Onychomycosis (Nail Fungal Infection)

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Overview

Onychomycosis is a mycotic infection (the human pathogenic fungus) which appears when fungi invade the nails of the hands or feet, as well as the the underlying skin (nail bed). The nails of the lower limbs are more frequently affected because they grow very slowly, thus favouring the development of mycosis.
Thus, foot onychomycosis requires a longer treatment than the onychomycosis of the fingers of the hand. There are four types of fungal nail infections, of which the most common type seen in 90% of cases is the one with dermatophytes (distal subungual onychomycosis).
Fungal nail infection is a relatively frequent disease. Worldwide, 2% to 18% of the population have a fungal infection of the nail at some time. It is more common among older people (over 60) and rare among children, occurring in less than 1% of all children of different ages.
 
Article Content
Overview
Causes
Risk Factors
Symptoms
Diagnosis
Consulting a specialist
Recommended medical specialists
Investigation
Treatment
Evolution
Prophylaxis


Causes

Onychomycosis is caused by three different fungi, alone or in combination, these being:
- The dermatophytes type, is a fungus that commonly grows in the skin, hair and nails and does not invade the deeper layers of the skin. The most common dermatophyte, Trichophyton rubrum, is the cause of the fungal nail infection occurring in athletes, with localization to the toenails. This type of fungal infection is transmitted either by direct contact or indirectly through the sharing of items such as some clothing and footwear, personal hygiene items (nail clippers, nail scissors, nail-file, towel, etc.), public bathrooms ( the floor, the wooden floor grating from saunas, swimming pools). This type of mycosis, produces about 90% of all onychomycoses localized at the nails of the feet.
- Yeast is a saprophytic fungus (which grows commonly in the skin and nails, being part of the normal flora of the body). Various factors, such as certain diseases, the overuse of antibiotics, oral contraceptives and immune system problems, may favour the occurrence of infection;
- Soil fungus, mold (also known as the nondermatophytes), a type of fungus commonly found in soil but it can also grow on the skin and nails. In most cases, this disease does not transmit interpersonally. Fungal infections are usually classified according to their first localization, as well as their final location. Most onychomycoses affect the nail and the nail bed (subungual tissue).
Onychomycosis located in the toenails is more common in people with ingrown nails, lesions at this level and frequent cutting (exaggerated) of the nails. A condition called onycholysis, in which the nail is separated from the nail bed, increases the risk of fungal infections in this level.
Onychomycosis occurs after the direct contact with a fungus, which starts to develop in the nail and the nail bed and it is favoured by the local heat and humidity. However, the presence of the fungus on the skin, does not always lead to the appearance of onychomycosis, some susceptibility is usually needed in order for the infection to develop. People prone to develop such infections should be aware that they are recurrent (recur), regardless of the treatment used and especially if prophylactic measures are not taken (prevention). It is not known exactly the reason why some people are more suscceptible to the development of the disease than the rest of the population.


Risk Factors

The risk of developing onychomycosis depends on each person’s susceptibility to fungal nail infection.
Risk factors which can not be influenced (which can not change):
- Susceptibility to fungal nail infection (which is not fully understood) or a history of fungal infections
- Weakened immune system, the consequence of HIV infection (human immunodeficiency virus), diabetes, cancer or immunosuppressive therapy with corticosteroids
- The insufficiency of peripheral circulation (secondary to aging or other diseases)
- Age, people older than 60 years are likely to develop onychomycosis
- Males.
The risk factors which can be influenced:
- Tight shoes
- Shoes that keep feet warm and humid
- Using wet shoes for several days in a row
- Sharing with others personal objects, such as shoes, socks, nail clippers or nail scissors to cut nails
- Hot and humid climate
- Using public baths or showers, without using sandals or slippers for shower
- Damage to the nail and nail bed (especially in the case of people who frequently cut their nails)
- People with ‘athlete’s foot’ (a type of nail fungal infection appeared to athletes)
- Living and working conditions that keep hands and feet wet or damp (for example, those who wash)
- smoking
- Wearing artificial nails. Fungal infection may occur at the limit between the insertion of the artificial nail and the natural nail, especially if it has not been cleaned with alcohol before applying the special adhesive. Also, some products or manicure maneuvers may increase the risk of onychomycosis


Symptoms

The symptoms of onychomycosis vary from case to case; they depend firstly on the type of infection. The most frequently encountered symptom is local discomfort, pain being usually absent.
Subungual distal onychomycosis, the most common form of fungal nail infection is caused by dermatophytes. Usually, both the nail and the nail bed are interested. Dermatophytes cause over 90% of all fungal nail infections.
Signs and symptoms include:
- Yellow streaks in the nail and nail bed
- Small deposits of skin and nail fragments with subungual localization
- The appearance of a new, discoloured, thinned nail under the nail affected by infection
- Brittle, crumbly, fragile and thickened nails.
 
White superficial onychomycosis is an infection in the nail surface, being the second cause of nail infection and it is also caused by dermatophytes.
Signs and symptoms include:
- White streaks or spots on the nail surface
- Soft, brittle and floury nails along with a chronic infection
- Brown brittle nails, but which do not get off the nail bed.
The other types of fungal nail infections are rare. Candidal onychomycosis occurs in up to 1% of all fungal nail infections. Proximal subungual onychomycosis is also a 1% of fungal nail infections, although it is common in people with HIV (human immunodeficiency virus).


Diagnosis

Only 50% of nail infections have a fungal etiology. The diseases with similar signs and symptoms are:
- Eczema, a chronic condition characterized by thickened and crusted skin. When located in the upper limb, it may be confused with onychomycosis
- Psoriasis, a chronic condition of immune nature, characterized by white and red lesions, shiny skin that is easily exfoliated. These lesions may occur also in the case of onychomycosis, but the excessive exfoliation of the tissues is not encountered
- Reiter’s syndrome, a bacterial infection that can cause changes of the nail similar to that of onychomycosis
- Pachyonychia (elephant nail), a condition characterized by a very thickened nail
- Darier disease, a genetic disease, in which the progressive thickening of the skin occurs
- Lichen planus, a rare, recurrent disease, characterized by skin pruritus (itchy skin), purplish, red spots and shiny skin
- Norwegian scabies (mange), a rare but severe form of scabies; it may have similar signs and symptoms to that of onychomycosis.


Consulting a specialist

It is necessary to immediately consult a specialist if these signs and symptoms specific to fungal or bacterial infection appear:
- Pain that increases in intensity, swelling, redness, accentuated sensitivity or local warmth
- Red streaks in the nail and nail bed
- Purulent secretion
- Fever higher than 37.7 degrees Celsius, without other known cause.
It is necessary to consult a specialist if people with onychomycosis have:
- Nail fungal infection that spread to the nail bed and periungual tissues
- Periungual tissues which are infected and extremely painful
- Discomfort produced by the excessive thickening of the toenail
- Worrying aspect of the nail and nail bed.
After analyzing the present signs, the doctor must establish the diagnosis and recommend an appropriate treatment. If the treatment is begun early, the disease may get worse.
A period of time in which the evolution of the infection is observed without the use of any treatment, is recommended.
If your nail is discoloured but painless, treatment may not be necessary, especially because antifungal medication does not guarantee healing and oral antimycotics are relatively expensive and have more side effects. However, the treatment can prevent complications of the infection and permanent damage of the nail; it can also shorten the necessary time for treatment and increase the chances of eradication of the infection.


Recommended medical specialists

The healthcare providers that can diagnose and treat onychomycosis, are:
- GP
- Generalist doctor
- Dermatologist
- Dermatologist resident.


Investigation

In order to determine the etiology of nail infection and confirm the diagnosis of onicomocoza, your doctor will need to conduct more tests and investigations, namely:
- Anamnesis and the positive medical history for fungal nail infections or diseases associated with onychomycosis (HIV-AIDS infection, diabetes)
- Careful examination of the ungual and perungual area
- Taking off tissue damaged by infection, directly from the subungual area where the skin is crumbly, or with the help of a fine scalpel. The samples are then analyzed through different methods:
- KOH ( Potassium hydroxide) is used to determine if the skin lesions has a fungal etiology. The test can be performed by a dermatologist in the lab.
- Fungal culture, which may emphasize the type and the fungal stem incriminated in the fungal infection. The disadvantage of this method is the slow growth of the microorganism, so that several weeks are necessary in order to achieve the desired result. It is known that over 90% of foot onychomycosis are caused by dermatophytes, so if KOH test is positive, it is supposed that this is the etiologic agent and the appropriate antifungal treatment can be instituted. However, in some cases, the dermatologist decides that he must know the exact etiology of infection, so that fungal culture is required.


Treatment

Treatment – Overview
The correct treatment of onychomycosis requires the eradication of infection, the prevention of relapses and in necessary cases, the surgical removal of the nail. The treatment is effective in most cases, however 20% -25% of patients have a failure of the initial treatment. Dermatologists can not treat uncomplicated onychomycosis (discolored, fragile but painless nail), because of the high costs as well as the adverse effects of antimycotic drugs. Left untreated, the infection tends to get worse, extending to the periungual tissues. The early treatment is more effective because it requires less time and increases the chance of the eradication of infection. People with onychomycosis, complaining about progressive discomfort, pain, that are embarrassed by the appearance of the lesion, may require to the doctor the initiation of the treatment. Also people with diabetes who are prone to develop various skin lesions and fungal infections, should begin the antimycotic treatment, despite the fact that the discomfort and pain are present or not.
The standard treatment for fungal nail infections includes one or more of the following drugs:
- Oral antifungal medication is the most effective treatmen; however, it requires a careful monitoring of the potentially dangerous side effects (especially hepatotoxicity). These drugs are commonly used in medium-severe forms of onychomycosis. The most commonly used oral antimycotics are: terbinafine (Lamisil), itraconazole (Sporanox) and fluconazole (Diflucan).
- Topical antifungal medication (creams, lotions, gels and varnishes); it is applied to the nail and the affected periungual area. Their efficiency is relatively low and it is usually used in light-moderate forms of onychomycosis. They are used also as prophylactic treatment in recurrent onychomycosis such as the athlete’s foot.
Some of the antifungal drugs for topical use are: terbinafine (Lamisil) and ciclopirox (Penlac). The surgical removal of the infected nail is required only in severe, recurrent cases. The sssociation of the local treatment with surgery is more effective than the single antifungal treatment. The non-surgical removal of the infected nail is made by a prior administration of an urea ointment that softens the nail, making it easier to remove. The surgical removal of the infected nail is achieved by total (avulsion) or partial (debridement) removal of the nail. Oral or local antibiotics are necessary only if the onychomycosis was complicated by a bacterial infection.
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Medication Choices
The first antifungal medicine used to treat onychomycosis was Griseofulvin (Fluvicin U / F, Grifulvin V), but this could not be used in the chronic treatment because of the serious adverse effects and the need to use it for a long time (12 to 18 months) in order to eradicate the infection. The new antifungal drugs are more effective, safer, with fewer side effects and require a shorter administration time. People with chronic liver diseases (hepatitis, cirrhosis) and those who consume alcohol during therapy have an increased risk of developing severe adverse reactions to the oral antifungal treatment.
Drug Interactions – The oral antifungal medication can provide cross-reactions with other treatments prescribed by the doctor (e.g. the chronic treatment for liver diseases), it can increase or decrease the concentration or elimination of other associated drugs. The doctor must be informed about other administered medicines, if he wants to prescribe an antifungal treatment, in order to avoid unpleasant side effects.
The dosage of the treatment – Establishing the type of treatment as well as the corresponding doses, depends on the severity of the fungal infection, so that you can choose between pulse therapy (the administratiom of an antifungal drug dosage once a week for 2, 3 or 4 months) or continuous therapy ( the daily administration of the antifungal drug). Although longer, pulse therapy is less expensive than the daily antifungal treatment.
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Surgical treatment
The surgical removal of the infected nail is reserved for severe and recurrent cases. Once removed the nail, an antifungal cream can be applied directly on the place of the infection, thus increasing the efficiency of the onychomycosis treatment. However, surgery is rarely required.
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Other therapies
Some people who have onychomycosis find the adjuvant treatment with oil made of green tea leaves effective, this being used also in the prevention of the athlete’s foot. Green tea products are also used to treat minor burns, acne, minor fungal nail infections, vaginal fungal infections and respiratory problems (in the latter case they are used as nasal infusions). The efficiency of oil made of green tea is not fully proven in the case of onychomycosis.

 


Evolution

Onychomycosis, is in most cases a slow-growing infection, the rate of the progression of infection depending on several factors, such as:
- the general state of health and susceptibility to infection
- the temperature and humidity of the environment
- the location of the infection, because the most common location, with the slowest evolution, is that at the foot, where nails grow more slowly.
The first signs of a fungal nail infection are discoloration, nail thickening or the tearing of the nail or nail bed. If left untreated, the infection spreads gradually towards the nail bed and the surrounding periungual tissues. In time, the infection includes the nail completely and it is followed by its fall. Nail fungal infections can be treated relatively easily, however, some types of onychomycosis are more easily treated than others. Subungual distal onychomycosis is a chronic,slow , and difficult to treat condition, in contrast with white superficial onychomycosis which is easily treated. Even after the treatment finished, the nail may have an irregular, deformed appearance, often being needed more than a year before the initial, normal aspect of the nail appears. Onychomycosis is a recurring disease; of the patients treated with antifungal drugs, 15% -20% of them have a relapse up to one year since the initial infection. When the initial treatment finished, the prophylaxis (prevention) of infection is important and it can me made by using antifungal ointments and keeping the skin of the feet dry. Some people with onychomycosis have difficulty when walking, especially those with disorders of the peripheral sanguine circulation which lower the sanguine flow in the extremities (foot and toe). This may worsen other associated medical conditions, favouring the appearance of foot ulcers in diabetics (painless lesion, often overlooked), and venous ulcers (occurring mainly in patients with venous insufficiency and varicose veins).
The bacterial infection can occur secondary to onychomycosis. A relatively common bacterial infection, associated with fungal nail infection, is acute paronychia, which causes the inflammation of the periungual tissue.
Although onychomycosis is not a danger to the overall health, yet it can affect the quality of life. Some people with onychomycosis, avoid various activities because of the bad nail appearance and the fear of spreading the disease among other people. Sometimes, pain may limit some activities or even daily work. Unfortunately, onychomycosis is seen as a cosmetic and not as a dermatological disease, so treatment can be more expensive, nor being compensated by the Health Insurance House.


Prophylaxis

Even after an apparently effective treatment with oral or topical antifungal drugs, in some cases recurrences can occur, either in the same location, or in another region and have another etiologic agent. Some onychomycoses with a special location (e.g. the hallux) are difficult to treat and have frequent relapses.
The prevention of onychomycosis requires the following of some steps, namely:
- Legs hygiene (washing and drying) and the application of an antifungal cream such as that with terbinafine (Lamisil) or ciclopirox (Penlac) in the ungual and periungual area
- Keep feet dry and apply talcum powder after bath
- Wear cotton socks and change them whenever it is necessary (sometimes even 2-3 times per day)
- Avoid uncomfortable shoes that cause damage to the toe tips, the most frequently involved aspect in the recurrence of infections at this level
- Wear casual shoes that allow feet to breathe (not materials that make the skin of the foot to sweat)
- Wear sandals or sflip-flops in public showers and baths
- Avoid sharing shoes, socks or personal manicure utensils
- Avoid the injury of the periungual region, sterilize the utensils for manicure and pedicure before each use, etc.
- People with diabetes who are susceptible to onychomycosis should pay attention
- Quit smoking.
In the case of people with mild or moderate fungal nail infections, who want to avoid adverse effects of oral antifungal therapy, it is recommended the use of antifungal ointments such as Lamisil or Penlac.

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