Nail fungus: What helps, how to recognize it?

Nail fungus: What helps, how to recognize it?

Nail fungus: short overview

  • Treatment: long-term and consistent treatment with anti-fungal agents (antimycotics) as nail varnishes, creams or pencils, if necessary also in tablet form. Furthermore laser therapy, in severe cases possibly surgical nail removal
  • Typical symptoms: Depending on the type of fungus, discoloration of the edge or the nail root, complete discoloration or spots, thickening and dissolving of the nail structure or splintering of the upper layers. Often also pain, reddening of the nail fold, inflammation of the nail bed.
  • Causes: Infection via shared towels, carpets, beds; damp environment in closed shoes (“sweaty feet”), use of shared showers (sauna, sports club, swimming pool), metabolic and immune diseases (e.g. diabetes mellitus, HIV infection), circulatory disorders, smoking
  • Diagnostics: Medical consultation and physical examination, microscopic and infectiological examination (fungal culture) of a sample of the diseased nail
  • Prognosis: good chance of recovery if long-term treatment is started early and carried out consistently

Nail fungus: treatment

The treatment of nail mycosis depends mainly on the type and severity of the symptoms. Local treatment is recommended at all stages of nail fungus. An anti-fungal nail polish is considered to be most effective here because it penetrates well into the nail tissue.

In the following table you will find an overview of the most important methods and remedies against nail mycosis. Before treatment, it can be useful to gently remove infected nail material. For this purpose, a urea ointment is usually applied once a day, which softens the horn substance of the nail. It can be carefully scraped off.

However, a self-treatment of nail fungus should not be carried out if the nail is already very strongly affected by the fungus. In such cases the doctor often prescribes additional tablets against the infection.


Method/means Application, advantages and disadvantages Notes
Anti-fungal nail polish (water soluble) – uncomplicated and fast application

– must be applied once a day

– after application, the nail must not be in contact with water for 6 hours

– after the 6 hours, paint residues can simply be washed off with water

– Anti-fungal active ingredient Ciclopirox also acts antibacterial and anti-inflammatory

Active substance: Ciclopirox;

obtainable without a prescription

never use cosmetic nail polish at the same time!

Anti-fungal nail polish (waterproof) – uncomplicated and fast application

– Active ingredient Amorolfin: apply once or twice a week

– Active ingredient Ciclopirox: in the 1st month apply every 2nd day, in the 2nd month at least twice a week, in the 3rd month at least once a week

– Varnish residues can only be removed with alcohol or nail polish remover

– Ciclopirox also has antibacterial and anti-inflammatory effects, Amorolfin does not

Active substance: Ciclopirox or Amorolfin;

obtainable without a prescription

never use cosmetic nail polish at the same time!

Anti-fungal cream/ ointment – contains the active ingredient bifonazole (and sometimes urea): is applied once a day (duration: several weeks)

– in any case, pre-treatment with urea ointment makes sense (to remove the nail)

– Bifonazole also acts antibacterial and anti-inflammatory

suitable for thickened nails and fungal infections under the nail plate;

obtainable without a prescription

Nail fungus pen – uncomplicated and fast application

– apply once or twice a day depending on the product

different active ingredients;

obtainable without a prescription

never use cosmetic nail polish at the same time!

Tablets with Terbinafine – Consecutive intake every day or with treatment breaks (e.g. intake for 1 week, then 3 weeks break)

– Application period: max. 4 months

– fewer interactions with other drugs than itraconazole and fluconazole, therefore especially suitable for elderly patients

Standard remedy against dermatophytes (most common nail fungus pathogens);

available only on prescription

Tablets with Itraconazole – Consecutive intake every day or with treatment breaks (e.g. intake for 1 week, then 3 weeks break)

– Application period: max. 3 months

– numerous interactions with other drugs possible

helps against special nail fungus pathogens, against which Terbinafine and Fluconazole are not effective

available only on prescription

Tablets with Fluconazole – Intake once a week

– Application period: 6 to 12 months

– less effective than Terbinafine and Itraconazole, but well tolerated, therefore especially suitable for children

– numerous interactions with other drugs possible

Used when other active ingredients do not help or may not be taken.

available only on prescription

surgical nail removal – fast result, but not more promising than other treatments

– high risk of relapse

– often pain and temporary incapacity to work after the operation

It’s hardly ever done anymore. More gentle is the nail removal with urea ointment.
Laser treatment – hardly any side effects, uncomplicated and effective

– expensive and only available in a few dermatological practices

Public health insurance companies do not pay for laser treatment. Private insurers demand proof of medical necessity.



Prevention tips: Through proper hygiene! For example, you should wash your socks at a minimum of 60°C. You treat the shoes with special sprays from the pharmacy or drugstore. An important trick in the application: After spraying, store the shoes overnight in a plastic bag. That’ll work better.

How is the therapy? – the therapy is lengthy. Nail mycosis usually develops from athlete’s foot. So protect yourself from athlete’s foot! Never run barefoot in public sports facilities or changing rooms. Dry your feet well after showering – a hairdryer can be helpful here. And: You can treat your feet with special disinfectants as a precaution after visiting a public institution.

How to cure it: It depends on the strength of the infestation. If less than 40 percent of the nails are affected, good results can usually be achieved with anti-fungal nail polishes or creams. For larger infestations only tablet therapy or laser treatment can help. However, the general rule is that a nail grows very slowly and therefore the treatment takes time. This can be up to 15 months. Have a little patience!

Anti-fungal nail polish, cream and stick

A local nail fungus treatment with anti-fungal nail polish, cream or pencil can be carried out by each patient independently at home. In mild cases, this self-treatment may be sufficient, that is, if:

  • only one nail is affected,
  • a maximum of half of the nail surface is affected and
  • the nail root (nail matrix) is not infected (this is the area where the nail plate is formed)

If you are unsure whether these points apply to you, you should ask a doctor or medical chiropodist (podiatrist) for advice.

Anti-fungal nail polish, cream and stick are an uncomplicated help for fungal nails. However, they must be used until the fungus is safely killed. Recognizing this is not easy for laypersons. Then the same applies here: When in doubt, consult a doctor!

Nail fungus treatment with tablets

Go to the doctor if an independent nail fungus treatment does not lead to success or many nails or larger nail surfaces are affected. The local nail mycosis therapy must then usually be supplemented by a systemic therapy – i.e. by taking antimycotically effective tablets that work from the inside out and throughout the body.

When selecting a suitable active substance (Terbinafine, Itraconazole, Fluconazole), the doctor takes the exact type of pathogen and other factors into account. For example, women in pregnancy should not take Terbinafine if possible, even if this is the most suitable active substance against filamentous fungi (the most common pathogens of nail mycosis). Instead, the doctor may prescribe for example clotrimazole or miconazole.

Older patients, on the other hand, should preferably be treated with Terbinafine. The risk of interaction with other drugs is much lower with this active substance than with itraconazole and fluconazole. This is particularly important for older people because they usually have to take several different medications (such as blood pressure medication).

Patients should also conscientiously inform the doctor about any possible illnesses and health complaints. This is because some antimycotics must not be given at all for certain diseases, for example Terbinafine for liver dysfunction.

Nail fungus treatment by surgery

In the past, the question “What to do in case of nail fungus in severe/hard cases” was often answered with the possibility of surgical nail removal. However, due to the side effects (such as pain) and the high risk of relapse, this procedure is rarely performed today. In addition, the surgical removal of diseased nails in nail mycosis treatment is not more likely to be successful than other methods.

Nail fungus treatment by laser

A new treatment option for nail mycosis is the irradiation with laser. In several sessions this can kill the fungal infection, even if you do not know exactly how it works.

Another advantage of laser therapy for nail mycosis is that it causes hardly any side effects if carried out correctly. Patients report at most a feeling of warmth or slight stinging in the irradiated toes.

However, the laser treatment of a nail fungus infection is very expensive and is not paid for by the statutory health insurance companies.

You can find out more about laser therapy for onychomycosis in the article Nail fungus laser.

Nail fungus: Homeopathy

Many affected persons ask themselves the question “What helps against nail fungus besides conventional medicine? They want to treat onychomycosis with alternative healing methods. Thus some trust in essential oils or Schuessler salts. Others still rely on homeopathy. Nail fungus is however rather rarely treated exclusively by alternative medicine. Instead, alternative healing methods are often used to accompany conventional medical treatment.

By the way: When asked “What helps with nail fungus?”, homeopaths mention remedies such as Acidum hydrofluoricum, Silicea, Antimonium crudum or Sepia. Aromatherapy uses the essential oils of Eucalyptus globulus, Origanum vulgare or Thymus vulgaris (chemotype thymol). No. 5 Potassium phosphoricum and No. 8 Sodium chloratum are considered suitable Schuessler salts against nail fungus. Which remedy is most suitable in the individual case should be discussed with an experienced therapist.

Nail fungus: household remedy

“Better natural than chemical” is what many people think and prefer home remedies in the fight against nail fungus. Applications include vinegar or acetic acid, lemon, marigold and aloe vera as well as tea tree oil. Such natural remedies are considered to be gentle help against the fungal infection. They are mainly used externally directly on the diseased nail.

However, it has not yet been scientifically proven that vinegar, tea tree oil & Co. are really effective against nail mycosis. Some doctors advise against it. At the very least, however, household remedies should not be used as a substitute but only as an accompaniment to orthodox medical treatment.

You can read more about the use of home remedies for fungal infections of the nails in the article Nail fungus home remedies.

Nail fungus: Symptoms

In general, nail fungus can affect fingernails and/or toenails. However, the latter are affected much more frequently. There are two reasons for this:

On the one hand, the feet are exposed to greater mechanical stress. This tends to result in tiny injuries that serve as entry points for fungi (and other pathogens). On the other hand, mushrooms love a warm and humid environment, and this is more likely to be found on the feet, for example when walking barefoot in the swimming pool or in communal showers, or when feet sweat in closed shoes.

The nail fungus often grows on the big toe, but it can also attack one of the other toes or spread over several nails. In severe cases all nails of a foot or hand are affected.

The nail mycosis symptoms vary with the different forms of onychomycosis as described below. However, the following applies to all of them: If the infection is not treated or is treated too late, the whole nail can be affected by the fungus and completely destroyed by it (total dystrophic onychomycosis).

Distolateral subungual onychomycosis (DSO)

The majority of all patients show this type of nail fungus. The pathogen is usually the filamentous trichophyton rubrum. It penetrates at the free (distal) end of the nail under the nail plate and spreads out towards the nail root on the underside of the plate. In the course of the disease, this typically results in the following nail mycosis symptoms (without treatment):

At first the nail plate looks dull and lackluster, before it turns white-yellowish. Further symptoms (pain etc.) are usually absent in this phase of nail fungus.

Due to excessive hornification under the nail plate (subungual hyperkeratosis), the nail gradually thickens and begins to separate from the nail bed. In some patients, the thickened nail plate can painfully press on the sensitive nail bed underneath. This can be particularly noticeable when wearing tight shoes and when walking.

There is also the risk that (in addition to nail fungus) bacteria will settle in the damaged tissue and cause nail bed inflammation. Pain is then also possible, and the entire nail is very sensitive to pressure.

Eventually the affected nail becomes cracked, brittle and crumbly.

Proximal Subungual Onychomycosis (PSO)

This form of nail fungus is also usually caused by the filamentous fungus Trichophyton rubrum. It penetrates the nail wall, where the nail grows out, through the skin into the nail plate and the nail bed. The nail shows a whitish discoloration and cloudiness. This onychomycosis occurs almost exclusively in people with a weakened immune system.

White superficial onychomycosis (WSO)

This nail mycosis is also called Leukonychia trichophytica. The trigger is usually the filamentous fungus Trichophyton interdigitale (T. mentagrophytes). It penetrates directly into the surface of the nail plate. As a result, white spots form in the nail.

Onychia et Paronychia candidosa (Candida paronychia)

The proximal nail wall (where the nail grows out) and later also the lateral nail wall are chronically inflamed by an infection with yeast fungi (mostly Candida albicans). Typical nail fungus symptoms here are a redness and swelling of the nail wall.

Later the nail plate discolours in the edge area where the nail grows out and on the sides. The colour varies from yellowish to brownish to greenish depending on an additional bacterial infection. Without treatment, the fungus also spreads to the nail matrix and nail bed.

This nail mycosis develops preferentially on the fingernails of people who often work with their hands in damp or wet environments.

Edonyx onychomycosis

For this very rare form of nail mycosis, mostly filamentous fungi of the genus Trichophyton are responsible. They penetrate directly between the layers of the nail plate and spread inside. The lustreless, whitish nail plate splinters open thereby lamellarly. The nail bed usually remains intact with this nail mycosis. Furthermore, there is no thickening and detachment of the nail plate from the nail bed.

Nail fungus: Causes and risk factors

Nail fungus mostly caused by filamentous fungi (dermatophytes). Sometimes moulds or yeast fungi are also responsible for the infection. The latter mainly affect the fingernails.

In principle, the fungi can attack all horny areas of the body (skin, nails and hair). They feed there on the main component keratin.

Is nail fungus contagious?

The nail fungus comes to the skin through fungal spores. Spores are microscopically small particles of the fungus, which can survive for a very long time and are used for spreading. The most common transmission path is from person to person.

In addition, fungal spores can also be transmitted to humans from contaminated objects. This includes, for example, towels, bath mats, carpets and beds.

Risk factors for nail mycosis

Mushrooms prefer to grow in warm and humid places – for example, on sweaty feet, especially if they are in shoes from which heat and moisture can hardly be dissipated to the outside. The resulting heat and moisture accumulation promotes fungal growth.

The same applies if you do not clean and dry the toe spaces properly. This is especially true for people who have a physical disability or, for example, a plaster leg. You can get foot and nail fungus more easily. Incidentally, experts suspect that nail fungus on the feet often develops as a result of a mycosis pedis infection. Many people suffer from both infections at the same time.

Other factors that could favour nail mycosis on the feet are

  • frequent contact with nail fungus pathogens, for example in the swimming pool, in shared showers or in the sauna
  • Nail injuries
  • certain skin diseases like psoriasis
  • Circulatory disorders in the legs, for example due to diabetes, peripheral arterial occlusive disease (PAD) or smoking
  • weakened immune system, for example in some diseases (such as HIV) or when taking drugs that suppress the immune system (such as cortisone)
  • family predisposition

By the way: diabetics are also more susceptible to fungal diseases because of the high amount of sugar in the blood – the sugar serves as food for the fungi.

People who often have damp/wet hands during their work are particularly susceptible to nail fungus on their hands. This includes cleaning staff, for example.

As general risk factors for nail fungus (and also skin fungus), vitamin deficiencies (vitamins A, B1, B2 and K) as well as deficiencies of zinc and folic acid are also suspected.

Nail fungus: examinations and diagnosis

The first contact person for the clarification of nail mycosis is the family doctor. You can also consult a dermatologist (skin specialist).

Collection of the medical history

The doctor will first take the medical history (anamnesis). He will ask you about your symptoms, possible underlying diseases and other factors that are important for the diagnosis. Possible questions are, for example:

  • Since when do the nail changes (thickening, discoloration) exist?
  • Do you have any known chronic diseases (such as diabetes or psoriasis)?
  • What do you do for a living?
  • Does anyone in your family have or had a fungal infection?

Physical examination

The interview is followed by a physical examination: the doctor examines the affected nails and surrounding tissue. Thickened, discoloured nail plates are often a clear indication of nail fungus. However, there are also other possible explanations for supposed nail fungus symptoms, which the doctor must exclude (differential diagnosis):

Psoriasis can extend to the nails and look like a fungus (nail psoriasis). In addition, nail involvement may occur in skin eczema (“eczema nail”) and other skin diseases such as nodular lichen (Lichen ruber planus), which can resemble a fungal infection.

In people with chronic varicose veins, the toenails are often thickened and have a grey-greenish discoloration. This can also fake a nail mycosis. The same applies to nail injuries such as bruising and bruising of the nail.

Further differential diagnoses are rare chronic nail changes, which develop for example with circulatory disorders, thyroid diseases, iron, calcium or vitamin deficiency.

Detection of nail mycosis pathogens

A nail fungus test helps the doctor to clarify the nail changes: he disinfects the affected nail with alcohol and then scrapes something off the nail plate. He can stain the tiny nail shavings with a special dye and examine them under the microscope for fungal spores. If he finds any, it’s a sign of nail fungus.

Under the microscope it is not possible to identify the type of fungus. However, the doctor must know this if he wants to prescribe anti-nail fungus tablets to the patient. Depending on the type of pathogen, certain active ingredients are more suitable than others. To identify the exact type of pathogen, it is cultivated from the tissue sample in the laboratory (fungal culture). That takes three to four weeks.

However, if the nail fungus is very pronounced, the doctor can start an antimycotic therapy beforehand with an active substance that is effective against a whole range of fungi (broad-spectrum antimycotic).

In rare cases, other tests are performed for nail fungus. For example, the nail tissue can be examined more precisely (histologically) in the laboratory.

What you should consider before consulting a doctor

In order for the doctor to make the correct diagnosis if nail fungus is suspected, you should not wear coloured nail polish during the examination.

If you have already tried a local nail fungus treatment in advance (e.g. with anti-fungal nail polish), you should have finished this two to four weeks before the doctor’s visit. Otherwise, the result of the fungal culture can be erroneously negative due to possible residues of active ingredients on the nail.

Nail mycosis: course of disease and prognosis

Nail fungus does not heal by itself, but must be treated. The following applies: The earlier nail fungus is treated, the better. In the early stages it is usually painless and easier to treat.

On the other hand, advanced nail mycosis can cause considerable pain, for example when wearing shoes or walking, as well as through the ingrowth of deformed nails. The skin around the nail or the nail bed can become inflamed. In addition, the nail fungus can develop into athlete’s foot or skin fungus, which spreads even further.

If the fingernails are affected by the fungal infection, the fingertip sensitivity can change so that fine motor skills are impaired.

Last but not least, nail fungus is an aesthetic problem that can put a great deal of psychological strain on those affected. That is why it is absolutely necessary to treat it at an early stage.

Keep up the therapy at all costs!

A nail fungus treatment is lengthy and requires a lot of patience and consistency from the affected persons. Even in mild cases, it extends over weeks to months. In severe cases, nail fungus therapy lasts up to a year or more. The reason: the diseased part of the nail must first have grown out completely before the patient is considered cured. However, some patients discontinue antimycotic treatment at an early stage when no more infestation is visible. However, part of the nail plate may still be infected. Starting from these places, the nail fungus can spread again and again to healthy areas.

By the way: With infected fingernails the treatment usually leads to success faster than with toenails.

Prevent nail fungus

A nail fungus can be prevented. Although the fungal spores are found everywhere in our environment, the fungi feel especially comfortable in warm and humid surroundings. The most important measure is therefore to remove the breeding ground from it.

Correct footwear

You should wear as few closed shoes as possible (like sneakers) in which your feet sweat a lot. Instead, prefer more breathable shoes (such as sandals or light low shoes). Do not wear wet or damp shoes.

You should air out your shoes well after each use. If you have perspired heavily, stuff your shoes with paper after wearing them and let them dry out completely. You can also disinfect the shoes regularly.

Do not walk around barefoot in public swimming pools, sauna facilities, solariums and changing rooms.

Socks and stockings

When choosing socks, you should prefer materials such as wool, cotton or cotton blends and avoid synthetic materials. Change your socks daily, or if you sweat a lot, several times a day. Furthermore, shoes and socks should never be shared with other people to avoid the transmission of nail fungus in this way.

Correct foot care

After washing and bathing you should dry your feet well before putting on socks and shoes. Pay particular attention to the spaces between the toes when drying off!

Regular and thorough foot care is especially important for people who are particularly susceptible to nail mycosis. These include, for example, diabetics and people with immune deficiency, but also athletes and senior citizens. It is often useful to visit a medical chiropodist (podiatrist) regularly.

Change and wash your clothes properly

Towels and bed linen should be changed regularly. If you already have nail fungus, you should even change the towel daily – just like socks and stockings. Wash them as well as shower mats at a minimum of 60 degrees Celsius. Use heavy-duty detergent or special detergents that kill fungal spores. These are available in pharmacies and drugstores.

For nail mycosis patients: Prevent spread

People with nail fungus should not walk barefoot, both outside and inside the house, in order not to spread the robust fungal spores in the environment and thus possibly infect other people.

People with nail fungus should wear socks when sleeping. In this way, they can prevent the fungal spores from spreading in bed and possibly reaching other parts of the body or the partner and causing a new infection.

Sandra Eades

Hello I am Sandra Eades, physician, researcher and author from Australia. I am working currently as researcher for a private institution. I have studied in Britain and Australia, where I currently reside. I write about research topics in the organization of the public health government agencies. For the iMS I write about general medical conditions. I also research scholar sources to provide information to writers of other articles. I also check the citations of scholar papers. Finally, I read other articles before they are published. I am also a mother of three children!

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