Fungal nail problems
Fungal nail infections, known to doctors as onychomycosis, can affect both toenails and fingernails, but toenail infections are more common.
Symptoms of fungal nail infections
Fungal nail infections can cause a variety of changes in the affected nail, including:
- white or yellow spots or streaks under the tip of the nail;
- nail thickening and roughness;
- brittle, crumbling nail edges;
- nail discoloration (nails may turn white, yellow or brown);
- separation of the nail from the nail bed; and
- pain and tenderness.
Fungal nail problems are caused by a fungus spreading under the nail into the nailbed. Different types of fungi can infect nails, including the dermatophytes, as well as some forms of moulds and yeasts. The fungus may infect a broken or injured nail, or may spread to the nail from a nearby skin infection, such as athlete’s foot.
Fungal infections can be picked up by walking barefoot in public changing rooms, pools, and showers. Anywhere warm and moist where the public walk barefoot is an ideal environment for the fungus to spread from person to person.
There are several factors that can put you at increased risk of developing a fungal nail infection. These include:
- having diabetes;
- having problems with your circulation;
- having a problem with your immune system;
- being older than 60;
- wearing footwear that is closed-in, has poor ventilation, and doesn’t absorb sweat;
- working in a humid or moist environment; and
- having constantly moist skin, often due to excessive sweating.
People involved in sporting activities such as running may be at increased risk of getting a fungal toenail infection because they often damage their toenails, which provides an opening for infections to get under the toenail. Also, wearing running shoes means that the feet are often exposed to warm, moist conditions, which are ideal for the development of a fungal infection.
People who frequently have wet hands, such as cooks and professional cleaners, are at increased risk of developing a fungal infection of the fingernails.
Your doctor will confirm the diagnosis by taking a scraping or clipping of the nail and sending it to a pathology laboratory for testing. This also identifies the exact type of fungus involved, which helps guide treatment.
Fungal nail infection treatments
Early treatment of fungal nail infections may prevent damage to or loss of the nail and treatment at any stage may reduce discomfort and improve the nail’s appearance. However, fungal nail infections can be difficult to treat, and can recur following successful treatment.
Also, because nails (especially toenails) grow slowly, it can take up to a year for the appearance of the nail to return to normal, even if treatment is successful. To check if your fungal infection has been successfully treated, your doctor may make a small scratch on the normal-looking new nail growing from the nail bed. As your nail grows, the appearance of the new nail growing behind the scratch is monitored. If the nail behind the scratch remains normal-looking, the infection has been treated and no further treatment is needed – the abnormal nail in front of the scratch just needs to grow out.
Fingernail infections can generally be cured more quickly and effectively than toenail infections.
Topical antifungal treatments
If the infection is superficial or involves only the end of the nail (less than half the total nail area), a topical (surface) treatment may be tried. However, sometimes these treatments will not penetrate the nail sufficiently to treat the infection.
There are several antifungal nail lacquers available that can be used to treat fungal nail infections, such as amorolfine (Loceryl), ciclopirox (RejuveNail Antifungal Nail Lacquer) and miconazole (Daktarin tincture).
Treatment with these topical nail lacquers should continue until a healthy nail re-grows (2 to 12 months). Nail polish, false nails or other cosmetic products should not be used on treated nails. These treatments should not be used by women who are pregnant or breast feeding, and are not recommended for use in children.
Another topical treatment that is available is Canesten Fungal Nail Treatment Set. The set involves 2 treatment phases: firstly softening and removing the infected parts of the nail with urea ointment and a plastic nail scraper (2-3 weeks); and then applying an antifungal cream (bifonazole) to the nail bed to treat the fungal infection (4 weeks). This treatment may not be suitable for children or pregnant or breast feeding women. Nail polish and artificial nails should not be used during treatment.
Possible side effects from local (surface) treatments include skin rashes, skin infection and irritation around the nail and nail discoloration.
Excilor Treatment for Fungal Nail Infection is a product that is available at pharmacies. The treatment is applied twice a day for a minimum of 3 months to the affected nail(s), using a special applicator. The main ingredient is acetic acid, and it can help treat fungal nail infections by penetrating the nail, making it more acidic and hostile to fungal growth.
Laser or photodynamic therapy is a new treatment for fungal nail infections. There is some evidence to show it is safe and effective in the short term, but its effectiveness long term is still uncertain. Treatment once every 3 months for up to 12 months may be needed to treat your fungal nail infection.
Oral antifungal medicines
More extensive infections (involving the base of the nail or the nail-bed) generally need oral antifungal medicine. The exact choice will depend on which fungus is causing the problem, whether you have other medical conditions, are pregnant or planning to become pregnant (some treatments may affect the unborn baby), and what other medicines you are taking. Oral antifungals include terbinafine (e.g. Lamisil), itraconazole (e.g. Sporanox) and fluconazole (e.g. Diflucan, Dizole). Treatment lasts from 6 weeks to 12 months or more, depending on the fungus in question and the site of the infection, with fingernails usually responding faster than toenails.
Oral antifungal medicines are associated with a number of potential side effects, including liver damage, skin rashes, headaches, gastrointestinal upsets (such as diarrhoea) and heart problems.
When medical treatments don’t work, another option is to remove the nail, either surgically or with chemicals. A new nail should grow back in its place.
Self-care and prevention
In addition to antifungal treatments, you can help manage a fungal nail infection (and prevent further infections from developing) by:
- keeping your nails short;
- filing down any thick areas;
- thoroughly drying your hands and feet, including between the fingers and toes, after washing; and
- using a separate pair of nail scissors for any infected nails.
For fingernail infections, protect your hands from moisture when doing wet work by wearing waterproof gloves. If a toenail is affected, wear open-toed shoes or shoes with plenty of room for your toes. Always wear clean, dry socks that absorb moisture, especially if your feet sweat a lot, and change your socks when they are damp from sweat. And remember not to walk barefoot in public change rooms, pools or showers.
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4. BMJ Group. Patient information from the BMJ Group – Fungal nail infections (updated 5 Dec 2012). http://bestpractice.bmj.com/best-practice/pdf/patient-summaries/532246.pdf (accessed Feb 2014).