Toenail Fungus / Athlete’s Foot

Fungus are organisms that commonly infect the skin. The majority of skin fungal infections are caused by a group of fungus known as dermatophytes. Certain yeast-like fungus including Candida and non-dermatophytic molds can also cause skin infections.

Fungal infections of the skin are generally self-limiting, yet they can cause a breakdown of the skin leading to secondary bacterial infections and therefore treatment is generally recommended.

Fungus lives in dark and moist environments making the toenails and skin of the feet more susceptible to these organisms.


Toenail Fungus (Onychomycosis)

Onychomycosis is the term used to describe fungal infection of the toenails. There are 4 commonly described types of toenail fungus including distal subungual, proximal subungual, white superficial, and Candidal.

  1. Distal subungual onychomycosis is the most common form of toenail fungus. In this type, fungus enters at the tip of the nail causing yellowing and loosening of the toenail from the nail bed. As the fungus works its way back towards the cuticle and nail matrix, the nail becomes thickened and can fall off
  2. With proximal subungual onychomycosis, fungus enters the proximal aspect of the nail at the cuticle and nail matrix resulting in loosening and thickening of the proximal nail. The loosened nail can eventually fall off
  3. White superficial onychomycosis is characterized by white and brittle nails with a powdery and chalky consistency
  4. The yeast-like fungus Candida albicans causes candidal onychomycosis. This condition involves the entire toenail plate and generally results in significant destruction of the nail


  1. Yellow nails
  2. Thickened nails
  3. Misshapen or dystrophic nails
  4. Whitening or scaling of the nails
  5. Brittle nails
  6. Hard nails that are especially difficult to cut
  7. Painful nails
  8. In certain circumstances, fungal nails can cause infection of the underlying nail bed and this is characterized by redness, swelling, pain, warmth, drainage, odor, bleeding, and loss of function
  9. Fungal nails can also cause ingrown nails characterized by pain along the border of the toenail


Diagnosis is typically made by clinical exam of the nails by Dr. Stewart. Diagnostic studies including KOH, PAS stain, and fungal cultures are frequently utilized to confirm the diagnosis.


Although toenail fungus itself is a benign condition, it poses a risk factor for secondary infection and it also can result in pain. Additionally, many people find toenail fungus cosmetically displeasing and embarrassing and would like to eliminate it. Toenail fungus can be difficult to treat.

Treatment for toenail fungus includes:

  1. Lasers utilize heat energy to destroy the fungus embedded in the nail and are approximately 85-90% effective in treating toenail fungus. There are no known side-effects of lasers and there are no known contra-indications to treatment
  2. Most topical medications are approximately 10% effective in treating toenail fungus. Dr. Stewart describes these medications as management tools to control the fungal load and to make the nails easier to cut
  3. Lamisil (Terbinafine) is an oral mediction used to treat toenail fungus. It is approximately 50-70% effective and it is taken over the course of 3 months. Patients undergo blood tests to test for liver dysfunction as this is a possible side effect of the medication. The medication is contra-indicated with certain medical conditions and cannot be taken in conjunction with certain medications
  4. Nail debridement (reduction in thickness and length) performed by Dr. Stewart is recommended for painful and thickened toenails. Patients should not attempt to cut thickened or hard nails on their own without professional assistance or guidance to prevent injury and infection to the toenail and surrounding tissue
  5. Patients treated with laser or Lamisil should be started on anti-fungal creams indefinitely to prevent recurrence of the toenail fungus in the event of a cure

Skin Fungus (Athlete’s Foot)

Tinea pedis is the term used to describe a fungal infection of the skin on the feet. This type of fungal infection is commonly referred to as athlete’s foot. There are 4 commonly described types of tinea pedis including acute vesicular, acute ulcerative, chronic papulosquamous, and interdigital.

  1. Acute vesicular tinea pedis, which is common along the arch of the foot, typically has vesicles or blisters that drain serous or clear fluid. This frequently causes itching
  2. Acute ulcerative tinea pedis generally affects a large portion of the foot and is characterized by an odor, clear or serous drainage, and sloughing of the top layer of skin.
  3. Chronic papulosquamous tinea pedis, commonly referred to as moccasin-type tinea pedis, generally occurs on the bottom of the foot and has characteristics of dry and scaling skin
  4. Scaling and/or maceration between the toes characterize interdigital tinea pedis


  1. Dry and scaling skin
  2. Itching
  3. Burning
  4. Wetness or maceration
  5. Blistering
  6. Redness
  7. Raw skin


Diagnosis is typically made by clinical exam of the skin by Dr. Stewart. Diagnostic studies including KOH, PAS stain, and fungal cultures are available when needed.


Skin fungus generally responds to topical medication, but in some cases oral medications are required.

Treatment for skin fungus includes:

  1. Topical medications including and not limited econazole, Loprox, or Lamisil
  2. Medicated baby powder, Drysol, and in advanced cases Botox injections to control perspiration
  3. Soaks with Domeboro solution help to dry out the feet are useful when treating acute vesicular, acute ulcerative, and interdigital tinea pedis
  4. In advanced cases, oral medications including and not limited to Lamisil or Griseofulvin
  5. Avoidance of barefoot walking in public settings such as gym lockers or around swimming pools
  6. Proper foot hygiene including daily foot cleansing, daily sock changes, and disposal of old shoes

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