OTC Nail Fungus Treatment vs. Rx: What Actually Works?

Nail fungus (onychomycosis) is a common problem, especially on toenails. An estimated 6 to 7 million people in the United States grapple with nail fungal infections, and about half of adults over age 70 develop them. A nail fungal infection can change the color of a nail, cause pain, and make the nail crumble, thicken, or lift up from the nail bed. 

Treating nail fungus properly is key because these infections usually don’t go away on their own. A nail fungal infection can become worse over time, spread, and potentially cause a secondary bacterial infection. Although nail fungus has a reputation for being difficult to treat, with the right treatment plan, infection is often treatable. Learn more about the nail fungus treatment options and how to choose the best one for your case.

Over-the-Counter vs. Prescription: Which Should You Consider?

Because nail fungus is such a common condition, there are a wide variety of over-the-counter treatment options available for it. These treatments are designed to treat mild cases, but typically are not strong enough to treat more serious or recurring cases of nail fungus.

Though over-the-counter treatments generally cost less than prescription treatments, consider the number of treatments needed as well when calculating the true costs. For example, nail fungus treated with an over-the-counter medication may require repeat treatments to remove the infection, or if it is not strong enough for your case of nail fungal infection, the infection may worsen over time. Read on to explore the factors to keep in mind when comparing OTC nail fungus treatment vs. prescription nail fungus treatment.

Over-the-Counter Options

Over-the-counter treatments are a topical liquid, gel, or cream. They usually contain a low-dose antifungal as the active ingredient, such as undecylenic acid, tolnaftate, or clotrimazole. However, these products are not FDA-approved to treat nail fungus and are primarily intended for fungal infections of the skin, such as athlete’s foot. Because most OTC antifungals do not penetrate the nail effectively, they are unlikely to treat an established nail infection on their own, particularly when the infection involves a large portion of the nail or extends deeper into the nail. 

Some people with mild nail fungus may still choose to use an OTC product, but prescription treatments are generally more appropriate for treating an established nail infection. Topical products containing urea or salicylic acid may also be used to soften and thin a thickened nail. This can make it easier to reduce or trim the affected nail and may help topical treatments reach the affected area more effectively. 

Prescription Options

Prescription fungal nail treatment usually comes in three forms: oral medication, topical liquid, and topical nail polish.

Oral medication is the best fungal nail treatment for severe fungus, with some experts calling oral treatment the “gold standard.” Oral antifungal medications enter the bloodstream, then stop the fungus from creating more ergosterol, which is a lipid that acts as a building block for fungal cells. The most common oral medications for nail fungus are terbinafine, itraconazole, and fluconazole.

Liquid topical prescription medications for nail fungus may be a better option for people who are concerned about taking a systemic medication and who have mild to moderate nail fungal infections. Common prescription topical solutions include efinaconazole and tavaborole. Another topical treatment option for milder cases of nail fungus is ciclopirox in its clear nail polish formulation.

Treatments For Severe Cases

The first line nail treatment for severe fungus is generally a prescription oral medication, but if this is not possible due to contraindications or allergies, these are other treatment options available:

• Nail debridement: Nail debridement describes removal of nail tissue that has a fungal infection. Nail debridement can include trimming the nails, scraping beneath them with a special tool, or using a file or grinder to remove thick and discolored nail portions. Nail debridement is a routine outpatient treatment. It is often used alongside topical treatments and may relieve pain caused by thickened or misshapen nails.
• Nail avulsion: A nail avulsion is most commonly a minor surgical procedure that goes beyond debridement and involves removing part or all of the nail from the nail bed. There is also a non-surgical nail avulsion technique that involves softening the infected nail with a special ointment until it can be removed from the nail bed. Nail avulsions may be required when an infection is severe and does not respond to other treatments.
• Nail matrixectomy: This procedure is more commonly used for ingrown toenails, but may be used when an infection is severe and hasn’t responded to other treatments. The first step of a matrixectomy is a nail avulsion to remove the entire nail. Then, the tissue that produces the nail is destroyed so the nail will not grow back.
• Laser and light therapy: Certain laser devices are FDA-cleared for the temporary improvement of nail appearance in patients with nail fungus. These treatments use focused light or heat energy and may be considered by patients who cannot take oral antifungal medications. However, laser and light therapies have not been established as a cure for nail fungus, and their effectiveness at eliminating the underlying infection is limited compared with standard antifungal treatments. 

When OTC May Be Enough – And When It’s Not

An over-the-counter treatment for nail fungus may be enough if you catch the infection early. But if the treatment doesn’t clear up the fungus or the fungus returns, a prescription-strength treatment may be needed. 

When To Bring In the Prescription Treatments 

If a fungal nail infection is moderate or severe, your best bet is beginning with a prescription antifungal nail treatment. Some experts recommend starting with an oral medication for nail fungus if more than half the nail looks infected, or more than three nails containing an infection. 

If there are bands or patches of thickened white or yellow spots on the nail, a prescription toenail fungus treatment, particularly an oral medication, is recommended. Topical treatments may not work in these cases, though sometimes a combination treatment of prescription oral and topical treatments are used together to tackle the issue.

Why Nail Fungus Is So Much Tougher Than Skin Fungus

Nail fungus is more difficult to treat than skin fungal infections, like jock itch and athlete’s foot. This is partly because topical antifungal treatments like creams and liquids can more easily penetrate the skin than they can a thick toenail or fingernail. The nails essentially provide a shield, so fungus can grow beneath and within the nail, where it’s hard for tropical treatments to reach.

Nail fungus is also often harder to treat because people don’t notice it right away, don’t treat it for long enough, or both. Nail fungus most commonly infects the toenails. Because many people wear shoes or socks a lot of the time, they may not often look at their toes closely and notice fungal infections early on, especially if they aren’t painful. Also, people often make the mistake of only using a topical treatment until the nail looks improved, when the infection might not actually be fully cleared up yet. An improved nail appearance does not necessarily mean the entire fungal infection has been treated.

Choosing a Nail Fungus Treatment

When choosing a nail fungus treatment, consider how long you’ve had a fungal infection, where it’s located, how severe it looks, and whether or not you’ve treated it in the past. Over-the-counter nail fungus treatments work best for mild cases of fungus that have recently appeared. Prescription treatments work best for moderate to severe cases, recurring infections, and fungus that has previously been treated unsuccessfully with an OTC solution.

If you decide to pursue a prescription fungal treatment, you’ll need to figure out which prescription options may work best for you. Oral treatments are generally the most effective, but they may not be ideal for those already taking medications that shouldn’t be combined with them. Your doctor can help you determine which medication or combination of medications to try. From there, you can fill your prescription through a traditional pharmacy or through a digital pharmacy platform like TelyRx. 

Why Your Nails May Look Different After Treatment

After you clear a fungal infection with treatment, your nails may still look unusual. For example, portions of your nails may look thicker, more brittle, or discolored compared to the nails that weren’t infected. Often, this change in appearance is the result of damage the infection did to the nail, and it will be gone once the damaged portion of the nail grows out.

In some cases, fungal infections damage the nail bed itself, and the changes to a nail’s appearance become permanent. The best way to prevent this permanent damage is to treat a nail fungal infection early, before it has time to become severe.

Your Next Steps

If you suspect you have a nail fungal infection, it’s important to take action fast. Most fungal infections do not go away on their own, so ignoring them isn’t a good idea. Prescription medications are the most effective treatment for nail fungus, and likely the only treatment that will work long-term if an infection is moderate or severe.

Talk to your doctor about your symptoms to see if a prescription antifungal is the best treatment for your nails. If you are prescribed medication, you can fill the prescription through a digital pharmacy platform like TelyRx, which provides fast shipping straight to your door.