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Q: I've had fungal infections of two of my toenails for 10 years. Over the last few years I have found treatment with Lamisil pills works, but the infections keep coming back. Any advice on how to get rid of this unsightly problem for good?

-- N.P., Amherst

A: Fungal infections are one of the most common problems. Almost everyone will have a fungal infection of the skin sometime. And it's estimated that as many as 10 percent of people have a fungal infection of the nails. Up to 50 percent of people over the age of 70 have this problem.

The medical term for nail fungus is onychomycosis. It may cause pain and discomfort, anxiety and embarrassment, and can lead to medical complications. It occurs when certain types of fungi invade the nail bed and nail plate (the area where new nail cells are formed).

It grows best when the circulation to the fingers or toes is compromised. Poor circulation can be caused by many diseases and also by smoking and caffeine intake.

Because only about half of nail problems are caused by fungus, diagnosis should be confirmed. Laboratory testing, by looking at scrapings under a microscope may be necessary to verify the diagnosis.

Fungal ointments are very effective on skin infections, especially when applied regularly for a full 10 days, not just until the symptoms go away. But nail fungus is one of the most stubborn medical conditions to treat effectively.

Physical removal of the nails may be required to cure some people. But this can be risky and expensive, and it may need to be repeated more than once.

A recent medical study showed that a prescription nail lacquer is fairly effective in treating nail fungus. Penlac Nail Lacquer, containing ciclopirox, cures about 50 percent of people when it's applied daily to infected nails for a year. Ciclopirox is also an ingredient of the antifungal cream Loprox. Although a small amount of the topical lacquer or cream is absorbed, side effects are limited to some inflammation of the areas where they are applied.

Fungal infection of the nails often requires treatment by oral medications. But it may take up to a year to work permanently. Terbinafine (Lamisil) and itraconazole (Sporanox) are now the drugs of choice.

These medications need to be taken over the time that the nail is growing out, which can take up to a year. Fortunately, recent studies have shown that intermittent pulse dosing (taking for one week, then not taking for two to three months) over a period of a year is as effective as continuous therapy, and more economical and convenient.

There are no medical studies evaluating the effectiveness or the side effects of using oral medications and topical ones at the same time. One of the biggest concerns in treating nail fungus is the risk of side effects from taking the medications. The oral medications can cause diarrhea, heartburn, rashes and elevated liver enzymes. Fortunately, these problems occur in less than 5 percent of people.

There is also a very small chance that these drugs will interact with other drugs to cause irregular heartbeats, so you need to talk with the prescribing doctor or pharmacist about this.

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