different types of infections transmitted in public showers, for sure. Warts.
Bottom Line: So the old adage about wearing flip-flops in showers really is true.
Dr. Youner: The adage about wearing flip-flops in showers can keep half my patients out of my office. I would say that 10% of young people present to the office with warts that they caught at a public pool, or athletes or just weekend warriors who go to the gym and don’t wear flip-flops and get athlete’s foot, warts, anything, from just stepping on the moisture in the shower. A shared shower—use bleach. Or wear flip-flops.
Bottom Line: Why is toenail fungus so hard to cure?
Dr. Youner: There’s not a lot of blood flow to the nail. As a matter of fact, there’s none, because nail is like hair, so it’s actually dead. The nail has to be cured from the base of the nail, literally by the cuticle.
Bottom Line: You get toenail fungus…but not as often hand fungus.
Dr. Youner: People can get fungal nails on their hands and on their feet. It’s much more difficult to get it on your hands because the fungus dies when it’s exposed to oxygen. So if it’s on your hands, it tends to be a little more obstinate. Your feet are in shoes in the winter; it’s dark, it’s moist. It’s the ideal environment to grow fungus.
Bottom Line: All right, let’s talk about treatment options. It is very difficult to treat, and you mentioned that a laser is what you find to be the most effective.
Dr. Youner: Yes. These days, lasers are FDA-approved for fungal nail treatments. Ten years ago, we would only be able to treat them with Lamisil pills—that’s a lot of medication to take to get rid of a situation that’s on the tip of your toenail. A laser will vaporize the fungal material with one treatment.
Bottom Line: Wow. That’s huge.
Dr. Youner: Yes, it’s huge. I do like to do a second laser treatment as a booster three months later. But also, getting rid of the fungus doesn’t always make the nail pretty. Sometimes the nail has been changed over years. People come in having these situations for 10 years or more. A laser treatment will eradicate the fungus, but the nail may not be perfect, so it’s best to get these things treated early.
Bottom Line: You mentioned Lamisil (I was given Nystatin at one point in my life), so these internal antifungal medications—don’t even bother with them?
Dr. Youner: It’s not don’t even bother. They’re very good and very effective treatments. If you have a very mild case, I would try other treatments—lasers, you can use topicals. I don’t think a very light topical will help a real situation. As an adjunct. If you have laser treatment, using a topical will help eradicate.
Bottom Line: I was just going to ask you about the topicals, because there’s all sorts in the drugstore, and then there’s tea tree oil, Clorox bleach, Vicks VapoRub—that whole world of things. Yes, no, maybe?
Dr. Youner: Yes, no, maybe. Maybe is the answer, because Clorox I find will treat nails better after I’ve lasered them. People get resistant to certain treatments. All of a sudden, the Clorox is working, somebody goes in a chlorinated pool, and their fungal nail that I’ve been working on for six months falls off—with no pain, because the fungus got disassociated from the toe because of chlorine. And it worked. And I’ve used medications, I’ve used lasers. One little ingredient of Clorox works. Using more homeopathic natural remedies, I’m not sure they’ll be as effective.
Bottom Line: So what’s the recipe for Clorox?
Dr. Youner: I like 1:10—one part Clorox to 10 parts water and a Q-tip.
Bottom Line: And you just rub it on?
Dr. Youner: Yeah. Just rub it on.
Bottom Line: How often?
Dr. Youner: Morning and night. Morning if you don’t remember, or night if you don’t remember in the morning. And just try to be consistent. It’ll allow the nail to grow out. It’s best in conjunction with another treatment—laser, even pills if you have a bad case.
Bottom Line: And even then, it’s still a long…
Dr. Youner: It takes 12 to 14 months for a nail to grow out.
Bottom Line: And you have to be diligent every day, putting this on.
Dr. Youner: It’s difficult.
Bottom Line: All right, so given how horrible it is once you have it, is there any prevention?
Dr. Youner: Prevention would be keeping your feet dry. If you’re somebody who has the tendency towards it, you may be somebody who sweats a lot. If that’s the case, use cornstarch in your shoes. Use cornstarch on your feet. Spray your feet with ARRID Extra Dry. Dry them out. Don’t create the situation, the climate, to make the fungal situation.
Bottom Line: And then as you said also, injuries on your feet.
Dr. Youner: Injuries. If you know that you’re going to get hurt, hiking every year or snowboarding in December, hiking in June, see the doctor a month later when you come back with your injury—not when your nail’s growing out and the nail is hanging by a thread or thickened or discolored or black with old blood. Get to the doctor soon.
Bottom Line: I also read that once you get it treated, you need to spray your shoes, or else you can reinfect from your shoes?
Dr. Youner: The fungus can stay living in the shoe for at least a year, so there are a lot of things on the market now—there are ultraviolet lights that work very well. SteriShoe sells an ultraviolet light. You can use Lysol spray. You need to clean your shoes as well, especially if it’s on all 10 nails.
Bottom Line: Thank you, Dr. Johanna Youner. The bottom line on toenail fungus? Treat it early and to prevent it, make sure that you wear shoes that minimize injury to your feet and keep your feet dry. This is Sarah Hiner with Bottom Line Publications.