Treating Onychomycosis | AAFP

PHILLIP RODGERS, M.D., AND MARY BASSLER, M.D.

Onychomycosis accounts for one third of fungal skin infections. Because only about one half of nail dystrophies are caused by fungus, the diagnosis should be confirmed by potassium hydroxide preparation, culture or histology before treatment is started. Newer, more effective antifungal agents have made treating onychomycosis easier. Terbinafine and itraconazole are the therapeutic agents of choice. Although the U.S. Food and Drug Administration has not labeled fluconazole for the treatment of onychomycosis, early efficacy data are promising. Continuous oral terbinafine therapy is most effective against dermatophytes, which are responsible for the majority of onychomycosis cases. Intermittent pulse dosing with itraconazole is as safe and effective as short-term continuous therapy but more economical and convenient. With careful monitoring, patients treated with the newer antifungal agents have a good chance of achieving relief from onychomycosis and its complications.

Onychomycosis (tinea unguium) is a fungal infection of the nail bed, matrix or plate. Toenails are affected more often than finger-nails.^1,2 Onychomycosis accounts for one third of integumentary fungal infections and one half of all nail disease.¹ Tinea unguium occurs primarily in adults, most commonly after 60 years of age. The incidence of this infection is probably much higher than the reported 2 to 14 percent.¹ Occlusive footwear, locker room exposure and the dissemination of different strains of fungus worldwide have contributed to the increased incidence of onychomycosis.³

Tinea unguium is more than a cosmetic problem, although persons with this infection are often embarrassed about their nail disfigurement. Because it can sometimes limit mobility, onychomycosis may indirectly decrease peripheral circulation, thereby worsening conditions such as venous stasis and diabetic foot ulcers.⁴ Fungal infections of the nails can also be spread to other areas of the body and, perhaps, to other persons.

Dermatophytes, yeasts and nondermatophytic molds can infect the nails.¹ The clinical significance of molds is uncertain, because they may be colonizing organisms that are not truly pathogenic.^3,5

Classification of Onychomycosis

DISTAL SUBUNGUAL ONYCHOMYCOSIS

The most common form of tinea unguium is distal subungual onychomycosis, which can also be distal and lateral (Figures 1 and 2). Distal subungual onychomycosis may develop in the toenails, fingernails or both. Some degree of tinea pedis is almost always present. The infection is usually caused byTrichophyton rubrum, which invades the nail bed and the underside of the nail plate, beginning at the hyponychium and then migrating proximally through the underlying nail matrix^2,3(Figure 3). Susceptibility to distal superficial onychomycosis may occur in an autosomal dominant pattern within families.¹

WHITE SUPERFICIAL ONYCHOMYCOSIS

White superficial onychomycosis accounts for only 10 percent of onychomycosis cases.³ The toenails are usually affected (Figure 4). White superficial onychomycosis is caused by certain fungi that directly invade the superficial layers of the nail plate and form well-delineated opaque “white islands” on the plate. As the disease progresses, these patches coalesce to involve the entire nail plate. The nail becomes rough, soft and crumbly. The most common causative agent isTrichophyton mentagrophytes.^1–3

PROXIMAL SUBUNGUAL ONYCHOMYCOSIS

Proximal subungual onychomycosis is the least common form of tinea unguium in healthy persons (Figure 5). It occurs when the infecting organism, usuallyT. rubrum, invades the nail unit through the proximal nail fold, penetrates the newly formed nail plate and then migrates distally. Fingernails and toenails are equally affected.¹ This form of onychomycosis usually occurs in immunocompromised persons and is considered a clinical marker of human immunodeficiency virus infection.¹ Proximal subungual onychomycosis can also arise secondary to local trauma.^1–3

CANDIDAL ONYCHOMYCOSIS

Patients with chronic mucocutaneous candidiasis may develop candidal infection of the nails. Candida species may invade nails previously damaged by infection or trauma.^1,3 Candidal paronychia more commonly affects the hands and usually occurs in persons who frequently immerse their hands in water.⁵

TOTAL DYSTROPHIC ONYCHOMYCOSIS

Total dystrophic onychomycosis may be the end result of any of the four main forms of onychomycosis. This condition is characterized by total destruction of the nail plate.³

Diagnosis

Because fungi are responsible for only about one half of nail dystrophies, the diagnosis of onychomycosis may need to be confirmed by potassium hydroxide (KOH) preparation, culture or histology. Psoriasis, lichen planus, contact dermatitis, trauma, nail bed tumor and yellow nail syndrome may be mistakenly diagnosed as onychomycosis.^1,2 A fungal etiology is unlikely if all fingernail or toenails are dystrophic.³

OBTAINING A SPECIMEN

The technique used to collect specimens depends on the site of the infection.^1,3

In distal subungual onychomycosis, the concentration of fungus is greatest in the nail bed. Therefore, the nail should be clipped short, and a small curette or number-15 scalpel blade should be used to obtain a specimen from the nail bed as close to the cuticle as possible. A specimen should also be taken from the underside of the nail plate.

In white superficial onychomycosis, a number-15 blade or curette can be used to scrape the nail surface or the white area, and remove infected debris.

In proximal superficial onychomycosis, the healthy nail plate should be gently pared away with a number-15 scalpel blade. A sharp curette can be used to remove material from the infected proximal nail bed as close to the lunula as possible.

In candidal onychomycosis, infected material should be collected from the proximal and lateral nail edges.

Treatment

Historically, the treatment of onychomycosis has been challenging. Orally administered griseofulvin (Grisactin, Gris-Peg) has been available for many years, but its use is limited by a narrow spectrum, the necessity for long courses of treatment and high relapse rates. The oral form of ketoconazole (Nizoral) is much more effective but carries a risk of hepatotoxicity.⁶

Onychomycosis has long been treated with topical antifungal preparations. However, these agents are inconvenient to use, and results are often disappointing. Treatment using nail avulsion in combination with topical therapy has been somewhat more successful, but this approach can be time-consuming, temporarily disabling and painful.

The U.S. Food and Drug Administration (FDA) has labeled ciclopirox (Penlac) nail lacquer for the treatment of mild to moderate onychomycosis caused byT. rubrum without involvement of the lunula. Although safe and relatively inexpensive, ciclopirox therapy is seldom effective.⁷

In recent years, treatment outcomes in patients with onychomycosis have improved substantially, primarily because of the introduction of more effective oral antifungal medications.⁸ Current evidence supports the use of these newer agents as part of individualized treatment plans that consider patient profiles, nail characteristics, infecting organism(s), potential drug toxicities and interactions, and adjuvant treatments.⁹

Triazole and allylamine antifungal drugs have largely replaced griseofulvin and ketoconazole as first-line medications in the treatment of onychomycosis. These agents offer shorter treatment courses, higher cure rates and fewer relapses.¹⁰ Of the newer drugs, terbinafine (Lamisil) and itraconazole (Sporanox) are the most widely used, with fluconazole (Diflucan) rapidly gaining acceptance. These medications share characteristics that enhance their effectiveness: prompt penetration of the nail and nail bed,^3,11 persistence in the nail for months after discontinuation of therapy^12,13 and generally good safety profiles. Published studies measuring “mycologic cure” (negative KOH preparation or negative cultures) and “clinical cure” (normal nail morphology) have demonstrated the effectiveness of all three medications.

TERBINAFINE

Terbinafine is an allylamine antifungal agent that is active against dermatophytes, which are responsible for the majority of onychomycosis cases. This agent is notably less effective against nondermatophytes, including Candida species and molds.

Adverse effects, including headache, rash and gastrointestinal upset, are reported more often with terbinafine than with placebo. Yet these side effects are uncommon and resolve with discontinuation of the drug.¹⁴ Because of its hepatic metabolism, terbinafine has several important drug interactions (Table 1). ^15–17

Drug or drug class	Terbinafine (Lamisil)	Itraconazole (Sporanox)	Fluconazole (Diflucan)
Benzodiazepines		Concomitant use of midazolam (Versed) and triazolam (Halcion) contraindicated; use of other benzodiazepines not recommended	Avoid concomitant use because of increased risk of sedation.
Cimetidine (Tagamet)	Increased terbinafine levels possible	Decreased itraconazole absorption	Decreased fluconazole levels possible
Gastric pH neutralizers (histamine H2 blockers, proton pump inhibitors, sucralfate [Carafate])		Monitor for treatment failure because of decreased itraconazole absorption with increased gastric pH.
HMG-CoA reductase inhibitors		Concomitant use contraindicated because of reported rhabdomyolysis
Hydrochlorothiazide (Esidrix) and hydrochlorothiazide combinations			Increased fluconazole levels possible
Oral hypoglycemics (all classes)		Increased hypoglycemia possible	Risk of significant hypoglycemia
Quinidines		Concomitant use contraindicated because of reported ventricular arrhythmias
Pimozide (Orap)		Concomitant use contraindicated because of reported ventricular arrhythmias
Rifampin (Rifadin)	Decreased terbinafine levels possible		Decreased fluconazole levels possible
Theophylline			Increased theophylline levels possible
Warfarin (Coumadin)	Bleeding events reported	Increased risk of bleeding	Increased risk of bleeding

Rare but serious complications, such as cholestatic hepatitis, blood dyscrasias and Stevens-Johnson syndrome, have been reported in patients treated with terbinafine. Consequently, liver enzyme levels and a complete blood count (including a platelet count) should be obtained before terbinafine is initiated and repeated every four to six weeks during treatment.¹⁸ Terbinafine should be discontinued if the aspartate aminotransferase or alanine aminotransferase level becomes elevated to two or more times normal.

The FDA-labeled dosage of terbinafine is 250 mg per day given continuously for 12 weeks to treat toenail infections and for six weeks to treat fingernail infections. Studies have shown that the regimen for toenails results in a mycologic cure rate of 71 to 82 percent and a clinical cure rate of 60 to 70 percent.^19,20 Shorter courses and pulse dosing of terbinafine have shown promise in small studies, but data are not yet sufficient to support the use of these regimens.²¹

ITRACONAZOLE

Itraconazole is a newer triazole medication with a broad antifungal spectrum that includes dermatophytes, many nondermatophytic molds and Candida species. Headache, rash and gastrointestinal upset occur in about 7 percent of treated patients, but hepatic toxicity is rare.²²

Because itraconazole is metabolized by the hepatic cytochrome P450 system, significant drug interactions can occur (Table 1).^15–17 Notably, concurrent use with quinidines and pimozide (Orap) is contraindicated because of the risk of ventricular arrhythmias. Itraconazole is also contraindicated for concomitant use with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, such as atorvastatin (Lipitor), because of the increased risk of rhabdomyolysis. In addition, itraconazole should not be taken with some benzodiazepines, such as midazolam (Versed) and triazolam (Halcion), because of exaggerated sedation and potential airway compromise.¹⁵

Increased gastric pH decreases the absorption of itraconazole. Therefore, the effectiveness of this antifungal agent can be decreased by histamine H₂ blockers such as ranitidine (Zantac) and famotidine (Pepcid), and by proton pump inhibitors such as omeprazole (Prilosec) and lansoprazole (Prevacid). For this reason, itraconazole should be taken with food.

The FDA-labeled dosage of itraconazole is 200 mg once daily taken continuously for 12 weeks to treat toenail infections and for six weeks to treat fingernail infections. The FDA has labeled pulse therapy only for the treatment of fingernail infections. Pulse treatment consists of 200 mg taken twice daily for one week per month, with the treatment repeated for two to three months (i.e., two to three “pulses”).^7,8,22,23 This dosage, given in three to four pulses, has also been shown to be effective in the treatment of toenail infections.^7,8,22,23 Published studies have demonstrated similar success rates for continuous and pulse therapies, with mycologic cure rates ranging from 45 to 70 percent and clinical cure rates ranging from 35 to 80 percent.^22,24,25

Liver enzyme monitoring is recommended before continuous therapy is initiated and every four to six weeks during treatment. No monitoring recommendation is given for pulse therapy. ²⁶

FLUCONAZOLE

Like itraconazole, fluconazole is active against common dermatophytes, Candida species and some nondermatophytic molds. Adverse effects, including nausea, headache, pruritus and liver enzyme abnormalities, are reported in approximately 5 percent of treated patients.²⁶ These side effects remit after the discontinuation of fluconazole. The absorption of this drug is not pH sensitive and is not affected by acid suppression or food intake. However, fluconazole has important drug interactions¹⁵(Table 1).^15–17

Fluconazole is not currently labeled by the FDA for the treatment of onychomycosis, but early efficacy data are promising.^13,27,28 Attention has focused on once-weekly dosing (450 mg), taking advantage of the drug’s pharmacokinetics to reduce treatment costs, decrease rates of adverse effects and potentially improve compliance.

In one placebo-controlled study involving patients with fingernail onychomycosis,²⁹ fluconazole in a dosage of 450 mg taken once weekly for three months was associated with a 90 percent clinical cure rate and nearly total mycologic eradication. Lower dosages were slightly less effective. No differences in complication rates were observed between the treatment and placebo groups. Published outcomes data^27,28 on the use of fluconazole in toenail fungal infections demonstrated “clinical improvement” (i.e., less than 25 percent of the nail still affected) rates of 72 to 89 percent, compared with 3 percent for placebo.²⁷ Treatment duration in these studies varied from four to nine months, with a small but measurable advantage shown for longer courses.^27–29

Treatment guidelines for the newer antifungal medications are provided in Table 2.

Comparative Clinical Trials

Much of the published data on the treatment of onychomycosis are of limited clinical use. Many studies have been small and observational, and they have lacked randomization and control subjects. Recently, however, the results of a handful of larger randomized, controlled trials have been published. These studies provide more convincing guidance in choosing appropriate therapy.

In a 1998 study³⁰ of 378 patients with dermatophytic onychomycosis, continuous terbinafine therapy was shown to be more effective than continuous itraconazole therapy in patients with toenail onychomycosis. Intention-to-treat analysis showed nearly 85 percent negative cultures in the treatment group compared with 55 percent in the placebo group, and 65 percent clinical improvement in the terbinafine group compared with 37 percent in the itraconazole group.

Other studies comparing terbinafine and itraconazole had similar findings.^31,32 A recent prospective, double-blind, randomized, controlled trial³³ compared the use of continuous terbinafine therapy and pulsed itraconazole therapy in 496 patients with toenail fungal infection. This well-designed study showed that terbinafine provided superior clinical and mycologic outcomes up to 15 months after treatment. To date, fluconazole has not been included in published direct-comparison trials.

Most patients in the published studies were infected with dermatophytes, against which terbinafine is most effective. Outcomes data for the treatment of nondermatophytic and candidal onychomycosis are limited, but broader spectrum triazole medications may be more effective against these pathogens.

Onychomycosis is expensive to treat. Costs include medications, procedures, laboratory tests and health care providers’ time, as well as expenses associated with the management of adverse drug effects and treatment failures.

One pharmacoeconomic study³⁴ compared the cost-effectiveness of continuously dosed terbinafine and itraconazole in the treatment of toenail onychomycosis.³⁴ The investigators concluded that continuous terbinafine therapy is less expensive, at a little over one half the price of continuous itraconazole treatment. It should be noted, however, that itraconazole pulse therapy is less expensive than continuous treatment (lower overall drug cost and no need for blood monitoring). Furthermore, the pharmacoeconomic study used national reference pricing and wholesale drug costs. Local laboratory standards, retail pharmacy costs and increasingly common payor formulary considerations may significantly alter individual costs.

Adjuvant Treatments

In addition to oral medications, some patients benefit from other treatments. Surgical or chemical nail avulsion may be useful in patients with severe onycholysis, extensive nail thickening or longitudinal streaks or“spikes” in the nail. These nail changes can be caused by a granulated nidus of infection (dermatophytoma), which responds poorly to standard courses of medical therapy.^35,36

Longer courses of antifungal therapy may be useful in patients whose nails grow slowly, who have diminished blood supply to the nail bed as a result of conditions such as peripheral vascular occlusion or diabetes mellitus, or who have total or nearly total nail plate involvement. ⁹

Topical antifungal creams or powders may also be beneficial, especially in patients with concomitant tinea pedis.

To improve treatment outcomes and prevent recurrence, patients should be counseled about proper foot hygiene (Table 3). Patients should be encouraged to wear breathable footwear and 100 percent cotton soc ks when possible. They should be advised to keep their feet dry throughout the day. Similar infection patterns observed in households and patrons of communal bathing facilities suggest a role for foot protection in high-risk areas.²¹

Wearing 100 percent cotton socks and changing them often

Choosing breathable footwear

Protecting feet in shared bathing areas

Keeping feet dry throughout the day

Recognizing and treating tinea pedis

Maintaining and improving chronic health conditions (e. g., controlling diabetes, quitting smoking, etc.)

There may be a familial predisposition to someT. rubrum infections. In such instances, prophylactic treatment of family members can be considered.³⁷

Treatment Failure and Relapse

Rates of treatment failure can be extracted from published trials, but data on relapse are less readily available. Post-treatment follow-up is long, drop-out rates in many studies are significant or unreported, and most studies have not allowed crossover of treatment regimens. Furthermore, especially in outcomes of clinical improvement (as opposed to cure or fully normal nail appearance), evaluation criteria have not been standardized and often include subjective assessments that are difficult to quantify. Published studies have not specifically addressed the management of treatment failures or relapse.

Despite these difficulties, several measures may be helpful in managing unsuccessful treatment or relapse. The first step is to confirm mycology. If the initial diagnosis was based on a KOH preparation alone, culture of properly collected specimens is mandatory. Culture reports often identify multiple organisms, including possibly nonpathogenic molds, and treatment should be directed at the organism(s) most likely to be causative. A microbiology or infectious disease consultation may be valuable in interpreting the culture report.

Of note, there has been some concern about evolving drug resistance among fungal pathogens, particularly with the widespread use of systemic fluconazole therapy to treat oropharyngeal and recurrent vaginal candidiasis.⁵ However, the impact of antifungal resistance on the treatment of onychomycosis is not yet clear.

Careful clinical review may identify patient or nail characteristics that are impeding treatment. These factors can be addressed with appropriate medication changes or adjuvant measures. Because of superior efficacy, continuous antifungal therapy may be considered in patients who fail or relapse after pulse therapy.

Onychomycosis in Children

Onychomycosis in children is rare, with an estimated prevalence of 0.2 percent.³⁸ Most often, onychomycosis develops in children with immunosuppression (e.g., acquired immunodeficiency syndrome, chemotherapy, congenital immunodeficiency syndromes), a strong familial history of onychomycosis or extensive cutaneous mycosis (tinea capitis or pedis).

Although griseofulvin remains the mainstay of onychomycosis treatment in children, the efficacy of this drug is variable, and relapse is common. Newly available medications may improve the traditionally mediocre treatment outcomes in this age group.

The FDA has not yet labeled terbinafine for use in children. However, some studies have shown terbinafine to be safe and quite effective in the treatment of tinea capitis, and it is licensed for this purpose in several countries.³⁹ In more limited trials, itraconazole has also been shown to be safe and efficacious in the treatment of tinea capitis. ²¹ If the safety and effectiveness of terbinafine and itraconazole are established over the longer courses needed to treat nail infections, they may become potent first-line therapies for onychomycosis in children.

Fungal Nail Infections | Fungal Diseases

Fungal nail infections, also known as “onychomycosis,” are very common. They may affect up to 14% of the general population. Fungal toenail infections are more common than fungal fingernail infections.¹

Symptoms

Most fungal nail infections are not serious. However, some people may experience pain or be bothered by the appearance of their nails.

Fungal nail infections may cause nails to become discolored, thick, fragile, or cracked. The nail may also become separated from the nail bed.

People who have fungal toenail infections often have a fungal skin infection on the foot, especially between the toes (commonly called athlete’s foot, ringworm on the foot, or tinea pedis).

How does someone get a fungal nail infection?

Fungal nail infections are caused by many different types of fungi that live in the environment. Small cracks in your nail or the surrounding skin can allow these germs to enter your nail and cause an infection.

Who gets fungal nail infections?

Anyone can get a fungal nail infection. Some people may be more likely than others to get a fungal nail infection, including older adults and people who have the following conditions: ^2,3

• A nail injury or foot deformity
• Trauma
• Diabetes
• Weakened immune system (for example, because of cancer)
• Venous insufficiency (poor circulation in the legs) or peripheral arterial disease (narrowed arteries reduce blood flow to the arms or legs)
• Fungal skin infections on other parts of the body

Occasionally, a bacterial infection can occur on top of a fungal nail infection and cause serious illness. This is more common in people with diabetes or other conditions that weaken the body’s defenses against infection.

Prevention

• Keep your hands and feet clean and dry.
• Keep fingernails and toenails short and clean.
• Don’t walk barefoot in areas like locker rooms or public showers.
• Don’t share nail clippers with other people.
• When visiting a nail salon, choose a salon that is clean and licensed by your state’s cosmetology board. Make sure the salon sterilizes its instruments (nail clippers, scissors, etc.) after each use, or bring your own.

Diagnosis

Fungal infections are not the only possible cause of nail problems. Other conditions can look similar to fungal nail infections.

Your healthcare provider should generally confirm your diagnosis using laboratory testing before prescribing antifungal treatment. To confirm the diagnosis, the healthcare provider might collect a nail clipping to look at under a microscope or to send to a laboratory for testing.

Treatment

Fungal nail infections can be difficult to cure, and treatment is most successful when started early. Fungal nail infections typically don’t go away on their own, and the best treatment is usually prescription antifungal pills taken by mouth. In severe cases, a healthcare professional might remove the nail completely. It can take several months to a year for the infection to go away.

Fungal nail infections can be closely associated with fungal skin infections. If a fungal infection is not treated, it can spread from one place to the other. Patients should discuss all skin concerns with their healthcare provider to ensure that all fungal infections are properly treated.

Even after treatment, fungal nail infections can come back. This is more common in people who have conditions like diabetes that make them more likely to get a fungal nail infection. If you suspect an infection has returned, contact your healthcare provider.

Information for healthcare professionals

Nail fungus – causes, symptoms and treatment

Dermatovenereologist (cosmetologist)

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Marua Azretovna

Experience 22 years

Dermatologist (cosmetologist)

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In medicine, nail fungus is officially called onychomycosis. This is a fungal disease that affects the nail plates on the fingers or toes. According to WHO, this is a fairly common disease. It occurs in about 27% of people, and pathology is diagnosed on the legs 2 times more often than on the hands. The problem of nail fungus is very delicate, because the unpleasant appearance of the affected plates makes the patient feel uncomfortable and hide them from others.

Symptoms and signs of nail fungus

Onychomycosis is very easy to recognize because its signs on the nails cannot be overlooked. First, the nail plates become dull and rough, lose their glossy sheen. Then the nail becomes dirty yellow, whitish or gray instead of pink. Further, other characteristic symptoms of the fungus appear:

• an increase in the thickness of the plate;
• defects in the form of stripes, bends, irregularities and waves;
• delamination and crumbling of the plate;
• Bad smell from nails.

As a result, the nail is completely destroyed and even exfoliates, exposing the nail bed. The skin next to the plates turns red and causes severe itching.

Causes of occurrence

The main reason for the development of fungal infections is the pathogen entering the body or inside the human body. As a rule, these are microsporums, trichophytons and epidermophytons. Here are some fungi that cause onychomycosis especially often.

When ingested, such fungi are localized on keratinized skin derivatives, i.e. nails and hair. This is due to the feeding of parasites, for which they use the fibrillar protein keratin, which is present in the nails and hair.

Ways of infection

The risk of contracting the fungus is especially high in public places with high humidity. These are saunas, swimming pools, gyms, public baths, etc. The most common ways of infection are:

• direct contact with an infected person. Here the fungus gets from its habitat to healthy areas, thereby causing an infection;
• household way. In this case, infection occurs when using the patient’s personal belongings: shoes, personal hygiene items, etc.

Risk factors

The incidence of onychomycosis increases by the age of 60. At this time, the likelihood of developing such an infection is 60%, which is explained by a slowdown in metabolism, especially in the distal (remote) parts of the body, which are precisely the fingers and toes.

Other risk factors for developing nail fungus include:

• diabetes mellitus;
• varicose disease;
• injuries of nails and adjacent tissues;
• HIV and other immunodeficiency conditions;
• long-term use of antibiotics;
• immunocompromised;
• vascular and skin diseases, dermatitis, diaper rash;
• circulatory disorders of the extremities;
• insufficient hygiene.

Complications

In an uncomplicated course, the disease causes symptoms traditional for the fungus, causing only severe discomfort in a person. But without treatment, onychomycosis can cause complications. Most often they are manifested in the addition of a bacterial infection.

Sometimes onychomycosis is very acute with the appearance of blisters, ulcers and weeping areas on the skin near the nail. In severe cases, the disease becomes generalized. This means that the nail fungus spreads to the internal organs and systems, and then the patient will need emergency hospitalization.

When to see a doctor

Many who have experienced onychomycosis know that the disease develops slowly and is treated with incredible difficulty. That is why it is very important to consult a doctor at the first signs of the disease. Onychomycosis of the nails is treated in our clinic in the center of Moscow by a dermatologist. The specialist will provide competent assistance and will guide you until complete recovery.

Preparing for a visit to the doctor

Before seeing a dermatologist, it is important not to treat the affected areas of the nails, i.e. do not use drugs, including iodine and brilliant green. It is also necessary to exclude the use of creams and ointments from the fungus. At the reception, it is worth taking all previously passed tests, including for other diseases. Affected nails should not be clipped for 3-4 days prior to the consultation.

Diagnosis of nail fungus

First of all, the patient is referred for microscopy, which reveals the presence of the pathogen. In the future, it is necessary to determine its variety in order to choose the right treatment for toenail fungus. JSC “Medicina” (clinic of Academician Roitberg) in the center of Moscow practices the most modern and common methods for diagnosing onychomycosis:

• cultural study of a biological sample of affected tissues. To do this, it is placed in an artificial nutrient medium, where the pathogen is grown in order to determine its type;
• polymerase chain reaction (PCR) method for the detection of pathogen DNA in a taken sample of affected tissues.

Treatment

At an early stage of the disease, local therapy is usually prescribed, which consists in the use of creams and ointments with antifungal effects.

Antiseptic solutions are also used as topical treatments for nail fungus. In addition to effective remedies for onychomycosis of the nails, antihistamines and desensitizing drugs are prescribed that relieve swelling, inflammation and sensitivity.

If the nail is completely affected by the fungus and drug treatment does not give positive results, then the plate is subjected to surgical removal. Also, with a total form of onychomycosis, antimycotic drugs are prescribed orally in the form of tablets that have a systemic effect on the body.

Home remedies

Consult your physician before using home remedies. With his permission, you can use the following recipes:

• iodine. Before use, the legs must be steamed, washed with laundry soap, and then the affected areas of the nail plates should be removed. Next, treat the nails and skin between the fingers with iodine, soak them in a bath with a soda solution for 20-30 minutes and dry thoroughly;
• vinegar. For 3 liters of water, take 1 tbsp. apple cider vinegar and add a little potassium permanganate. Soak in the foot bath for 20-30 minutes, then dry thoroughly;
• hydrogen peroxide. After carefully steaming the legs, remove the affected areas of the nail plates. Put cotton pads moistened with hydrogen peroxide on them, wrap them with a bandage and leave for half an hour.

Myths and dangerous misconceptions in the treatment of nail fungus

One of the most important and dangerous myths is that nail fungus is not considered a serious disease. In fact, onychomycosis, progressing, can lead to serious consequences up to deformation and complete rejection of the nails from the nail bed.

In addition, an infected person poses a daily danger to loved ones, because, being close to him, they also risk getting sick. That is why it is important to know how to cure nail fungus in time.

Prevention

To prevent the development of onychomycosis, it is necessary to exclude the negative impact of risk factors on the body:

• treat systemic diseases in time;
• do not wear other people’s shoes;
• in the pool and sauna walk in slates;
• change socks daily and observe personal hygiene;
• do not wear wet shoes – dry thoroughly;
• avoid direct contact with potential carriers of the fungus.

How to make an appointment with a dermatologist

To make an appointment with a dermatologist, use the online form on the website or contact us at +7 (495) 775-73-60. JSC “Medicina” (clinic of Academician Roitberg) is located in the center of Moscow, not far from the metro stations Tverskaya, Belorusskaya, Chekhovskaya, Mayakovskaya and Novoslobodskaya. Specialists work every day, so you can sign up for a consultation even on weekends or holidays.

causes, first signs, main symptoms. Treatment of onychomycosis in Moscow

Take care of your nails

Nail fungus (medical name onychomycosis) is a fairly common disease. According to doctors, more than 15% of the world’s population suffers from it, although this pathology is diagnosed much less frequently (in 2% of people). This discrepancy is explained simply: the nail fungus does not threaten life, and if it worsens its quality, then in most cases it is very insignificant. Therefore, they do not always turn to a doctor about onychomycosis, trying to cope with the disease on their own or simply leaving it without treatment.

Nail fungus develops rather slowly. Therefore, the first signs of a fungal infection usually escape the attention of the patient. When the changes in the nail caused by the fungus begin to catch your eye, this means that the process has already gone far enough, and it will not be easy to defeat the fungus.

Onychomycosis is often perceived as a cosmetic problem: nails affected by a fungus look ugly. But it is necessary to fight the fungus not only in order to return the correct shape and shine to the nails. If the fungus is left untreated, it will spread further. The big toe nail is usually the first to be affected. If treatment is not started, the fungus passes to other toes, and since we inevitably touch our feet with our hands, then infection with the fungus of the nails and hands is also possible. The fungus also spreads to the skin surrounding the nail, causing it to become irritated and itchy.

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Causes of onychomycosis

Onychomycosis can be caused by various types of fungi. First of all, these are dermatophytes. In second place are yeast fungi of the genus Candida, which are always present in small quantities on human skin (they often affect the nails of the hands). Infection with mold fungi is also possible (usually they are accompanied by other pathogens. Isolated damage by mold fungi is typical not for ours, but for a tropical climate).

The risk of fungal infection increases with age. In children, nail fungus is very rare, and, conversely, in older people it is detected relatively often. At the same time, men suffer from onychomycosis more often than women.

The age specificity of the fungus is explained by the fact that our local immunity decreases over the years, while the natural defense of a young organism, as a rule, suppresses the activity of fungi well, preventing them from colonizing the nail plate. There is a dependence not only on local immunity, but also on the general one. Weakening of general immunity is a favorable background for the development of any fungal infection.

For fungi of the genus Candida, it is enough that there are problems with the immune system: they simply begin to multiply actively. Mushrooms of other species still need to somehow get into our body from the external environment. Some types of mushrooms can be carried by animals. Molds are found everywhere; they are able to reproduce without a host. However, in most cases, the fungal infection spreads from person to person.

Mushrooms love moist environments. Therefore, infection with the fungus often occurs in places where the humidity is high. These are swimming pools, saunas, locker rooms, gyms. Wearing socks and shoes on wet feet can also be a trigger.

If there are wounds and cracks, they allow the infection to get right into the tissues, avoiding the need to storm the protective barrier that forms the surface of our skin.

The spread of fungi is facilitated by negligence regarding personal hygiene: you can not use other people’s slippers, soap, towels. It is precisely because not every family follows this rule that nail fungus often becomes a family disease.

Damage to the nail usually starts from the edge. Dermatophytes penetrate
under the free edge of the nail plate (into the subungual notch). In this case
the pathological process develops mainly in the nail bed. The second way of penetration of fungi is from the nail fold. The fungus Candida usually affects the posterior nail fold first (paronychia occurs), and only then the nail itself suffers. One of the types of dermatophytes (T. mentagrophytes) can penetrate directly through the nail plate.

Symptoms of onychomycosis

Signs of nail mycosis

The first sign of fungal infection is the loss of luster of the nail, clouding, discoloration. In cases where the infection affects the skin around the nail, itching is observed. If treatment is not started, the fungus begins to destroy the nail plate: the surface of the nail becomes rough, the nail can exfoliate, peel, break, crumble.

Specific manifestations depend on the pathogen, as well as on the location, duration of the pathological process and its form. There are normotrophic, hypertrophic and atrophic forms of fungal infection.

Normotrophic form

It is characterized by the fact that the thickness of the nail plate remains unchanged. The disease manifests itself in the form of white or yellowish spots, which gradually increase in size. In the end, the color of the entire nail changes. The nail plate can peel off, as the fusion of the nail with the subungual tissues is disrupted.

Hypertrophic form

It is characterized by a significant increase in the thickness of the nail plate (due to the growth of the subungual epithelium). The nail acquires a brownish-yellowish or gray color. The nail plate usually actively crumbles. Especially strongly the nail is destroyed from the sides, as a result of which it acquires a claw-like shape.

Atrophic

With this form of fungal infection, the nail becomes thinner and destroyed, starting from the outer edge. Destruction goes deep into the posterior nail fold; the nail bed is filled with a loose mass formed by decaying particles of the epithelium. Eventually, the nail may be completely lost.

Diagnostic methods for onychomycosis

Discoloration and brittle nails should be a reason to visit a dermatologist. You should not replace the doctor and make a diagnosis yourself – you can make a mistake: changes in the nail may have a different reason.

The doctor makes a diagnosis based on a visual examination (a microscope can be used). Laboratory diagnostics is carried out to confirm the diagnosis. It is also necessary in order to establish the type of pathogen (this will allow you to prescribe the most effective treatment).

Laboratory diagnostics

At the appointment, the doctor will make a scraping from the affected nail plate. If the pathological process has affected only the free edge of the nail, then a scraping of the subungual epithelium is also taken.

Microscopy is performed in the laboratory. Cultural studies are also carried out (the material is placed in a favorable environment and see if a colony of fungi appears). Cultural studies allow you to determine which fungi caused the disease.

To accurately diagnose the disease, make an appointment with the specialists of the Family Doctor network.

Onychomycosis treatments

Nail fungus treatment

Nail fungus treatment involves the removal of the affected part of the nail. Further treatment is carried out with the help of local antifungal agents (ointments, drops, sprays, varnishes). With significant lesions, the doctor may prescribe general antimycotic agents (tablets).

Since fungal activity increases in the face of immune problems, the proposed course of treatment may include measures aimed at increasing overall immunity.

Local treatment

Local remedies (ointments, creams, drops) should preferably be applied to the open nail bed.