For many Americans, slipping into sandals and baring one’s toes is a summer ritual right up there
with wearing sunscreen and a new swimsuit.

But a couple of summers ago, Nicole McLaughlin of Huntington Beach, Calif., hesitated to wear sandals. When she did, she kept her toenails covered with dark nail polish even when she would have wanted to wear a lighter shade or go without.

The big toe on her left foot had onychomycosis, better known as fungal nail infection. Millions of Americans — 2 percent-12 percent of the population — have this condition. For the 20-something McLaughlin the condition turned into more than just a minor inconvenience — her toe would hurt when she wore shoes.

Onychomycosis results in discoloration, thickening, loosening or deformity of the nails, which in turn makes wearing shoes or walking painful.

After much discussion with her dermatologist and podiatrist, McLaughlin tried one in a new generation of oral prescription medications designed to treat fungal nail infections.

Her big toenail started clearing up after McLaughlin took terbinafine (Lamisil) tablets for two months.

Terbinafine (Lamisil), itraconazole (Sporanox) and fluconazole (Diflucan) have proved more effective and less likely to produce side effects than traditional medications such as griseofulvin and ketoconazole, said Dr. Warren Joseph, associate professor of medicine and chief of infectious diseases at Temple University School of Podiatric Medicine in Philadelphia.

Terbinafine and itraconazole have been approved by the Food and Drug Administration for treating onychomycosis.

Several studies on the drugs show that 50 percent to 87 percent of patients got results from terbinafine, while itraconazole had a response rate of 50 percent to 82 percent. Too few studies have been conducted on fluconazole to get reliable response rates, Joseph said.

Some people experienced an improvement in their symptoms, while others were cured.

“Both drugs work well compared to earlier antifungals,” Joseph said. “They’ve given us an opportunity to try to treat or cure toenail fungus.

Previous drugs were not as effective, so doctors were hesitant to prescribe them. And debridement — cutting down the infected nail — didn’t address the problem. It made patients feel better and their nails look better, but the results were temporary. The fungus was still there.”

The most common side effects for both include gastrointestinal problems, nausea and headaches; in rare cases, some patients experienced liver complications. Doctors sometimes recommend a blood test to check on liver enzymes before prescribing the drug.

Cost, rather than side effects, might be a bigger deterring factor. A month’s supply for either medicine can cost $220-$250, and the generally recommended period of treatment is three months. Many insurance plans don’t cover fungal nail infections.

“Insurance companies don’t view it as important enough,” said Dr. Lynn Drake, chairwoman of the department of dermatology of the University of Oklahoma.

The perception by insurance companies, patients, primary-care physicians and even some specialists such as dermatologists and podiatrists that fungal nail infections are merely cosmetic nuisance could not be more erroneous, said Drake, who wrote studies on the effect of onychomycosis on the quality of people’s lives.

“I myself have been guilty of not taking the disease seriously before these studies,” she said.

And that needs to be changed.
Some of Drake’s findings: 30 percent to 40 percent of people had difficulty putting on shoes and/or standing, and experienced general discomfort; 15 percent had difficulty walking; and 50 percent experienced pain.

Patients lose about four working days a year. That makes it more than a cosmetic problem, Drake said.

They’re hesitant to wear sandals or go to the gym or beach. Their relationships can be affected. Some are afraid to date. Others are afraid to show their toes to their partner.

BOX:
WHAT DOCTORS ARE PRESCRIBING
Some insurance companies will cover a month’s supply of the latest prescription treatments for nail fungal infections. But podiatrists and dermatologists generally recommend taking the medicine for three months or more, so patients might have to shoulder the remaining cost.

Here is what doctors are prescribing:

Name: Lamisil (terbinafine)
Typical dosage: one tablet once a day for 12 weeks
Possible side effects: diarrhea, stomach cramping, headache, nausea, vomiting, skin rash or itching. Rare cases of liver problems have been reported.
Possible drug interactions: None known, but possible interaction with anti-depressants is being examined.
Estimated cost: $245 per month

Name: Sporanox (itraconazole)
Typical dosage: one capsule twice a day for one week a month for three months
Possible side effects: nausea, vomiting, diarrhea, headache, skin rash and edema. Rare cases of liver problems have been reported.
Possible drug interactions: It should not be taken with Halcion (triazolam), Versed (oral midazolam), Mevacor (lovastatin) and Zocor (simvastatin).
Estimated cost: $219-$233 per month