Nail fungus is a very common infective disorder of nails, medically known as onychomycosis. It is responsible for approximately 50% of all the consultations in podiatry for nail disorders. It is usually caused by anthropophilic dermatophytes (Trichophyton rubrum, T. mentagrophytes var. interdigitale), molds (Scopulariopsis brevicaulis, Aspergillus species), and yeasts (Candida albicans, C. parapsilosis). It is mostly prevalent in males and increases with increasing age. Children are rarely affected, involving about 0.5-2.6% of all pediatric population. The major risk factors include peripheral arterial disease, diabetes mellitus, and immunosuppression (HIV, medications) in adults. Children acquire nail fungus either through trauma, dystrophy of the nail or indirectly through environment contamination (from parents). Nail fungus is mostly found in the toenails than in fingernails involving multiple nails.(1)
When Should I Go To The Doctor For Nail Fungus?
The clinical presentation of nail fungus is varied depending on the causative agent and the location of the disorder in the nail bed. Nail fungus can either be distal and lateral subungual onychomycosis (DLSO), white superficial onychomycosis, proximal subungual onychomycosis (PSO), endonyx onychomycosis and total dystrophic onychomycosis.
DLSO affects the nail plate distally and laterally spreading to the proximal surface. It leads to detachment of the nail plate from the nail bed along with yellowish-white discoloration and hyperkeratosis. In white superficial onychomycosis, the dorsal superficial nail plate is affected that can be easily scraped off. PSO rarely results from dermatophytes and is usually an infection by non-dermatophyte molds, such as Aspergillus and Fusarium species. It is seen in ventral nail plate that produces proximal leukonychia. It is associated with white discoloration of the proximal nail plate along with acute periungual inflammation. In endonyx onychomycosis, there is diffuse involvement of the nail plate without the involvement of the nail bed and the nail remains attached to the nail bed. Total dystrophic onychomycosis is the most severe form of onychomycosis that usually results from long-standing DLSO or PSO. The nail plate usually appears diffusely yellow, thick, and brittle.(1)
Diagnosis Of Nail Fungus
There are a lot of conditions that can resemble a fungal infection. Increasing age can cause thickening and yellowish discoloration of the nail. Trauma to nails can lead to bruising of the nail bed. Psoriasis can lead to skin and nail flaking. Chemicals in nail paint can also lead to discoloration of nails resembling a fungal infection. However, it is wise to visit a podiatrist/ doctor as soon as nail discoloration and distortion is noted to avoid the progression and severity of the infection. Only a lab test can confirm the presence of fungus by examination of affected nail scrapings.(2)
The common procedures for the identification of fungal infection include a direct microscopic exam (KOH 40% solution) and culture. Digital dermoscopy, confocal laser scanning microscopy, dermatophyte test strip, fluorescence microscopy, and Raman spectroscopy are some of the tools for the diagnosis of nail fungus.(1)
Management Of Nail Fungus
The management of nail fungus depends on the type of fungus, the severity of infection, and the number of nails involved. Since, nail fungus usually involves the nail bed, due to the poor penetration of topical antifungals, their efficacy is limited and chances of re-infection and relapse are in the range of 20-25% cases. Also, systemic antifungals pose a threat to the health of the patient due to their interactions with other drugs and potential hepatotoxicity. Therefore, the combination of these approaches is used to treat the infection.(1)
Recently, two topical agents efinaconazole (Jublia) and tavaborole (Kerydin) are found to be more effective than ciclopirox (Penlac), which is a commonly used topical antifungal. Itraconazole (Sporanox) and terbinafine (Lamisil) are commonly used oral antifungals. The liver panel should be updated when taking oral antifungals, in addition to monitoring the drug interactions. Their benefits should outweigh the cons; and they are especially beneficial when other co-morbidities are present (diabetes, vasculitis). The limiting factor is that the treatment needs to be carried out for nearly a year to see results.(2)
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