Toenail fungal infection i.e. onychomycosis incidence is rate is 3%. The main contributing microorganisms are mostly dermatophytes, non-dermatophyte filamentous like molds, and yeasts. Age and traumas are the major factors responsible for the cause of toenail fungal infection which are common in type 2 diabetics and poor immunity patients and patients who as peripheral arterial diseases. Sportspersons and labors wearing protective metal toe-capped shoes tend to develop toenail injuries that facilitate infection (1, 2).

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Onychomycosis is a common grievance. It can be treated either orally or with topical agents. Topical treatments have traditionally been more readily available as over‐the‐counter preparations, and they are the first‐line treatment for fungal infections. Oral treatments are more commonly prescribed for onychomycosis, and they appear to have the benefit of shorter treatment times and better cure rates than topical preparations (3).

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What Is The Prognosis For Toenail Fungus?

Prognosis is defined as foretelling the progress of disease whether it will improve or worsen (4). Onychomycosis is not a life‐threatening illness, but it can alter many important nail functions and have adverse effects on the person's quality of life. Particularly, those with diabetes mellitus face more severe complications such as foot ulcers and cellulitis. The most common side effects of oral antifungal agents include headaches, gastrointestinal side effects, and rashes (4).

Adverse Reactions Because Of Drug Therapy

Drug interactions can cause serious problems during oral treatment therapy, and azole drugs can inhibit hepatic drug metabolism. Severe adverse reactions, including fatal hepatotoxicity, are seen in less than 1% of cases. Women who are pregnant or may become pregnant should not use oral antifungals. Ketoconazole, fluconazole and terbinafine may be excreted in breast milk; therefore, it is not advisable to breastfeed whilst being treated (5).

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Disadvantaged Topical Antifungals

Thickened nails, extensive involvement of the entire nail, lateral disease, and yellow spikes contribute to a poor response to topical treatment (6).

Recurrence rates are high for onychomycosis, with prophylactic topical antifungal use proposed to counter recurrence. There are multiple factors that may contribute to the high rate of fungal nail infection reappearance. Patients with a genetic predisposition to onychomycosis, who are immunocompromised, or who have diabetes, are likely to experience relapse and may never achieve a permanent cure.

Arthroconidia, which are chains of fungal conidia that are formed by breakage of the fungal hyphae, are considered to be the primary means of nail invasion. These arthroconidia, which have thicker cell walls than conidia formed in vitro, have been shown to be more resistant to antifungals and, thus, may remain in the nail bed as a reservoir for recurrent disease (7).

How To Avoid Reoccurrence Of Toenail Fungal Infection?

During the course of treatment, the patients were instructed to follow several prophylactic measures to avoid recurrence: inspection of potentially contaminated footwear and disposal of the oldest footwear (possible source of self-contagion), application of antifungal powder in all footwear to be worn during treatment, and disinfection of pedicure utensils (8). Basic hygiene rules were prescribed: the use of an acidic (5.5) pH soap in daily hygiene of feet thorough drying with unshared towels, no sharing of footwear, and the avoidance of areas of potential contamination in order to prevent reinfection.

Conclusion

Onychomycosis is a common complaint and it is not a life‐threatening illness. Topical treatments and oral medications are more effective in the treatment and better cure rates. However, the rate of fungal nail infection reappearance is high because of many factors such as immunocompromised condition and diabetes. During the course of treatment, the patients were instructed to follow several prophylactic measures to avoid recurrence. If basic hygiene rules are followed, it would be easier to prevent reinfection.

References:  

  1. Onychomycosis: a compendium of facts and a clinical experience. Schlefman BS J Foot Ankle Surg. 1999 Jul-Aug; 38(4):290-302.
  2. Study of clinically suspected onychomycosis in a podiatric population. Jennings MB, Weinberg JM, Koestenblatt EK, Lesczczynski C J Am Podiatr Med Assoc. 2002 Jun; 92(6):327-30.
  3. Gupta AK, Daigle D, Paquet M. Therapies for Onychomycosis A Systematic Review and Network Meta‐analysis of Mycological Cure. Journal of the American Podiatric Medical Association 2015;105(4):357‐66
  4. Berker D. Clinical practice. Fungal nail disease. New England Journal of Medicine 2009;360(20):2108‐16.
  5. Dermatology Expert Group, Skin Infections Expert Group. Therapeutic Guidelines: Dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  6. Onychomycosis in clinical practice: factors contributing to recurrence. Scher RK, Baran R. Br J Dermatol. 2003 Sep; 149 Suppl 65():5-9.
  7. Arthroconidia production in Trichophyton rubrum and a new ex vivo model of onychomycosis. Yazdanparast SA, Barton RC. J Med Microbiol. 2006 Nov; 55(Pt 11):1577-81.
  8. Zalacain A, Merlos A, Planell E, Cantadori EG, Vinuesa T, Viñas M. Clinical laser treatment of toenail onychomycoses. Lasers Med Sci. 2018;33(4):927–933. doi:10.1007/s10103-017-2198-6

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Sheetal DeCaria MD

Written, Edited or Reviewed By:

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Last Modified On: June 12, 2019

This article does not provide medical advice. See disclaimer

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