Onychomycosis starts as a yellow or white spot beneath the tip of the fingernail or toenail. Onychomycosis slowly extends deeper into the nail and changes the color of the nail. Disease is observed in 10% of general population.1 Continuation of infection thickens the nail, which is followed by crumbling or deterioration of edges of the nail. Most of the patients are embarrassed because of the discoloration and changes in texture of nail. Onychomycosis is difficult disease to treat. Chances of recurrence are very high.
Causes of Onychomycosis
- Fungus belonging to a category of fungi known as dermatophytes is commonly responsible for Onychomycosis.1
- Fungi are the microscopic organisms, which can survive without sunlight.
- Some fungi are beneficial, whereas, some are harmful and cause infection or illness.
- Fungi live in moist warm environments, such as swimming pools, bath and shower rooms.
- Fungus can enter the skin through any minor cuts or injuries, such as separation of the nail and nail bed.
- Continuous exposure of the nails to moist and warm environment causes the ideal environment for spread and growth of fungi.
- Toenails are more prone to having Onychomycosis than fingernails.
- Toes are enclosed in warm, dark and moist environment inside the shoes creating a thriving environment for fungi.
- The blood circulation to the toes is also lesser when compared to the fingers making it harder for the immune system to identify and fight fungal infection.
Risk Factors For Onychomycosis
- Elderly are at high risk because of atherosclerotic diseases and decreased circulation of peripheral tissue.
- Elderly are prone to increased exposure to fungi, slow growth and thickening of the nails.
- Men are at an increased risk for Onychomycosis.
- Family History-
- Onychomycosis is often seen in among family members.
- History of Perspiration-
- Individual with history of heavy perspiration often suffer with Onychomycosis.
- Tight Fitting Shoes-
- Wearing tight shoes and socks restricts ventilation and restrict absorption of perspiration which increases the risk for developing Onychomycosis
- Skin Disease-
- Fungal infection of nail is observed in psoriasis and athlete foot.
- Skin Exposure In Public Places-
- Individuals who walk barefoot in moist public places like gyms, swimming pools, shower rooms etc. are at an increased risk for developing Onychomycosis.
- Working Condition-
- Individuals who work in moist, humid environments are at a greater risk for developing Onychomycosis.
- Skin or nail causing damage or other types of infection to the nails increases the risk for Onychomycosis.
Symptoms of Onychomycosis
Onychomycosis Symptoms Includes-
- Patient may complaint of pain of fingertips.
- Abnormal Appearance of Nail-
- Patient often complaints of discoloration and thickening of nail.
- Abnormal Odor-
- Few patients may complaint of abnormal odor.
Onychomycosis Signs Include-
Examination of Nail-
- Increased thickness of the nail(s).
- The nail is dull in appearance without its healthy shine.
- There is discoloration of the affected nail due to accumulation of debris under the nail.
- The nail edge becomes ragged and brittle and starts to crumble.
- The shape of the nail becomes distorted.
- There may be separation of the affected nail(s) from the nail bed
- Patient may also experience pain in the fingertips or toes with a slight foul odor.
Investigations To Diagnose Onychomycosis
- Microscopic Examination-
- Some of the debris under nail is scraped and sent for testing to lab to observe fungus under microscope.2
- Biopsy of the fugal tissue is cultured to observe the type of fungus and culture to confirm the diagnosis of Onychomycosis.
Treatment For Onychomycosis
It is quite difficult to treat Onychomycosis and moreover it can be very persistent with a high tendency of recurrence. Over-the-counter antifungal nail ointments and creams can be used; however, they are not very effective. If a patient has athlete's foot along with nail fungus, then the athlete's foot should be treated first with topical medication.
Oral Antifungal Medications For Onychomycosis -
- Medications Prescribed For Onychomycosis -
- Itraconazole (Sporanox) and Terbinafine (Lamisil)3
- Newer agents, such as oral itraconazole and oral terbinafine, are efficient in eliminating fungal growth and cure Onychomycosis in short duration of treatment.
- 12-week therapy of oral terbinafine eliminates the disease.
- Broad-spectrum oxaborole antifungal agent with low molecular weight, permitting optimal nail plate penetration.
- Superior nail-penetrating properties of Tavaborole compared to existing topical antifungal medications are approved for the treatment of onychomycosis.
- Itraconazole (Sporanox) and Terbinafine (Lamisil)3
- Indications For Oral Antifungal Medications-
- Risk of cellulitis in diabetic patient.
- Symptoms of continuous and persistent pain or discomfort in the affected nail.
- Course of Treatment-
- Six to 12 weeks
- It takes more than four months to eliminate the infection.
- Side Effects Of Antifungal Medications-
- Skin rashes
- Liver damage.
- Congestive heart failure
- Decrease liver function
Antifungal Lacquer or Nail Polish-
- Medications Prescribed-
- Indication For Prescription-
- Mild to moderate fungal infection of the nail.
- Course of Treatment-
- The nail polish or lacquer is painted on the affected nail(s) and the surrounding skin.
- Medicated nail polish applied over nail for over a week.
- The buildup of the medicine is cleaned using alcohol before applying the next dose.
Combination Of Oral And Topical Treatment For Onychomycosis -
- Topical antifungal medications can be used with oral medications.
- The doctor will debride some of the affected part of the nail before the patient starts using topical antifungal. This will increase the efficacy of the medicine.
Surgery For Onychomycosis
- Surgery is recommended if Onychomycosis is causing severe pain.
- The infected nail (nail avulsion) is removed so that a new nail will grow in its place.5
- Surgery can also be done in combination with the medicine ciclopirox for treating the nail bed.
- It can take almost a year for the new nail to completely grow back.
Laser or Photodynamic Therapy For Onychomycosis
- Laser or photodynamic therapy is used to eliminate the fungal growth under nail.6
- The dead tissue and debris may be discarded or need to be removed by surgery.
Home Remedies For Onychomycosis
- Soaking your affected nails of hands or feet for about 15 to 20 minutes in a liquid mixture containing 1 part vinegar and 2 parts lukewarm water may help with the fungal infection. Rinse well after soaking and gently pat your hands or feet dry.
- Rubbing Vicks VapoRub on the infected nails can help; however, there is no concrete proof for its effectiveness.
Preventive Therapy For Onychomycosis
- Always keep your nails trimmed and dry.
- Cut your nails, straight across, especially the toenails.
- File the thickened areas.
- Dry your hands and feet thoroughly after a bath, especially the areas between the toes.
- Take off your shoes a couple of times during the day and especially after exercise to air your feet.
- Wear the right socks, which can absorb the sweat and moisture.
- Sprinkle some antifungal powder on your feet and inside your shoes.
- Try alternating open-toe shoes with closed-toe shoes.
- Avoid picking or trimming the skin surrounding your nails.
- Always wear rubber gloves when doing the dishes or other work involving water.
- Never, ever walk barefoot in public places such as showers, gym, pools, locker rooms etc.
- Avoid the use of nail polish and artificial nails, as they can trap moisture under them and cause or worsen an already existing condition of Onychomycosis.
- Get manicure and pedicure done at a reputable salon.
- Always wash your hands after application of medicine or touching an infected nail, as the fungus causing Onychomycosis can spread from one nail to another.
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Hong Kong Med J. 2011 Apr;17(2):127-31.
6. Treatment of onychomycosis using a submillisecond 1064-nm neodymium:yttrium-aluminum-garnet laser.
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