Fungal nail infections are common infections of the fingernails and toenails that can cause the nail to become discolored, thick (change its shape), distorted, and more likely to crack and break. Fungal nail infections can be caused by microorganisms that belong to the class of fungi [dermatophytes (e.g., Trichophuton rubrum) yeasts (e.g., Candida albicans blastomyces) and moulds (e.g., Scopulariopsis brevicaulis)]. Fungal infection may involve any component of the nail unit, including the matrix, bed, or plate.
As a disease, fungal nail infection does not threaten our overall health, but if left untreated, can cause severe damage to fingernails and toenails. They can spread to the adjacent nails or to combine and cause a widespread fungal infection on the skin of the feet and hands. Fungal nail infections can cause pain, tenderness upon pressure, nail thickening and nail detachment. This infection can also cause to the patient serious psychological, social and employment related problems.
During the summer months, the number of patients who seek a solution for fungal nail infection increases, as the incidence of the infection is highly increased during these months. Heat, local perspiration in conjunction with contact with sea water, the sand or the swimming pool water favor the spread of nail fungi.
The pathogenesis of nail fungi varies, depending on the type of fungal nail infection. Most often, fungal nail infection results from a fungal infection from the skin of the palm. Then, it enters the area under the nail and causes the most common form of fungal nail infection, called subungual onychomycosis. In other cases the nail fungus directly affects the nail body (corpus unguis) without being transferred from the adjacent skin. In rare cases, nail fungus affects the nail derived from the skin from the back of the hand.
Onychomycosis or fungal nail infection can affect men and women, but it rarely affects children. Men suffer from onychomycosis more often compared to women. In the general population the incidence of onychomycosis ranges from 2‑13%.
Fungal nail infections account for 50% of all nail disorders. Onychomycosis most commonly affects the toenails and to a lesser extend the fingernails. Thirty percent (30%) of the patients presenting with onychomycosis have some form of skin fungal infection. The frequency of onychomycosis has generally increased in recent years due to factors such as diabetes mellitus, immunosuppression as well as the increase in average life expectancy.
The incidence of onychomycosis is generally higher in elderly. It is worth mentioning, that fungal nail infections are 30 times more common in adults compared to the younger population where the incidence of onychomycosis in people aged less than 18 years is only 2.6%, and 90% in the elderly population.
There are five main subtypes of fungal nail infection depending on clinical presentation, i.e., they are named for the area the fungal infection starts:
Distal subungual onychomycosis (DSO), or distal lateral subungual onychomycosis (DLSO), is the most common form of onychomycosis and the infection starts from the free edge of the nail.
White superficial onychomycosis (WSO) is less common than DSO and occurs when certain fungi invade the superficial layers of the nail plate directly causing the entire surface of the nail to become whitish in color.
Proximal subungual onychomycosis (PSO) is also known as proximal white subungual onychomycosis (PWSO), a relative uncommon subtype, and occurs when the infection starts from a part of the nail which is closest to the skin.
Endonyx onychomycosis (EO) is a fungal nail infection that begins from an inner part of the nail that is in contact with the nail plate.
Finally, candida onychomycosis, or yeast infection of the nail is an infection caused by Candida spp., and is a very common type of fungal nail infection. Its characteristic is that this type of fungal infection can affect the nail as well as the skin bordering the nail (nail folds). Thus, in candida onychomycosis, there may be signs of infection (reddened, swollen, tender or warm) in the skin next to the nail (nail fold).
Some patients may have a combination of the above types of fungal nail infection. Total dystrophic onychomycosis is the most advanced form of any subtype. Any of the five fungal nail infection subtypes if left untreated and neglected can lead to this form of complete nail dystrophy.
Many nail disorders can be mistakenly perceived as onychomycosis, thus a differential diagnosis should be made. Patients often attribute any damage and deformity of their nails to onychomycosis, ignoring the fact that the symptoms of many diseases are initially manifested on the nails.
Initially the symptoms only involve the appearance of the nail and do not cause pain or discomfort to the patient. The main symptoms of the infection include thickening of the nail, change of its color, distortion and detachment of the nail from the nail bed.
The nail can develop a yellowish, brownish and even greenish or black color. As fungal nail infection progresses without treatment, the symptoms include pain, difficulty in walking, in standing and during exercise, as well as leg hypoaesthesia or paraesthesia.
In many patients these simple symptoms of fungal nail infection can lead to serious psychological problems, problems in social interactions and personal relationships and to low self-esteem.Distal subungual onychomycosis (DSO) – Symptoms
In this fungal nail infection the nail shows subungual hyperkeratosis and onycholysis (detachment of the nail), which is usually yellow-white in color. Yellow longitudinal lines (streaks) and/or yellow onycholytic areas on the central portion of the nail plate (surface of the nail) are commonly observed. White superficial onychomycosis (WSO) – Symptoms
This fungal nail infection is mainly confined to the toenails and manifests as small, white spots or patches on the surface of the nail plate. The nail becomes roughened and crumbles easily. Proximal superficial onychomycosis (PSO) – Symptoms
The main symptom of this category of fungal nail infection includes leukonychia in the proximal nail plate that moves distally with nail growth. A common symptom of this onychomycosis is also the marked periungual inflammation (cuticle, the skin around the nail). Endonyx onychomycosis (EO) – Symptoms
This fungal nail infection presents as a milky white discoloration that develops on the nail plate, but in contrast to DLSO, no evidence of onycholysis or thickening of the nail (subungual hyperkeratosis) is present. Candidal onychomycosis – Symptoms
It develops in patients with chronic mucocutaneous candidiasis or immunosuppression. It affects several or all digits of both hands and feet. A characteristic symptom of this type of fungal nail infection is periungual inflammation, the inflammation of the skin bordering the nail that becomes red and may swell. The nails often become bent and fragile. Such fungal nail infection symptoms are very common in people who are involved in manual work or have long contact with water, such as housewives and hairdressers.
The symptoms of fungal nail infection, often, cannot be classified solely in any of the above types as many patients experience a combination of the aforementioned subtypes of infection. Total dystrophic onychomycosis is the most severe of the forms mentioned as it represents the final stage of all the above types if left untreated.
Fungal toenail infections are favored by poor feet hygiene, feet perspiration and the use of tight shoes. The humid, moist and warm environment is an excellent substrate for the development of fungal toenail infections. Tight shoes, nail deformities in athletes as well as diseases that affect the nails (such as psoriasis) increase predisposition for developing fungal toenail infection. Frequent use of nail varnish reduces nail’s natural defense making them more susceptible in developing toenail fungal infection. Finally, the use of a swimming pool with bare feet as well as the common use of towels can lead to fungi growth.
Initially, fungi change the color of the nail to yellowish and increase its thickness. Then, they can lead to whitish, brownish, greenish and black-colored nail. Toenail fungal infections lead to deformity and dystrophy of the nail and ultimately to the detachment and shedding of the nail.
Fungal nail infection diagnosis can be made by microscopic examination of nail scrapings and culture of nail material.
The sample is taken from the affected nail after it is cleaned. Nail scrapings are taken which are then examined under the microscope and cultured in specific culture media.
Treatment of fungal nail infections should begin with proper feet and hand hygiene.
Frequent (but not excessive) washing of hands and feet is necessary.
Keeping the area dry is the first step to fight fungal nail infections. Especially at the feet, frequent sweating complicates the treatment of fungal nail infection. Sweating of the feet should be avoided.
The use of leather shoes and cotton shocks aids in feet’s hygiene.
The use of antifungal powder helps both in maintaining the area dry and in fighting nail and feet fungal infections generally.
Avoiding contact with the sand and common areas with bare feet is a prerequisite for treatment.
Treatment of fungal nail infections should be done based on the advice of a dermatologist who is the only specialist to make a proper diagnosis and suggest a treatment.
Cosmetic Derma Medicine offers the entire range of fungal nail infection treatments available, ranging from topical treatment and medicines to laser treatment.
Topical medications for the treatment of fungal nail infections include creams or solutions (lacquer). Topical medications are effective in incipient forms of onychomycosis that involve single nails and not in severe forms of fungal nail infections that involve the co-infection of several nails. Among the most common topical medicines for the treatment of fungal nail infections are itraconazole, terbinafine and cyclopyroxolamine. Their use is required for several months until improvement is observed in the appearance of the nails.
Daktodor, daktarin, loceryl and mycomycen are some of the medicines used for treatment.
The systemically administered drugs are considered more potent for the treatment of fungal nail infections. These are orally administered. Fingernail fungal infections require a treatment period of 2‑3 months, while toenail fungal infections require a treatment period of 3‑4 months.
Among the systemically administered drugs for fungal nail infection treatment are itraconazole (sporanox, sporizol), fluconazole (stabilanol) and ketoconazole. Terbinafine (lamisil) is considered particularly effective for the treatment of dermatophytes.
The steps of proper treatment are as follows:
Fungal nail infections – treatment using general measures:
– Keep your hands and feet clean and dry, no excessive washing
– Don’t share towels with other people
– Don’t walk around barefoot in public swimming pools, showers and the sand
– Always use individual tools for manicure – pedicure
Fungal nail infections – treatment using topical formulations:
Many patients prefer topical therapy for the treatment of fungal nail infections. Topical treatment is ideal for mild and early forms of fungal infections, as well as for patients who have contraindications to the use of orally administered drugs. These require good patient adherence since treatment should last for several months. Topical treatment of fungal nail infections should be applied on top of the nail and the surrounding skin.
Fungal nail infections – Laser treatment:
Laser treatment of fungal nail infections is the most common treatment used. The laser emits high doses of light energy which are used to destroy the fungus leading to natural sterilization. The laser light acts as a fungicide and eradicates the fungi without the side effects caused by drugs. This is a quick, easy, painless and very effective treatment of fungal nail infections.
For the laser treatment of onychomycosis an ND-Yag laser is used, which is the only device approved for the treatment of fungal nail infection. Full treatment requires 4 to 7 sessions. Treatment of the infection is certified by comparing the culture results received post-treatment with the results obtained after the end of treatment. Laser treatment is continuously gaining ground, as it offers many advantages compared to conventional treatment, such as:
- Lacks side effects, since it acts locally on the nails without influencing the rest of the body
- It is fast; the patient is subjected to 10 minutes of treatment, once a month
- It is effective and active since laser light has fungicidal activity
- It is also preventive; in each session laser treatment is not only applied to the affected nail but to all fingernails and toenails, leading to prevention of onychomycosis from spreading to surrounding nails.
Fungal nail infections – Treatment with orally administered medications
Orally administered drugs are very effective in specific forms of fungal infections. This is the standard – traditional treatment of onychomycosis in which most patients turn to. The main drugs for the treatment of fungal nail infections are ketoconazole, itraconazole and fluconazole. The adverse reactions of fungal nail infection treatment using drugs include the increase of the level of liver function enzymes in the blood, as these drugs are metabolized in the liver. As the treatment lasts for several months, frequent blood tests are required in order to avoid adverse reactions caused by these medical preparations.