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 this type of fungus.
This condition was rarely seen a hundred years ago, but has become more common due to the lifestyle changes we all experience such as communal bathing areas, greater use of occlusive footwear, and the increasing incidence of diabetes. Athletes, particularly runners are more inclined to develop this problem.
The incidence of onychomycosis increases with age, the majority being over age 55, but we also see it in teenagers as well. For most people this is a progressive disease that if left untreated will continue to spread from toe to toe.
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 with nail fungus if not properly treated.
Below is a picture of a typical fungus nail.
Compare the above picture to that of a psoriatic nail.
There is no shortage of nail fungus cures on the internet, products sold in drug stores, and in general dissemination of incorrect information. Treatment can be difficult because of the fact that nail fungus thrives in “dark moist environments” and happens to grow underneath the nail. Wearing closed shoes and socks all day with feet that perspire creates a perfect breeding ground for nail fungus. 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 nail fungus present.
Nail fungus medication include both oral and topical treatments.
For years the gold standard for treating onychomycosis in an otherwise healthy individual has been 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 fairly 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 for fungus nails.
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 for nail fungus and am generally 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. A thick discolored nail may also be a result of mold and spore infestation and have nothing to do with fungus.
The other problem of not doing a nail sampling is that a few of the insurance companies out there will not pay for oral antifungals without proof of nail fungus.
Taking the oral therapy one step further, it should be noted that oral Lamisil only kills the two most common types of fungus. By taking a nail sampling as just mentioned, one will be able to see if the oral medication will be effective assuming the nail sampling comes back positive for one of the two most common pathogens. It is worth noting here that most infections are mixed infections, meaning there is more than one kind of "bug" underneath the nail and that becomes one of the contributing factors in a patient whose nails do not totally respond to the oral medication.
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. Another issue 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.
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. If you do not want to take oral medication or are not sure you even have true onychomycosis then the 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 rather 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." A precursor to those thick yellow nails we have been discussing is a situation where you notice white specks on your nails. Many women will notice them when they remove nail polish.
This is superficial nail fungus where the fungus is growing on top of the nail and without proper treatment may burrow through the nail and cause thickening and discoloration. People with this condition should treat their fungus immediately as it is fairly easy to remedy.
The last option available for nail fungus is laser treatment. Laser became popular in the United States a few years ago, but until recently none of the available laser units were FDA approved. This has changed and as a result I have started performing laser surgery on fungus nails. Unlike either topical or oral medicine, laser destroys all the different organisms that are growing underneath the nail.
Studies are now available that are older than one year and I have seen some very impressive results. I have personally found that people prefer laser surgery over other options because it is a safe, painless procedure with the highest rate of success.
Laser is a painless procedure but is not covered by any insurance. Prices for this service will vary from one doctor to the next. Some doctors will only treat the nails that exhibit visible fungus, while others will treat all ten nails, the idea being that some of the healthy looking nails may actually have fungus in them and they will re-infect the other nails.
With laser surgery or any other treatment therapy you undertake, it is important to note that the diseased nail itself does not change in appearance initially; what happens is the diseased nail goes from live fungus to dead fungus but the appearance does not change. Over time as the nail grows forward and the diseased nail is cut away, it is eventually replaced with healthy nail which begins at the growth plate of the nail which is the back portion of the nail.
No matter what treatment method you employ to rid yourself of those unsightly nails, that ends up only being half the battle. The other half is preventing recurrence.
There are many reasons people develop fungus. It may be from nail trauma in playing sports to those people who develop it simply because of the environment their feet live in.
Once your nails have cleared up here are my recommendations for prevention:
BETTER HYGIENE OF THE FEET
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. If you are one who notices nail discoloration when you remove polish, this might be an option to consider. You might want to consider Dr.'s Remedy nail polish which may be purchased below.
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.
Abnormalities of the fingernails or toenails are usually the result of injury or infection directly to the nails. However, at other times, changes to the nails and the skin immediately surrounding the nails may be indicative of systemic disease processes occurring in the body.
Some of these abnormalities include:
Black Bands- this is a normal finding in African-Americans and Asians but in Caucasians a black band starting at the cuticle and growing forward to the tip of the nail may be a sign of melanoma. In this case the nail needs to be removed and a section of the nail bed has to be biopsied.
Clubbing- the affected nails become bulbous in appearance as does the surrounding skin. This may be indicative of congestive heart failure, emphysema or even lung cancer.
Onycholysis-the nail separates from the underlying nail bed and loosens up. In most cases this is the result of micro trauma to the nail as in walking in a shoe that is too tight. But in some cases this may be evidence of an overactive or underactive thyroid. This would be particularly true if it is occurring on the hands and feet.
Red cuticles-redness around the actual nail itself may be indicative of lupus.
Red nails-this condition may be seen in congestive heart failure.
Splinter hemorrhages-again in most cases this is indicative of trauma to the nail, but when there are multiple nails exhibiting multiple signs of splintering this can be indicative of endocarditis.
Spoon nails-when there is a concavity in the nail’s surface (the exact opposite of clubbing) this may indicate iron deficiency anemia.
Thin nails-when the nails seems to be very thin and pliable this may indicate a vitamin deficiency of vitamin B. Biotin 2mg taken daily should resolve this problem in 2-3 months. Biotin can be purchased in any health food store.
White nails-nails that are extraordinarily white may be a sign of cirrhosis of the liver.
UPDATES TO FUNGUS NAILS
11/25/2022 Not all thick discolored nails are actually fungal in nature. Brittle nails are a very common condition which many will mistake for nail fungus. This type of condition will not respond to typical fungal nail treatments.
In a recent article from the Cleveland Clinic, dermatologist Rosemary Keskinen MD discusses the causes and treatments for brittle nails.
The most common causes of brittle nails are excessive hand washing. Nails tend to lose water faster then skin making them more brittle over time. Aging itself will increase the chance of nails becoming brittle simply because as we age, our nails grow slower making them more susceptible to drying out. Nail length is also a factor as longer nails tend to split more frequently and nail cosmetics will help exacerbate the problem. Those undergoing chemotherapy may also experience brittle nails as a side effect of the treatment.
The article then goes on to discuss ways you can improve the appearance of your nails. These are tips worth taking a look at.
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If you happen to live in the New York - New Jersey area and are interested in laser surgery for your fungal nails, we have two locations. Our fees for this service are very competitive. (Laser is performed in the Summit office)
To make an appointment on line or for directions to our office click here.
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