nail fungus

Nail fungus or onychomycosis is an infection of the nails occurring both on the hands and feet but certainly more prevalent on the feet due to the environment that feet find themselves in. This condition generally thrives in dark, moist environments, so when you consider wearing shoes and socks all day along with perspiration that occurs, it ends up being a perfect growth media for nail fungus.

The true, tough to get rid of fungus, actually grows underneath the nail. As it grows, it forces the nail up off the nail bed and the nail becomes thick, crumbly and discolored ranging in color from yellow to brown. There may also be an odor. It is not uncommon for these infected nails to then spread to the remaining healthy nails on the foot. It is also not uncommon for nails to fall off and unfortunately, in most cases grow back the same way if not properly treated.

Below is a picture of a typical fungus nail

Aside from the unsightly appearance of the nail fungus, other problems can arise. Having nail fungus makes most people more prone to developing athletes foot of the skin. (The opposite also holds true). Additionally, thick fungal nails can be uncomfortable in closed shoes as they feel like rocks underneath the top of the shoe. These infections can make people more susceptible to secondary bacterial infections as they exacerbate the formation of ingrown nails, plus the sheer distortion of the nails tends to irritate the healthy skin of the adjacent toes causing abrasions that can become infected. This is especially dangerous in people who suffer from diabetes or have poor circulation.

Treatment can be difficult because of the fact that fungus thrives in “dark moist environments”. Eliminating those factors can go a long way to reducing recurrence.

Many patients ask me if the infected nail has to be removed. The only time I remove them is if they are already partially loose. If the onychomycotic nail is adhered to the nail bed I no longer advocate removal of the nail because the simple truth is, just removing a nail all the way back to its growth plate will cause the nail to grow out with a degree of thickness even if there is no fungus present.

Toe nail fungus cures include both oral and topical medication treatments. The gold standard for treating onychomycosis in an otherwise healthy individual is the oral therapy. The most widely prescribed medication today is Lamisil tablets (Novartis), although there are certainly other oral antifungals that can be used. The newer generation of oral antifungals are very safe medications if properly used. Lamisil tablets has adverse response rate of less than 3 percent. Typically, the dosing for Lamisil is one tablet per day for three months. Recently, a dosing schedule known as pulse dosing has become popular. Instead of 90 days worth of Lamisil, the pulse dosing is as follows: one pill a day for seven days, then no medication for the next three weeks, then one pill per day for one week, then no medication for three weeks, then one pill per day for seven days. As you can see you end up taking 21 pills versus 90 pills and the end results are the same. I have been using pulse dosing now for quite a while and am pleased with the results. The obvious advantage to this type of dosing is less adverse affects from the medication and overall cost.

Your doctor may prescribe one or two blood tests during the course of therapy to make sure there are no adverse effects. (As a side note, ever since I have started the pulse dosing regimen for oral Lamisil, I no longer do blood work. The logic here is that the medicine is not in your system long enough to cause any adverse effects.) Additionally, your doctor should take a sampling of the nail and have it tested to confirm that it is true nail fungus. Visual inspection is not the proper way to make a diagnosis. Many times a thickened nail is nothing more than keratinization of the underlying nail bed, which is a thickening of the skin underneath usually from repeated trauma. This can eventually lead to nail fungus because the increased thickened skin is a good focal point for fungus to enter. The other problem of not doing a nail sampling is that a few of the insurance companies out there will no pay for oral antifungals without proof of nail infestation.

Although topical treatments are available, they tend to be less effective. The main problem, as stated earlier, is that fungus grows underneath the nail; so applying medication to the top of the nail becomes an effort in futility. Trying to force the medication underneath the nail rarely works.

The best way to use topical medication is to see a foot specialist who will grind down and cut away as much of the diseased nail as possible (a painless procedure), so that the topical medication will penetrate to the live fungus more readily. This can become a tedious process as the medication generally has to be applied twice a day by the patient, (being lazy about it defeats the whole purpose) and then the nail has to be ground down on a regular basis. The other problem is that depending on the degree of fungus this process can take upwards of a year. The other problem is that the greater the number of nails that are infected, the less the likelihood is of clearing them all up with the topical medication. Having said that, I have seen some very gratifying results with topical medication. Again it is important to note that along with treating the nails for fungus, any fungal skin infection also needs to be treated.

Update April, 2011. Take a look at this picture of a fungal nail. This patient originally presented to the office about 6-7 months earlier. Keep in mind, at that time the whole nail was infected. Because oral medication was not an option, I started her on a topical medication. She states that she has been using the medication twice a day, everyday, since that visit. Look how clear the back portion of her nail now appears. Eventually as the diseased part of the nail grows forward it will be cut away and her nail will be totally clear. Compare it to her second toe nail. I challenge anyone to scour the internet and see a better looking nail as a result of using topical medication. Of course, the treatment is tedious (9-12 months) for a big toe nail, but the medication is safe and inexpensive. If you are interested in learning if this medication might help your nail problem, e-mail me about fungus nails and I will let you know what medication I used.

The other problem with most commercially available topical antifungal medications is that they are either of a water or alcohol base and neither ingredient penetrates nail which is primarily protein and fat (not calcium). Oil based topical antifungals are much better at penetrating the nail (which acts as a protective barrier) to get to the actual fungus.Click the link below to learn more about the oil based topical antifungal that I recommend. If you do not want to take oral medication or are not sure you even have true onychomycosis then this topical medication is a very safe alternative.

Keep in mind there can be failure using either topical or oral medication. But, here is an important point to take away from this article and that is if you only have a little fungus such as maybe on a nail or two, you are much better off trying to eradicate that than waiting, while the condition further worsens and then you are stuck trying to clear up a more severe case. A good rule of thumb is...."the worse the fungus condition, the harder it is to clear up."

Lately,(October, 2009) many of my patients have been asking me about laser treatment for eradication of nail fungus. There is a lot of advertising going around the internet. Here is what I know.

There is a company that offers a pulse laser that it claims kills nail fungus. It is an FDA approved device for use on the skin but it has not yet been given approval for the treatment of nail fungus. The company itself has done small clinical trials and claims a high success rate but I am never really impressed with company trials as historically they tend to be skewed in their favor. It is my understanding that there are larger clinical trials in the works. Having said that, it is also my understanding that this laser is approved in Europe for the treatment of nail fungus.

The procedure itself is relatively painless, usually one treatment is all that is necessary, but there are a couple of potential pitfalls.

To my knowledge, no insurance company will pay for this procedure and I have seen advertised prices of anywhere from $1000-1400 for this procedure. (these high fees alone may lead many doctors to misrepresent the true facts) My other concern is reinfection rates. Just because the nail(s) may appear clear I would be curious to know how many end up re-infected.

I have been in medicine long enough to know that just because some new technology comes along as the latest and greatest new treatment, in many instances it ends up disappointing and both doctors and patients end up wasting a lot of money. If you are interested in this option, my best advice would be to wait a year or two until follow up studies have been performed.

Update September,2011. There is now a laser that I am aware of known as the Q-laser that now has FDA approval for use on mycotic nails. This is a standard that most medical devices have to meet in order to ensure safety and efficacy.

Studies are now available that are older than one year and I have seen some very impressive results. If you are thinking of having laser surgery it is important to mention that the best way to reduce fungal nail recurrence after laser surgery is to remove the factors that caused it in the first place. Better hygiene of the feet, avoidance of nylons on a regular basis, use of a prophylactic anti-fungal spray will all go a long way in reducing a relapse. Laser therapy will probably rid you of your nail fungus but it is up to you to do various measures to prevent the problem from popping up again.

Lastly, women who wear toenail polish on a very regular basis are more prone to nail fungus, generally the superficial type of nail fungus. The polish is removed and the nail appears yellowish with pockets of white specks. If left alone this will usually invade the nail plate and become the deep type of onychomycosis. The good news is that this superficial type of fungus can be sanded out with an emory board and along with application of a topical antifungal and the avoidance of regular polish the nail will remain healthy.

There is actually nail polish manufactured that has anti-fungal medication in it; the idea being that. the medication will help prevent formation of fungus. To my knowledge there have been no studies to confirm this and it may be nothing more than a "more in theory than practice" idea. I do not see any harm in trying this type of polish and have seen it sold online, so for those women who are experiencing the superficial type of nail fungus, it might be worth a try.

Any discussion of thick discolored nails is not complete without mention of a rare but occurring condition known as melanoma of the nail. A melanoma may begin from the growth plate of the nail (the area just behind the nail) or it may occur on the nail bed itself. In either event it will cause the nail to become thick and discolored and can mimic a fungus nail. Look at the picture to the left. It is a melanoma of the nail bed.

For that reason, any suspicious discoloration or distortion of a nail should be checked by a doctor to make sure it is nothing more than a fungus nail with the knowledge in very rare cases it could be a melanoma.

Changes in the appearance of toenails and fingernails can be an early indicator of problems going on in the body. Click here for more information on various conditions that manifest themselves with changes in the nail appearance.