Tinea Unguium is a very common fungal infection of the nails especially of the toes. The fungal infection causes the nails to become thickened and unsightly which very rarely becomes painful. Tinea Unguium is also commonly known as Onychomycosis. Tinea is basically the name of a group of diseases caused by a fungus. The various types of Tinea include ringworm, athlete's foot and jock itch. The infection caused is not so serious in general but can be extremely uncomfortable. One can get tinea unguium by touching an infected person, damp surfaces as well as by touching a pet.
What is Tinea Unguium?
Tinea Unguium or Onychomycosis is a very common condition that starts off as a white or yellow spot under the fingernail or the toenail. As the fungal infection goes deeper, it results in the discoloration of the nail and ultimately the nail thickens and starts crumbling at the edges. It can affect several nails at the same time but generally not all of the nails together. In general, Tinea Unguium does not cause pain and in that case it is considered to be mild and does not require any treatment; however, if the nail is painful and has caused the nails to thicken, some self care steps and medication is required to prevent the condition from getting worse.
Symptoms of Tinea Unguium
In most of the cases of nail fungus infection like Tinea Unguium, one nail is affected or in some cases there might be more than one being affected as well. At the very beginning of infection it is usually painless. The nail may appear to be thickened and discolored often a greenish yellow color. Most commonly this is what usually occurs and there are no other symptoms but it can look very unsightly. Sometimes it may happen that the infection worsens. The symptoms of Tinea Unguium can be white or yellow patches appearing where the nail has come away from the skin that is under the nail bed. Sometimes even the nail comes away. The nail becomes soft and brittle and bits of nail may start falling. The skin next to the nail may be inflamed or scaly in some cases. If it is not treated properly, it may result in the destruction of the nail and the nail bed and also become painful. Walking may be very uncomfortable if the toenail is affected with Tinea Unguium.
Causes of Tinea Unguium
The most common causes of tinea unguium including the spread of the disease are as mentioned below:
- Spread from a Fungal Infection: For example athlete's foot is a fungal infection of the toes and this can spread to the toenails if it is not treated early.
- Fingernail Infection: It may occur after the infection of toenail has occurred. The fungus might spread to the finger after scratching the itchy toes and toenail with the finger.
- Nail Infections: These are very likely to occur if hands or feet are washed very frequently and this may be also related to one's profession. For example if one is a cook or a cleaner the hands need to be more frequently washed. This constant washing results in the damage of the protective skin at the base of the nail that allows the fungi to enter and cause the infection.
- A recently damaged nail is more likely to be infected with tinea unguium.
- The chances of nail infection increases if other conditions like Diabetes, Psoriasis, poor blood circulation, a poor immune system or a general state of poor health condition is present.
- Nail infections like tinea unguium are more common in people living in hot and humid climates.
- Smoking also increases the risk of developing a fungal nail infection.
- Sometimes, the cause of nail infection like tinea unguium comes from no apparent reason. Fungal germs are common and infection can occur from almost nowhere.
Prevalence Rate of Tinea Unguium
Recent studies have revealed that the prevalence rate of tinea unguium has started to rise. The prevalence rate is between 2 -8% from the population based studies. 3-8 out of 100 people in the United Kingdom has a fungal nail infection at some point in their lives. Fingernails are less commonly affected as compared to toenails. Tinea unguium appears to be more common in people over sixty years of age and in younger people who share communal showers viz., swimmers or athletes. Tinea Unguium is extremely common in India with more than ten million cases being reported per year. It is found to be steadily increasing with age. It is not very frequent among the children but definitely found in children. The prevalence rate of Tinea Unguium is supposed to increase further without adequate prevention and effective treatment.
Pathophysiology of Tinea Unguium
Tinea unguium is an infection of the nail tissue of hands and especially feet. T. rubrum and Trichophyton interdigitale are the most common dermatophytes to cause tinea unguium. The non dermatophytes account for the remainder of infections which occur from yeasts belonging to the Candida species, as well as molds belonging to the Fusarium and Acremonium species. There are generally three forms of tinea unguium:
- Distal subungual Onychomycosis is the most common form with the big toe being the first nail to be affected. This involves the end part of the nail that is farthest away from the cuticle and starts off with a whitish, yellowish, and/or brownish discoloration of the nails. The discoloration ultimately spreads to the entire nail and finally extending slowly to the cuticle. The discoloration is due to keratinous debris in between the nail and the nail bed.
- Superficial white onychomycosis infects the top surface of the nail completely and has a flaky appearance.
- Proximal subungual onychomycosis is the rarest form with a deeper infection which occurs near the cuticle under the nail and then extends distally.
Risk Factors of Tinea Unguium
The risk factors of tinea unguium are as mentioned below:
- Older age
- Trauma to the nails
- Weak immune system
- Living in hot and humid conditions
- Living with someone having infection as the infection spreads through direct contact.
Diagnosis of Tinea Unguium
Proper diagnosis is very important in this case so as to prevent a severe condition. To avoid misdiagnosis such as nail psoriasis, contact dermatitis, lichen planus, nail bed tumors such as melanoma, yellow nail syndrome or trauma, pathological tests may be of utmost importance. The three main approaches to proper diagnosis are as follows:
- Potassium hydroxide smear
This involves microscopic examination and culture of the nail scrapings. Recent results indicate that the most sensitive approach to correct diagnosis is a combination of direct smear with histological examination and nail plate biopsy. For correct identification of non-dermatophyte molds, several samples may be required for proper diagnosis.
Treatment of Tinea Unguium
It was observed that half of the suspected fungal nail infection cases actually no fungal infection but only nail deformity. It is due to this reason that a confirmation of fungal infection is extremely important and only then the treatment should start. Avoiding the use of oral antifungal treatment in persons without a confirmed infection remains a concern because of the side effects of the treatment as well as persons without an infection should not have this treatment. Antifungal drugs like Triazole and Allylamine are more in use these days due to the fact that a short course of medication is required and yet it gives a better cure rate and lesser relapses of Tinea Unguium.
Prognosis of Tinea Unguium
It has been reported that in general the fungal infections like Tinea Unguium do not cause any severe problems and the treatment methods is improving over time. Therefore the prognosis of Tinea Unguium is quite good. However, in some cases it can be very uncomfortable to walk if it deeply affects the nails. The most irritating part of it is that the nails can look very unsightly causing embarrassment in front of all.
Prevention of Tinea Unguium
The preventive steps that can be taken to avoid fungal nail infection like Tinea Unguium are as follows:
- Keeping the nails short and file down any thickened nail.
- Using a separate pair of scissors to cut the infected nails is recommended to prevent contamination of the other nails
- Sharing of scissors should be avoided
- Avoiding any kind of injury to the nails which may increase the risk of developing a nail infection
- If toenails are affected, wearing properly fitted shoes with a wide toe box can be effective.
- Keep the feet cool and dry as much as possible
- Wear footwear such as flip-flops in public places such as communal bathing places, locker rooms, etc.
- Towel sharing should be avoided
- Old footwear should be replaced as this could be contaminated with fungal spores.
Complications of Tinea Unguium
Tinea Unguium does not have any complications in general unless the infection is left untreated. In general, it is very simple in appearance with the nail changes without any pain. However, in some cases where the infection is deep rooted, proper and effective treatment for Tinea Unguium is required. If not treated, in extreme cases, the nail bed gets infected and the nail falls off completely which cause pain and makes it uncomfortable to walk.
Since tinea unguium is not a severe disease in general one should not panic at all. One can go and consult a specialist if required. The symptoms should be detected early to prevent severity in the future. Pathological tests should be done as suggested by the specialist. Proper care should be taken and effective treatment is enough to keep one away from the fungal nail infection. One should always try to follow the preventive measures so that the infections remains at a distance and most importantly these infections should never be ignored which can prove to be very harmful in the future.
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