Several months ago, one of my family practice patients came to see me for his “toenail fungus problem.” The patient said to me, “Doc, I’ve tried all of these different things I’ve heard people say and nothing has worked. My neighbor told me a banana peel worked for her toes.” I looked down at his feet to see that he had wrapped a banana peel around all the toes on both feet, which he had secured with duct tape and rubber bands. He said he’d had this contraption on for a day so far, but was willing to do it for “several weeks if necessary.”
Topical Home Remedies Being Tried
As many of you have no doubt heard from your patients with toenail fungus, anecdotal reports abound regarding treatment results for this pesky nail condition.
One of the most common treatment ideas circulating in the general public and on the Internet is Vicks VapoRub. Other subjective reports say that tea tree oil applied faithfully will cure this condition as well. (I have one patient who swears that it cured hers after a year of applying it three times daily.) And there are still other non-proven recommendations out there, including banana peels, vinegar soaks, beer soaks, and even undiluted bleach soaks. Another patient would soak his feet in a basin of Listerine twice daily. Rubbing alcohol, 3% hydrogen peroxide, oil of bitter orange, and vitamin E capsules (broken to release the contents) are other topical home remedies that people are trying. There were also recent reports on the Internet advising daily oral intake of raw garlic cloves or grapefruit seed extract.
Evidence of Efficacy
So, do any of these alternative treatments have scientific merit?
The medical literature is sparse (at best) for well-designed studies examining non-conventional topical therapies for toenail onychomycosis, and the studies that have been done are not very recent.
A literature search of PubMed journals revealed only three alternative agents that have a small amount of clinical data behind them, including one focusing on Melaleuca alternifolia (tea tree) oil,1-2 vitamin E,3 and oil of bitter orange.4 No evidence for or against any of the other aforementioned modalities was identified.
Tea tree oil. Of these three topicals, tea tree oil is the only one with more than one clinical study done in an effort to assess its effectiveness in onychomycosis treatment. The two studies by Syed et al and Buck et al demonstrated a cure rate ranging from 0% to 11% with twice- and thrice-daily applications for 4 months.1-2 This poor rate, coupled with the cumbersome treatment regimen of 2 to 3 applications daily for many months, make this alternative treatment an unattractive option for most — especially now that low-cost generic terbinafine is available!
Vitamin E. The evidence for vitamin E is limited to a single case report in the Journal of the American Academy of Dermatology, which reported a patient who broke open a 400-IU vitamin E capsule over his affected toenails nightly for 6 months. This report states that the “results were dramatic,” and after 6 months, “there were no clinical traces of his former affliction.”3 Although this is an interesting report, the literature search revealed no further evidence on this potential topical treatment.
Oil of bitter orange (OBO) was studied in 60 patients with either tinea corporis, tinea cruris, or tinea pedis, but did not specifically investigate those with onychomycosis.4 The results were promising for those treated with OBO, showing clinical (not mycological) cure rates of 90% by the end of week 2 of a 4-week treatment period, while the control group (treated with an imidazole derivative cream) showed 80% clinical cure by the end of week 4. No further studies have extrapolated on this study to specifically look at onychomycosis.
Proven Therapies Available
As you can see, the evidence is inadequate regarding alternative therapies for onychomycosis. Therapies that have been heavily studied for onychomycosis include mechanical measures (i.e., debridement or surgical nail avulsion), chemical debridement, topical antifungal agents, systemic antifungal medication or a combination of any of these.5
Oral antifungal agents are the foundation of onychomycosis treatment and have a higher rate of cure than other forms of treatment. Complete cure rates range from 13% to 95% for oral antifungal agents5 to 0% to 89% for conventional topical therapies (i.e., ciclopirox).5
Why People Turn to Alternative Therapies
Up until recently, these medications have been expensive (and usually are not covered by insurance), and the oral antifungal agents have some risk of undesirable side effects. The oral antifungals also may interact with other medications patients may be on for diabetes, hyperlipidemia, or hypertension. Because of this, many patients with nail fungus are attracted to less-expensive, easily accessible, and natural options instead.
What to Tell Your Patients
As complementary and alternative medicine becomes increasingly popular in the United States, patients will be asking you about natural oral and topical therapies. Although the evidence so far for natural agents is limited, hopefully more studies will be done to explore various natural treatment options — either alone or in conjunction with proven, conventional therapies.
Keep in mind that toenail onychomycosis can recur at rates varying from 11% to 53% with either conventional oral or topical antifungal preparations.6-8 Although more research is needed concerning recurrences, advise your patients to follow some simple precautions in addition to whatever treatment — conventional or alternative — they choose:
• Keep feet as clean and dry as possible Wear waterproof sandals or flip-flops at swimming pools or other wet public areas.
• Clip toenails straight across and keep them shorter than tips of toes.
• Change socks or hosiery daily, or sooner if they are damp or wet.
THE MANY FACES OF ROSACEA
CME Critical Reviews of Clinical Data:
Fall Clinical Dermatology 2007
Acne Case Reports
2007 ADVANCES IN COSMETIC &
MEDICAL DERMATOLOGY
“MAUI DERM” CONFERENCE
July 2007 CME Supplement
2007 Winter Dermatology Conference Hawaii®
2006 4th Annual Fall Conference Supplemental Proceedings