Honestly, when I read anything about Vicks VapoRub (Procter and Gamble) and onychomycosis, my “mythbusters” mind activates. I can’t even count the times I have heard physicians and patients extol the positives of this over-the-counter ointment. I understand the cost benefit of using an easily attainable product but I want to see the evidence before recommending it.
What are the components of Vicks VapoRub? Thymol, menthol, camphor and oil of eucalyptus seem to be broad spectrum anti-infectives that have shown activity in vitro against Candida, Aspergillus and some dermatophytes.1 That said, in a recent literature search for a chapter I am writing on the myths of onychomycosis, I came across several articles on the use of the mentholated ointment for toenails, one of which was a clinical trial.1
The first clinical trial completed using Vicks VapoRub on mycotic nails was a pilot study by a family medicine group.1 Eighteen people who had nail disease completed the 48-week study. There are some positive aspects of this study but it did not follow all of the protocols that researchers normally do for topical antifungal studies. Unlike Phase 3 clinical trials for toenail onychomycosis, this study did not exclusively enroll patients who had cultures for dermatophytes like T. rubrum or T. mentagrophytes, and did not limit the percent of the affected nail to 50 or 60 percent.
Instead, the study authors included patients who cultured organisms like: “fungal elements,” Cryptococcus, Candida, Penicillium and Fusarium, and allowed people who had up to 100 percent of the nail affected visually.1 Of the 18 patients, only nine had cultures of either T. rubrum or T. mentagrophytes. The study authors found that five of the 18 patients (27.8 percent) had a mycological and clinical cure, and 10 (55.6 percent) had “partial clearance.”
Let’s dissect this further. If we were to look at the nine people who had cultures for the most common dermatophytes causing onychomycosis, those who had T. rubrum fared the worst. Five patients had partial clearance (at times only a 10 percent change in the nail appearing clearer at week 48) and one study participant had no change at all.1 T. mentagrophytes infected toenails did the best with all three patients going on to a complete cure but the authors did not define a complete cure as 0 percent of the surface area affected. These patients still had 5 percent or more of the nail visually affected at 48 weeks. In regard to the other organisms involved, both people who had Candida parapsilosis went onto a complete cure but there was no change for those who had Penicillium species and Candida albicans (one patient each).
Ten of the 18 patients had greater than 60 percent of the nail affected at the beginning of the study with some having 89 or 100 percent affected nails. This is highly unusual for a toenail clinical trial and one can certainly argue that a 48-week treatment period isn’t long enough to manage a nail that is totally dystrophic. Adding a modality such as nail debridement could be synergistic for a topical study that enrolls patients with nails as involved as these.
Did this study convince me to recommend Vicks VapoRub to my toenail onychomycosis patients? No.
While I think this study is a positive start in supporting or shattering the use of a mentholated ointment for mycotic nails, a study that controls the percentage of nail involvement, nail thickness, nail debridement, organisms cultured and product use — some patients used it daily while some only used it three to five times per week — while having a vehicle arm and a larger sample size would be more convincing to me. Time will tell if this ointment truly can eradicate fungus or, by virtue of its ointment properties, simply creates a more hydrated nail unit that gives the appearance of a healthier nail.
- Derby R, Rohal P, Jackson C, et al. Treatment of onychomycosis using mentholated ointment. J Am Board Fam Med. 2011;24(1):69–74.