Written by PPMA Member Tracey Vlahovic, DPM

Honestly, when I read any-thing about Vicks VapoRub (Proctor and Gamble) and onychomycosis, my “Myth-busters” mind gets activated. I can’t even count the times I have heard physicians and pa-tients extol the positives of this over-the-counter ointment. I understand the cost-benefit of using an easily attainable product, but I want evidence for or against it before recom-mending it.  

What are the components of Vicks VapoRub? Thymol, menthol, cam-phor, 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.  
The first clinical trial completed using Vicks VapoRub on mycot-ic nails is a pilot study that was performed by a Family Medicine group (1). Eighteen subjects 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 are normally done for topical antifun-gal studies. Unlike Phase 3 clinical trials for toenail onychomycosis, this study did not exclusively enroll patients who cultured dermato-phytes like T. rubrum or T. men-tagrophytes and did not limit the percent of affected nail to 50% or 60%. Instead, they allowed patients who cultured organisms like: “Fun-gal Elements”, Cryptococcus, Can-dida, Penicillium, and Fusarium and allowed up to 100% of the nail affected visually. Of the 18 patients, only nine subjects cultured either T. rubrum or T. mentagrophytes.  

Their results were the following: Five of the 18 (27.8%) had a my-cological and clinical cure, and 10 (55.6%) had “partial clearance”. But let’s dissect this further: if we were to look at the nine subjects who cultured the most common derma-tophytes causing onychomycosis, those who had T. rubrum fared the worst: Five had partial clearance (at times only a 10% change in the nail appearing clearer at week 48) and one had no change at all.  T. menta-grophytes infected toenails did the best with all three subjects going onto a complete cure, but a complete cure was not defined as 0% surface area affected—these patients still had 5% or more of the nail visually affected at 48 weeks. Of the other organisms involved, both subjects who had Candida parapsilosis went onto a complete cure, but Penicillium species and Candida albicans (one subject each) had no change. 

Ten of the 18 subjects had greater than 60% nail affected at the beginning of the study—with some having 89% or 100% affected nails. This is highly unusual for a toenail clinical trial, and certainly can be argued that a 48-week treatment period isn’t long enough to manage a totally dystrophic nail. Adding a modality such as nail debride-ment could be synergistic for a topical study that enrolls nails as involved as these.  

Did this study convince me to recommend Vicks Va-poRub 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 percent nail in-volvement, nail thickness, nail debridement, organisms cultured, and product use (some patients used it daily; some only 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 prop-erties, simply create a more hydrated nail unit that gives the appearance of a healthier nail.  

Reference:  
Derby R, Rohal P, Jackson C, et al. “Treatment of Onychomycosis using Mentholated Ointment,” J Am Board Fam Med 2011;24:69 –74.