I have an ingrown toenail. It’s hurting less and the top is white. I do not want to go to a doctor. Is this ok? My mom said that I just have to keep cutting it and it will just work itself out. Is there any way I can prevent this in the future?

 I don’t think I need to get it dug out. I’m not just saying that, it hurts less. I was wondering, can I do the cotton ball thing with an ingrown toenail? My nail is (i think) in the process of growing out

My answer:

Hi Emma,

I wanted to do a write up about griseofulvin because it is the most used to treat ringworm in kids that need an oral treatment. 

Griseofulvin (Grifulvin) is the current prescription drug of choice.  Griseofulvin was first isolated  in 1938 and yet, over 70 years later, it continues to be first line of treatment.  Griseofulvin is available in microsize suspension and tablets (Grifulvin V) and ultramicrosize tablets (Gris-Peg).  It has been approved in children older than 2 years old.

Griseofulvin works by inhibiting fungal growth and helps protect new skin from being infected. This means it stops the fungal infection from progressing, allowing the infection to clear as the infected skin dies and sheds.  Because it does not kill the fungi, griseofulvin has a long length of therapy.  General ringworm of the body is usually treated for two to four weeks, whereas infections involving the head or feet can be treated for as long as four to 12 weeks.  Yes, that’s right, 2 to 3 months of  treatment.

Griseofulvin is typically given to children in the suspension form because it allows specific weight based dosing.  Both suspension and tablets are best absorbed when taken with a fatty meal.  Peanut butter or ice cream are recommended, which makes administering the medication a bit easier for parents J.  The ultramicrosize tablets may be crushed and mixed with 1 tablespoon of applesauce and taken right away without chewing.

Griseofulvin has a low incidence of serious side effects.  The most common adverse reaction is headache.  Also included are belly upset, oral thrush, sensitivity to sunlight and dizziness.  Rare but serious side effects include liver toxicity and decrease in white blood cells; these often disappear even with continuation of therapy.  Perhaps most interesting and pertinent is the estrogen-like effects that griseofulvin can cause in children.  Estrogen-like effects in children can include bloating, depression, headaches, thyroid interference and impaired blood sugar control- once again serious but rare.

Other antifungal medications used to treat ringworm are terbinafine (Lamisil), itraconzaole (Sporanox) and fluconazole (Diflucan).  These drugs appear to have similar efficacy as griseofulvin but with a shorter therapy cycle, typically four weeks.

It is imperative to treat ringworm in children.  If left untreated, bacterial infections and permanent hair loss can occur.  Griseofulvin remains the drug of choice for treatment of ringworm, however this is mostly based on old information.  Back in the day, griseofulvin was the only treatment option available in generic formulation and was therefore bumped to first in line due to price.  Nowadays, all of the medications have some dosage forms available in generic.  When discussing your child’s treatment plan with her physician, be sure to consider the length of treatment, dosage forms and price of the medications.

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Ringworm can occur anywhere on the body but typically involves the scalp, feet (athlete’s foot), and groin (jock itch).  Typically,  ringworm can be treated with over the counter medications but with more serious and widespread infections, prescription drugs may be needed.

OTC Antifungals:

Strongest OTC -use for 1 to 2 weeks:

1.  terbinafine (Lamisil AT)

2.  butenafine (Lotrimin Ultra) -this is the same medication as prescription Mentax but cost 5 times less!

Other OTC options -these work as well but need to be used for longer.  Use for 3-4 weeks:

3.  clotrimazole     

4.  miconazole          

Should I use the cream, solution, spray or powder?     Creams and solutions work best.  Solutions should be used for hairy parts of the body.

Important notes:

•  Apply the medication to the rash and 2 inches beyond the rash.  The infection area is usually larger then just the rash area.  
• Treat the rash for as long as advised -even if the skin looks okay. 
• Do not use any topical steroids (i.e. hydrocortisone).  Often, topical steroids can worsen the infection. 

Oral Prescription Drugs:

• These would be used to treat ringworm of the scalp, nails and extensive skin infections or when topical OTC medications fail.

1. terbinafine (Lamisil) the scalp, nails, extensive skin infections, and those that fail topicals.

2. itraconazole (Sporanox)

3. fluconazole (Diflucan)

4. griseofulvin (Gris-Peg)

So, there you have a quick rundown of your options!  If you have any specific questions, please leave us a comment!

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Want more info on -Boric Acid for Yeast Infections.

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When I lived in Miami, I had a regular patient (aka Janet) that would come in and talk with me about her dogs (my favorite subject!)   She had been in New York for a few weeks for work.  Before she had left for her trip, she had picked up a prescription for Diflucan (fluconazole)-a treatment for a yeast infection.

Janet came into the pharmacy and barely mentioned her new puppy (Charlie).  She seemed upset and irritated.  She was picking up another Diflucan prescription.  So, I asked her what was up. 

She was at wits end- she had been treating a yeast infection for about 2 months.  At first, she self treated with OTC medications then with her physician.  Janet’s physician gave her some prescription creams and then Diflucan.

Janet said she felt horrible and was super frustrated.  The on-going issue had even affected her relationship with her husband.     

Once we started talking, all of Janet’s concerns came flooding out…

We talked about how you get a yeast infection…

          All women naturally have a small amount of  yeast in the vagina.  The infection occurs when there is too much of the yeast.  This can happen anytime –it is usually caused by medications (like antibiotics), injury, stress or other sickness.

What the symptoms are…

          Symptoms range from none to swollen, red, itchy, irritated vaginal/vulvar tissues, discharge and odor –or any combination.

          Even once the infection is treated and cleared up (about 3-5 days) the symptoms can remain for up to 14 days –this is a problem because many women think that they still have an active infection.

How is it treated?…

          OTC vaginal creams and suppositories (such as Monistat) –they usually come in 1-day, 3-day and 7-day treatments.  Quite often the 1-day treatment is not quite enough to get rid of the infection.  I usually recommend a 3-day treatment for most women.

          Prescription vaginal creams and suppositories (like Gynazole) –these are not usually any better than the OTC creams.

Helpful Hint: Be careful –the creams can breakdown condoms and make them useless.

Diflucan (fluconazole) is a prescription oral medication.  Usually 1 tablet is taken once.  Sometimes, one tablet will be taken right away and then an additional tablet is taken 3 days after.  The tricky thing about the pill is that although it is often only one tablet, the symptoms still take about 3 days to go away (you can use an OTC cream to help). 

Helpful Hint: When you have a yeast infection, if you have vaginal sex –you can give it to your partner (not usually a big deal for him) but he can give it back to you (so you would be re-infected)! 

Boric acid vaginal suppositories –this is what Janet and I talked about mostly because she had already been through all the other options.  She wanted to know why it had to come down to some random treatment she had never even heard of.  There are three main reasons

1)    There are different kinds of yeast that can cause infections.  Most kinds of infections can be taken care of with typical treatments.  But there are some yeast infections that can ONLY be treated with boric acid.

2)    Sometimes the infection is not caused by yeast but by a bacteria…none of the anti-fungal will help but boric acid can treat yeast and bacteria.

3)    Sometimes, when a woman with a yeast infection uses a bunch of different treatments, the vagina just gets “unbalanced” –boric acid corrects the pH and kinda gives the vagina a “re-boot” back to baseline.

The regular dose is 600mg boric acid (in type 0 capsules) inserted vaginally at bedtime for 14 days.  They need to be compounded so –you need a prescription and a compounding pharmacy. 

Back to Janet- I printed out some info about boric acid that she could show her physician.  She had to go back up to New York for another month but she called a couple of times to update me on her progress –she said her doctor looked at her like she was crazy at first but after reading about it gave her the prescription. 

She then said it had been difficult to find a compounding pharmacy but eventually she got the suppositories and they had worked great for her.  She is all back to normal, her husband is doing fine and Charlie (the pup) is getting along with the other two dogs (Charlie did eat a pair of her heels J). 

So that is great…here is the funny part- a few weeks later, I had a woman come to the pharmacy and asked if we have boric acid.  I started talking to her about how it needs to be compounded with a specific capsule so that it will absorbed in the vagina because yadda yadda yadda…

Her face was frozen in confusion and a bit of fear…I stopped talking and she said, “I…uhhh….just wanted some boric acid powder,” pause while we both looked at each other puzzled.  She then continued, “You know…for cleaning.”

Boric acid for cleaning….who knew?! J

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While visiting with my Aunt Jan, she brought up her toenail fungus issue.  She was told about a medication that may work to get rid of the infection, but that it may be too dangerous for her considering her age. 

The medication she is talking about is called Lamisil (there is a generic for it called terbinafine), and it is the most effective drug out there to treat fungal infections on the toenail (It also works for fungal infections on the fingernails).  Lamisil, compared to the other medications available to treat toenail fungus, causes fewer interactions with other drugs.  

The reason there may be some concern about her safety is that Lamisil can damage the liver, and the older one gets, the more likely they will be to get this liver damage. 

With her case, since she has no prior history of liver problems and she doesn’t drink alcohol pretty much at all, her liver should be fine.  Lamisil should be avoided in kidney disease.   She did have fairly severe kidney stones (surgery was needed), but her kidney problem is long gone – she has a clean bill of health. 

I think, with her doctor watching over her, that she will be fine taking Lamisil.  This medication is generally taken once a day for 3 months straight.  Many doctors like to keep an eye on your liver by doing blood tests once a month during treatment. 

Be warned – if you do not take your Lamisil every day, there is a good chance it will not work to get rid of your toenail fungus.  You should also know that even with taking Lamisil, treatment failures are common and there is a 20 to 50% chance you will get the toenail fungus again…sorry dudes! 

I actually had a toenail fungus that I picked up from all those years of walking around the pool deck barefoot, and I treated it by taking Lamisil – it came back several years later.  I used Lamisil again, and the fungus has not come back as of yet.  I also drank quite a bit of alcohol while taking Lamisil and I lived to talk about it – I WOULD NOT RECOMMEND IT THOUGH (I could have been the lucky one!)

Also, there is no need to worry if your toenail fungus is not completely gone after the 3-month Lamisil treatment – it may take 9 to 12 months to be fully cured.

There are some over-the-counter nail polish type options (called a lacquer) to treat toenail fungal infections, but they are not very effective since the fungus is usually living in the bed of the nail – the nail polish doesn’t seem to get into the nail bed very well.  Only 1 out of 15 patients find success with the OTC med, but even then, it is common for the infection to come back after you stop the treatment.

Let me know if you have any questions about Lamisil or toenail fungus by e-mailing me at cate@getpharmacyadvice.com – I am the Lamisil guru for crying out loud (I have had two courses of it in my lifetime already)!       

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