Why Seniors are at greater risk for nail fungus and harder to treat

Nail fungus, medically known as onychomycosis, is a common condition in adults and especially seniors. It consists of a fungal infection of the fingernails or the toenails, with the big toe or the little toe nails most frequently affected. Usual symptoms are a yellow or white discoloration as well as thickening and disfigurement of the nail. The condition is caused by a variety of types of dermatophytic fungi that invade the nail plate directly or through the surrounding tissue and then continue to spread by feeding off of the keratin proteins that make up the hardened surface of the nail plate.

Incidents of nail fungus are unusual in children but increase markedly with age. A large scale epidemiological  study[i] found that nearly 20% of those over 60 years of age in the United States were suffering from onychomycosis and it is estimated that half of the population over 55 will have at least one finger or toe affected by the time they are 70. So, as a senior, even if you do not have onychomycosis now, it is very likely you will have to deal with it at some point in the near future.

Unfortunately, aging often brings a number of complications that make nail fungus treatment far more difficult and the condition more dangerous. Circulatory problems, diabetes, depressed immune systems and lessened hygiene can substantially increase infection rates and coupled with slower nail growth, difficulty taking oral medicines that are hard on the liver and inability for insurance to cover expensive treatments make treating onychomycosis more challenging. Without proper treatment, finger and toenail fungus can become a chronic condition that can lead to dangerous complications as you get older.

  • Circulatory Problems – As people age, they are likely to experience problems with poor blood circulation as their activity level diminishes. They begin to have a progressive loss of muscle fibers which can make exercise more difficult and complications from diabetes can also impair blood circulation. Diminished blood circulation limits the nutrients the extremities needs to fight off fungal infections and it takes longer to heal and repair. Plenty of low impact exercise, massage therapy, hydro therapy (alternating hot and cold water) and vasodilators like nitroglycerin can keep the blood flowing properly.
  • Weakened Immune Systems – Seniors often have a range of medical issues that depress the body’s immune systems and increase vulnerability to invasion by pathogens of all types. Dermatophytic fungi, the primary cause for onychomycosis, can more easily spread from one person to another and from one digit to another where the normal defense systems have been compromised. Auto-immune diseases, immunodeficiency disorders and certain medications can further contribute to disabling the body’s natural defenses against fungal infections.

  • Slow Nail Growth – The rate of nail growth is inversely proportional to age. In healthy people, the average rate of nail growth in fingernails is 3.5mm per month, taking about 4-6 months to grow out and for toenails only 1.6mm per month, taking anywhere from 6 months to 12 months to grow out completely. Growth drops significantly as you get older, however, decreasing 0.5% each year between 20 and 100 years of age.[ii] The slower nail growth facilitates the spread of the infection throughout the nail and means it takes longer to get clear nails once the infection has been eliminated.

  • Diabetes– The additional pounds and resistance to insulin due to diets in highly processed foods are causing the rates of Type 2 Diabetes to skyrocket, most especially in the over 55 population. Diabetes causes poor circulation, particularly in the extremities, and weakens the immune system, and being weakened, the body has increased vulnerability to invasion by pathogens, including dermatophytic fungi. A fungal infection of the nail can cause the loss of the nail itself and increase susceptibility to a secondary bacterial or viral infection which can lead to amputation of the toe or finger.
  • Hygiene – Often hygiene can suffer when health deteriorates, as every day actions like bathing and changing clothes can become more difficult. This can make it much easier to contract nail fungus in the first place. When socks and shoes are not changed daily, it can make toenail fungus spread to other toes and the other foot and make it far more difficult to eradicate.  Best practices are to wash your hands (and feet when you can) with a good antimicrobial soap often and make sure to have clean socks at least once a day.
  • Trouble Taking Oral Medications – Podiatrists often prescribe Lamisil, an oral form of the antifungal medication terbinafine for patients suffering from nail fungus. While oral terbinafine can be reasonably effective in treatment, the drug causes significant duress on the patient’s liver. Unfortunately, many seniors and diabetics already have lowered liver function and cannot afford to risk further damage.

  • Lack of Insurance Coverage for Treatment – Treatment of onychomycosis is often not covered by most insurance plans or Medicaid unless there are already additional complications. When treatment is covered, usually only oral medication is made available while even more expensive methods like laser therapy remain out of pocket. Popular topical treatments are also not usually covered. This can represent an additional hardship in seeking successful treatment to those seniors who are on fixed incomes.

If you are a senior, nail fungus is a medical condition you will need to address now and in the coming years. The best course is diligent prevention and proper diet, exercise and general hygiene can go a long way toward keeping you “fungus free”. If, in spite of your precautions, an infection does occur or you have nail fungus now, it is important to get treatment with a strong antifungal like FixaFungus ToeNail Fungus Treatment as early as you can. By taking action sooner than later, you can keep the infection from spreading and help ensure successful therapy, while avoiding more dangerous complications and expensive medical visits.

 


[i] Ghannoum MA, Hajjeh RA, Scher R, et al. A large-scale North American study of fungal isolates from nails: the frequency of onychomycosis, fungal distribution, and antifungal susceptibility patterns. J Am Acad Dermatol. 2000;43:641-648

[ii] Singh G, Haneef NS, Uday A. Nail changes and disorders among the elderly. Indian J Dermatol, Veneveol Leprol. 2005;71:386–92.

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Can Lasers Be Used to Treat Toenail Fungus?

Onychomycosis, better known as toenail fungus, is an ongoing problem for a significant part of the population. This fungal infection can come from several sources which are very common in many environments and if left untreated, can eventually become very unpleasant and even dangerous. Estimates have shown that only around 20% of the people that suffer from a toenail fungal infection have actually been diagnosed by a podiatrist or other medical professional. Moreover, out of those diagnosed only around half have actually undergone treatment in order to eliminate this problem.

There can be a number of possible reasons for this. Some people do not see toenail fungus as a big deal. Others tend to ignore it until it starts to discolor or when it becomes painful. And some people simply cannot afford the medication. There are several treatment options but most of them are expensive and will require a long period of treatment before they are effective. However, with the continued progress of technology come new medical innovations and new techniques which are supposed to be superior to the ones we had before. This is apparently true for the treatment of onychomycosis, as well, which now benefits from a new method which uses lasers to kill the infection. However, there is still disagreement among medical professionals regarding whether this new technique is effective or not since the evidence to back it up has not been fully substantiated.

The Early Stages

Toenail fungus treatments using lasers have been practiced as early as 2009. One pharmaceutical company called Nomir Medical Technologies based in Waltham, Massachusetts began adapting a laser named Noveon in order to be used for nail treatments. This technology had already been in use for a long time in dental work, cataract surgery and even hair removal. The laser uses two different light wavelengths which can target and kill the fungi in the nails.

Only a small study has been made regarding the positive effects of Noveon. However, it showed that half of the 39 toenails which were exposed to the Noveon laser were free of infection just after four sessions (Singer). Out of those test subjects, 76% were growing regular toenails 6 months after the initial experiment.

With these encouraging results a number of podiatrists started using this method in order to treat their patients. In theory, there was no need for FDA approval thanks to a loophole which allowed doctors and other medical professionals to use products and technologies which were approved by the FDA previously for purposes others than the ones that they were originally intended for.

Skepticism Regarding Noveon

Thanks in part to the curious legality of using Noveon in order to treat toenail fungus infections as well as the limited research surrounding it there has been some criticism regarding its efficiency. At the moment, the number one treatment option for this kind of problem is Lamisil, a pill which is taken orally. This medication has been verified and approve by the FDA as being efficient at treating infection in 2 out of 3 people. This efficiency rating is bigger than the one obtained by Noveon in its small study so, in theory, it should have never been in doubt which one is the better method of treating this kind of infection. However, the selling point used by those that developed this technology as well as the podiatrists that use it is the lack of side effects which cannot be said about Lamisil. Use of this medication can come with headaches, rashes, diarrhea and in some cases it has even been linked to liver problems. In the meantime, the use of laser technology is advertised as being painless and safe which has attracted the attention of a lot of medical professionals.

In order to clear some of the confusion and controversy regarding the validity of laser technology in nail fungal treatment there has been one official study done focusing on the results and side effects of Noveon which was then published in the Journals of the American Pediatric Medical Association.

Their study took place over the course of 180 days where treatment using the laser was administered under strict supervision and following a tight protocol on days 1, 14, 42 and 120 (Landsman et al.). Each toe used in the study was evaluated, measured and photographed at different intervals throughout the 180 days. 26 toes were found to be suffering from onychomycosis: 10 of those cases were mild, 7 were moderate and 9 were severe.

After the 180 day treatment, an expert panel which was blinded in regards to which were the control and which were the treatment group evaluated the results and established that 85% of all the infected toenails saw some form of improvement and growth. At the end of the study, the researchers concluded that laser technology is a viable form of treatment for onychomycosis.

This study was seen as a significant strike for those advocating using Noveon technology to treat toenail fungus, but there were a lot of medical professionals that were still unconvinced. There are still some issues which have not been resolved. First is the price. This form of treatment is much more expensive than any other alternative. It usually costs around $1000, although in some cases the price went as high as $1500. Not only that, but at the moment it is not covered by any form of insurance. Lastly, there is still no work regarding the relapse rate. That is the only professional study done regarding this issue and there was no focus placed on relapse rate so there currently is no official number or even an estimate. Lamisil has a relapse rate of around 15% so it would need to be similar in order to be a viable treatment.

New Technologies

Since laser technology started gaining popularity there have been other companies which have been working on their own treatments. At this moment, the best is a company called PinPointe which has developed its own laser. There is one advantage to using this new technology and that is the fact that it is FDA-approved. In the study submitted and approved by the US Food and Drug Administration this laser technology has shown improvements in 70% to 80% of all patients after just a single 30 minute treatment. 81% of them had sustained growth after 12 months.

These results seemed very promising and they have renewed faith in laser technology as a viable treatment in the future. Since then there has been another laser cleared by the FDA called GenesisPlus. There is no clear benefit to using one or the other. Each treatment comes with the steep price of around $1000 and there still is no clear indication regarding how effective this method is at preventing any further infections after a longer period of time. It will take a few more years until there is a definite consensus regarding the efficiency of this new method and, until then, people who can afford to undergo laser treatment only have a financial loss to fear as there are no negative side effects towards using any of the lasers available.

Works Cited
Adam S. Landsman, DPM, PhD , Alan H. Robbins, MD , Paula F. Angelini, DPM , Catherine C. Wu, DPM , Jeremy Cook, DPM , Mary Oster, BS and Eric S. Bornstein, DMD. “Treatment of Mild, Moderate, and Severe Onychomycosis Using 870- and 930-nm Light Exposure”. Journal of the American Podiatric Medical Association Volume 100 Number 3 166-177 2010.
MarylandPodiatrist.net. Web. 10 Jul. 2012.
Singer, Natasha. “False Start on a Laser Remedy for Fungus”. NYTimes.com. 19 Mar. 2009. Web. 10 Jul. 2012.

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The Link between Candida and Nail Fungus

What Is Candida?

Candidiasis, more commonly known by most people as Candida, is a fungal infection. It is also a systemic infection in the sense that it can spread from one area of the body where the initial infection occurred to various other parts by travelling through the bloodstream. This particular fungal infection can be found in a litany of different body parts, presenting itself with different symptoms and causing different problems in each particular case. One instance of Candida can spread to the toe or finger nails, causing a type of onychomycosis or nail fungus.

Candida can cause a lot of health problems and some of them can be very serious. This is mostly due to the fact that it can stay for a long time in a person’s body before it gets detected and during that time the infection can spread. It is also quite difficult to treat since it must be eradicated completely otherwise it will simply spread again in time.

Can Candida Lead to Nail Fungus?

Candida can travel through the bloodstream and infect all parts of the body. This can lead to common problems such as vaginal infections or thrush in the mouth, but it can also cause one other common fungal infection which usually is blamed on another fungus altogether: toenail infections. There are four different types of fungal infections which can spread to the toenail which are currently recognized by the American Podiatric Medical Association. The first three are caused by dermatophytes and include distal subungal onychomycosis which is the most common type found in people, white superficial onychomycosis, proximal subungal onychomycosis and lastly there is a fourth kind of infection which is caused by Candida. This is the least common type of toenail infection, which is why many people are not aware of it but it is quite common for fingernail infections. While most toenail fungus infections are due to dermatophyte fungi, almost 50% of fingernail fungal infections are caused by candida. If you have symptoms of nail fungus on the fingernails you should be checked by a medical professional for candidal overgrowth. Candidal onychomycosis is also more prevalent in children than adults, especially in children that suffer from a genetic disorder known as chronic mucocutaneous Candidiasis. This disease causes an excessive growth of the Candida fungus to target areas such as the nails, mouth and scalp.

People can look for symptoms in order to determine what kind of toenail infection they have. In the case of the yeast infection, the nail will turn green or yellow and, with time, it will get more opaque. It is possible for the skin which surrounds the nail to have puss and swell up which will cause a lot of discomfort and, in some cases, even serious pain. It is best to start treatment right away otherwise the pain will only get more intense as the infection progresses. The nail will continue to get thicker if left untreated and during more advanced stages the nail plate can detach completely from the nail bed which is called onycholysis. The sooner treatment with an effective agent like Toenail Fungus Treatment occurs, the greater probability of a successful cure before there is significant damage to the nail or surrounding tissue.

How Do People Get Candida?

Candida is already present in the human body. It is a fungus which occurs naturally and it actually helps people with their digestion. However, the medical problem known as Candidiasis comes from an excess growth of the production of this fungus in the body which will then lead to the systemic infection which can cause various health issues.

As a disease, Candidiasis has only been recognized relatively recent so precise and detailed information regarding its causes, treatments and other topics is still a little scarce. However, there are several known causes to this date which have been reviewed and approved by the medical society[1]. The main cause of this excessive fungus growth is antibiotics. They are very efficient at destroying the harmful bacteria which has infected a person’s body, but in doing this it also damages the beneficial one which keeps our bodies in check. This allows microorganisms that can develop and spread fast such as Candida to increase its presence in the body dramatically. Best course of action would be to avoid taking antibiotics when there are other alternatives available. There are plenty of minor medical issues such as a cold which some doctors prescribe antibiotics for but the reality is that they can be easily treated with a lot of different other types of medication.

While antibiotics are the leading cause of Candidiasis, they are by no means alone. The regular diet of a person also contributes heavily. This fungus grows faster if it has access to a sugar rich environment, so people that eat a lot of sugar are more likely to get this infection. Women have an increased risk of contracting nail Candida since they are exposed to one particular cause which men are not: contraceptive pills. Lastly, ingesting chlorine can also have the same effect. Chlorine is a powerful disinfectant which can sometimes be found in drinking water and often in swimming pools. Like antibiotics, it destroys the friendly bacteria in the body, allowing other microorganisms to develop at a much faster rate than usual. This is why those active in water sports and people who tend to work with their hands often submerged in water are more likely to be infected with Candidal Onychomycosis or candida of the nail.

How Is Candidiasis of the Nail Treated?

There are several different types of treatment available in order to treat Nail Candida and most of them do not differ significantly from the treatments used for onychomycosis. Oral medication is still the most common form of treatment. Some of the medicine prescribed for toenail fungus includes Lamisil and Sporanox. Each contains particular ingredients which fight off the infection and may be successful at preventing future recurrences. However, they can come with a lot of nasty side effects. In fact, some of them can even be dangerous than the original fungal infection as there has been a link made between Lamisil and liver damage in some people. Treatment of nail fungus with oral medication requires a lengthy use of medication that can be harmful where people also suffer from other medical ailments. This is perhaps most critical in people with candida, considering that they are likely to already have a weakened system, and thus it is recommended to seek alternatives, where possible.

Using antifungal ointments or lacquer is another common choice. One common polish used in this treatment is called Penlac which is applied directly to the top of the nail. The problem with Nail Candida as opposed to other types of toenail fungal infections is the fact that the nail gets thicker and thicker. This can prevent almost all of the medication applied to the toe to not be able to penetrate the nail and reach the infected area. A lot of the times most of the active substance in the medication disperses onto the skin surrounding the infected nail and only a fraction actually gets absorbed by the nail bed. This can lead to various problems such as taking too long for the medication to be effective or it simply not working at all. Almost all topical treatments for nail fungus have this limitation. Unless a comprehensive treatment  with a penetration agent like Keratrate is used to make the nail bed permeable followed with a strong multi-class antifungal drug, it is unlikely that topical treatment will have high success rates in Nail Candidiasis.

There is also the option of using various types of lasers in order to treat the infection. There are a few which have been FDA approved, but their results at this time are still relatively inconclusive since enough studies regarding their efficiency have not yet been performed.

 

References

[1] Kauffman CA. Candidiasis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 359

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Minimizing the Effects of Toenail Fungus

Is Toenail Fungus Contagious?

Developing a toenail fungus is a common problem for a lot of people. It can be caused by a lot of different things so the chances of someone dealing with a fungal infection during their lifetime are rather high, especially as they get older. This is a medical issue which can be treated, but most treatment options require a long period of time before they take care of the problem completely and eradicate the infection from the body. This can lead to a few worrisome questions for people: If I have a toenail fungal infection, how likely am I to pass it on to someone else? If it is such a common medical problem, how likely am I to get it from someone else?

The truth is that this is a fungal infection and, like all fungi, it is contagious. A fungus can spread throughout a person’s body by traveling through the bloodstream and it can also jump to another person. However, Dr. Andrew Schneider of the American Podiatrist Association mentions that the chances of catching this particular fungus are very slim. In a lot of the cases when one person has contracted the infection from someone else that patient already has an additional infection such as athlete’s foot which increases the chances that the onychomycosis can spread from one human to another.

Excluding the case of an additional infection, the other way in which a person could catch a toenail infection from another person is through prolonged and/or intimate contact. Exposing the nails to areas or items which have also been in contact with an infected nail such as sharing bathrooms or public showers at the gym will increase the likelihood. Podiatrists note that sharing socks or shoes is one of the fastest ways to catch a toenail infection from someone else and it is strongly advised against. In order to prevent spreading the infection as much as possible people that have been diagnosed with this problem should seek out treatment as soon as possible.

How Do You Get a Toenail Fungus?

A toenail infection can occur in anybody, but there are some which are definitely more susceptible to this problem than others. The European Academy of Dermatology lists aging as the number one risk factor which can contribute towards getting a toenail infection[1]. This is due because the toenails will grow more slowly and will become thicker in older people and this makes it easier for the fungus to infect the area. There is also the poorer blood circulation to contend with which also helps the infection spread faster.

There can be a genetic predisposition for this infection. If a person is aware that toenail infections are in his family medical history he should be more vigilant as he is exposed to an increased risk of catching this fungus. Studies conducted by the Dermatology Academy revealed that this predisposition is found more in men than women. In the sample test conduced, men were almost twice as likely as women to show signs of the toenail infection.

A Gym Shower Is a Common Source of Fungal Infection.

The environment also factors heavily on the ability for this fungus to spread. Like any other fungus, it develops faster in a humid or moist environment. This means that people that work or are around such areas for longer periods of time have an increased likelihood of catching this infection. Additionally, being in situations where heavy perspirations occurs only creates a more suitable and inviting environment for the fungus. Things can be made even worse by wearing socks and shoes from materials and fabrics that do not allow the skin to breathe and be properly ventilated. They do not absorb the perspiration and increase the chances of getting infected.

How Can You Decrease the Chances of Catching this Toenail Infection?

People can severely decrease the chances of catching a toenail infection with a few minor adjustments to their personal habits. The biggest factor which can contribute towards this goal is an increase in hygiene. Washing the feet frequently as well as using foot powder will not allow the fungus time to infect your body.

The Mayo Clinic lists a couple of very useful tips for toenail prevention which have been reviewed and approved by the American Academy of Dermatology. First of all, people should make sure to dry their feet whenever possible. Whether it is after a shower or simply in the cases of people that perspire a lot, creating a dry environment is the best way to keep a fungus away. There are a lot of antiperspirant sprays available which can be used in order to keep a foot from sweating too much and creating a moist environment where the fungus can thrive.

Proper grooming of the toenails can also help avoid this problem in the future. By cutting them straight and often it prevents the nails from hitting against the insides of shoes. This can lead to the nail cutting the skin underneath which makes it a lot easier for a fungus to infect the foot.

People that work out a lot have a bigger likelihood of contracting this infection. That is because they perspire a lot more and some of them also have some habits which are not advised. For one, they should always make sure that their workout shoes are always dry before using them. They should be stored in a cool and dry place and not in common storage areas such as a locker or a car trunk. Ideally, people should use several different pairs of shoes for workouts and rotate between them so they have enough time to dry out.

What to do when You Are Infected?

Flip Flops Are the Best, but They Need to Be Washed Regularly.

Even with vigilance, sometimes a toenail infection still occurs. In these situations, the person infected has a responsibility to increase his awareness regarding his actions in order to minimize the chances of infecting other people. First off, they should look into treatment alternatives right away. After that they will need to take a few precautions and make some changes to their daily routine.

They need to avoid sharing any of his socks or shoes with anyone else because this will severely increase the chances of him spreading the infection around. They should also be careful to thoroughly clean the shower after they use it, especially if they share the bathroom with other people. They should avoid walking around barefoot because he can spread the fungus around. Avoiding walking barefoot is also a very good tip for people that do not want to be infected. On the other hand, it is also recommended to allow the feet as much air time as possible so not using socks or shoes works best. Usually, sandals or flip flops are the best in these situations. In the event that this is not possible, cotton socks are the best alternative since they allow the feet to breathe more than any other material. However, they should be changed frequently. Eliminating the environment in which the fungus thrives is the best way to ensure that it does not get the chance to grow and spread.


[1] Siqurqeirsson, B. Steingrimsson, O. “Risk Factors Associated with Onychomycosis”. Journal of European Academy of Dermatology. Jan. 2004

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What’s growing on my toenail?

Recognizing different types of nail fungus

Fungal infections of the nail plate or nail bed are collectively called onychomycosis or tinea unguium .  These infections account for approximately one-half of all nail disease, and one-third of all fungal infections of the skin.1,2  Onychomycosis is becoming increasingly common worldwide, particularly in Western countries; approximately 10 % of the general public suffer from nail fungus.  This increases to 50 % of individuals over the age of 70, and up to 1 in 3 individuals with diabetes.  Elderly and diabetic individuals are both at increased for toenail fungal infections due to decreased blood supply to the feet and weakened immune systems.4,5  While not usually life-threatening, these infections can cause embarrassing disfigurement and pain, to the point of interfering with the quality of daily life. Fungal infections of the toenails also have the potential to spread to other parts of the body.

Understanding nail anatomy can help in understanding the different ways fungus can infect the nail.  The growth center of the nail is called the matrix; the distal part of the matrix is visible as the light-colored half-moon at the bottom of the nail (the lunula). The remainder of the visible nail is called the nail plate.The nail plate grows by extending over the nail bed, the supportive layer of connective tissue underneath the nail. The most distal part of this nail bed is called the hyponychium.Toenails grow at a rate of only 1 mm per month, so it typically takes between 12 and 18 months to completely replace a great toenail that has been disfigured by fungal infection, and between 4 and 6 months for a little toenail.7   The rate of growth is slowed even further with increasing age; between the ages of 25 and 100, the rate of growth slows approximately 1% every two years,5  possibly due to decreased blood flow and decreasing circulating levels of human growth hormone (HGH).  Given this slow rate of growth, prompt Toenail Fungus Treatment in the early stages of infection can significantly decrease the amount of time and money required to regain the appearance of a healthy nail.

Four main types of onychomycosis (nail fungus) 

Toenail fungal infection is divided into four main types. The first three, distal subungual onychomycosis, proximal subungual onychomycosis and white superficial onychomycosis, are based primarily on where the infection starts in the nail. This can be at the nail tip (distal), at the base near the cuticle (proximal) or on the surface of the nail (superficial). The fourth subtype, candidal onychomycosis, is based on the infecting organism, candida. The below table helps to summarize the key characteristics of the four main types of toenail fungus.

Distal subungual onychomycosis

The most common type of toenail fungus is distal subungual onychomycosis (DSO) and distal subungual lateralonychomycosis (DLSO) . This infection is usually caused by Trichophyton rubrum, a fungus that also causes athlete’s foot and jock itch; most patients with distal toenail fungus have an accompanying athlete’s foot infection (also called tinea pedis).  Individuals with a family history of toenail fungus may be more likely to develop this distal infection; researchers have discovered that follows an autosomal dominant (form of genetic inheritance) pattern within families.8

The fungus invades the nail bed under the nail, beginning at the distal portion (the hyponychium) and gradually growing inward toward the nail matrix at the base of the nail.2,9  The infection can also enter via the lateral folds on the side of the nail. As the infection spreads, the associated inflammation worsens. This can result in onycholysis, or separation of the nail from the nail bed. The fungal infection also results in thickening of the tissue under the nail, the subungual tissue and will often appear as yellow and “crumbly”. This thickened tissue serves as a breeding ground for bacteria and molds, resulting in the typical yellow or brown appearance.10

The chart above depicts the appearance of a distal fungus infection of the toenail with lateral entry. The affected portion of the nail is thickened and yellow-brown in color, with irregular erosion of the nail tip. If left untreated, the infection is likely to spread throughout the entire nail.

Proximal subungual onychomycosis

Proximal subungual onychomycosis (PSO) is a relatively uncommon form of nail fungus in the general population. As opposed to distal nail infections, proximal toenail fungus starts near the cuticle, invades the newly formed nail, and grows outward toward the tip of the nail. The fungus Trichophyton rubrum is also the most common agent responsible for proximal nail infections, although the association with concurrent athlete’s foot is not as strong.  Proximal fungal infection can be seen in the setting of trauma (damage) to the cuticle or proximal nail.11   Unlike distal toenail fungus infections, the surface of the nail usually remains smooth and regular. However, because the infection involves the proximal nail near the matrix, or source of new nail tissue, severe proximal fungal infections have the potential to destroy the entire nail unit.

While proximal nail fungus infections are uncommon in the general population, they are seen commonly in patients with HIV/AIDS. In one study of patients with both AIDS and onychomycosis, nearly all (88.7%) had the proximal subungual subtype.12    The association is so strong that many doctors consider proximal nail fungus infection as an early sign of HIV infection, especially in younger patients. PSO can also occur in those who have other factors that lead to a compromised immune system, such as diabetics and those taking antibiotics over long periods.

The above table depicts proximal fungal infection in a toenail.  An area of whitish or yellowish discoloration develops in the proximal nail in the region of the lunula (half-moon). The nail remains fairly thin and regular.

White superficial onychomycosis

White superficial onychomycosis (WSO) accounts for approximately 10% of nail fungus cases.9   The most common causative agent is a fungus called Trichophyton mentagrophytes var interdigitale. These fungi directly invade the superficial layers of the nail. Because the infection predominantly involves the superficial nail and not the underlying connective tissue, the degree of associated inflammation is relatively mild.

There is a less common presentation of WSO consisting of a diffuse (involving the entire toenail) and deep infection of the nail. This is usually associated with infection by more aggressive molds including Fusarium sp. and Aspergillus sp, in otherwise healthy adults, or with infection by Trichophyton rubrum in children and immunocompromised individuals with HIV/AIDS.13  This subtype is no longer considered a superficial infection, and has the ability to progress to total dystrophic onychomycosis (see below).

White superficial toenail fungus is characterized by opaque white patches on the nail.  Each of these white patches represents a separate colony of fungi.13  As the infection progresses, the patches can grow together and involve the entire nail, which becomes soft and crumbly.9

Candidal Onychomycosis

Candida is a blanket term for a number of related species of yeast, a type of fungus.  These yeast live on the skin and mucus membranes (the moist linings of cavities such as the mouth and vagina), and typically do not cause problems.  However, in some individuals, the yeast become so numerous that they cause infections, known collectively as candidiasis. Individuals with chronic (long-lasting) candidiasis of the skin and mucus membranes are at risk for developing candida infections of the nails. Candidal infection most commonly involves the fingernails, although the toenails can also be affected. Yeast infections of the nails are more common in people who frequently immerse their hands or feet in water.14

The most common form of candidal nail infection begins as an infection of the soft tissue structures surrounding the nail; this swollen, reddened pad is known as a paronychia.15    The nail becomes involved only after the infection spreads from the soft tissues into the adjacent nail plate. When the nail matrix at the base of the nail becomes infected, transverse grooves (Beau’s lines) can appear, and the nail becomes irregular and rough.7

A second form of candidal toenail infection is much less common, accounting for fewer than 1% of fungal onychomycosis. Like proximal subungual onychomycosis, this infection is seen primarily in immunocompromised patients (patients with poorly functioning immune systems, like those with HIV/AIDS). In this setting, the yeast can directly invade the nail plate without first involving the surrounding tissues. The affected toes can start to look rounded on the end, like a “chicken drumstick”.9

 The table above depicts a candidal toenail infection, with edematous (swollen) surrounding soft tissues and a markedly thickened irregular toenail.

Total dystrophic onychomycosis

All of the four subtypes of toenail fungus can result in an end-stage disease known as total dystrophic onychomycosis, which involves the entire nail unit. In dystrophic onychomycosis, the nail matrix (source of new healthy nail tissue) may become permanently scarred, and the nail plate can be completely destroyed.

This image depicts total dystrophic onychomycosis of the great toenail. Note involvement of the entire nail, which has a shrunken, dystrophic (misshaped) appearance.

Toenail fungus: final thoughts

If you have a toenail or toenails that are thickened and irregular, or have an abnormal color, particularly yellow-brown or white, this may indicate a fungal infection.

Hopefully, this overview has given you a better idea of what causes toenail fungus, and what might be growing on your toenail. It is important to note that ignoring toenail fungus will not make it go away; fungal infections do not resolve on their own without treatment. Prompt intervention with agents such as FungicillinTM  can help to stop the insidious spread of toenail fungus, and speed the reappearance of a healthy toenail.

 

References

1. Scher  RK, Coppa  LM.  Advances in the diagnosis and treatment of onychomycosis.  Hosp Med.  1998;34:11–20.

2. Crissey  JT.  Common dermatophyte infections. A simple diagnostic test and current management.  Postgrad Med.  1998;103(2):191–1,197–200,205.

3   Thomas J, Jacobson GA, Narkowicz CK et al. Toenail onychomyocosis : an important global disease burden. J Clin Pharm Ther. 2010 Oct;35(5):497-519.

4. Gupta AK, Konnikov N, MacDonald P et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Dermatol. 1998 Oct;139(4):665-71..

5. Singh G, Haneef N, A Uday. Nail changes and disorders among the elderly. Ind J Dermatol Venerol Leprol. 2005;71:386-92

6. Clinical Courier. New strategies for the effective management of superficial fungal infections. Clin Courier. 1997;16:2–3.

7. Cohen J L, Scher R K, Pappert A S. The nail and fungus infections. In: Elewski B, editor. Cutaneous fungal infections. New York, N.Y: Igaku-Shoin Inc.; 1992. pp. 106–122.

8. Scher  RK, Coppa  LM.  Advances in the diagnosis and treatment of onychomycosis.  Hosp Med.  1998;34:11–20.

9. Elewski  BE.  Onychomycosis: pathogenesis, diagnosis, and management.  Clin Microbiol Rev.  1998;11:415–29.

10. Cohen J L, Scher R K, Pappert A S. The nail and fungus infections. In: Elewski B, editor. Cutaneous fungal infections. New York, N.Y: Igaku-Shoin Inc.; 1992. pp. 106–122.

11. Rodgers P, Bassler, M. Treating Onychomycosis. Am Fam Physician. 2001 Feb 15;63(4):663-673.

12. Dompmartin D, Dompmartin A, Deluol A M, Grosshans E, Coulaud J P. Onychomycosis and AIDS: clinical and laboratory findings in 62 patients. Int J Dermatol. 1990;29:337–339.

13. Piraccini B, Tosti A. White Superficial Onychomycosis: Epidemiological, Clinical, and Pathological Study of 79 Patients. Arch Dermatol. 2004;140(6):696-701.

14.  Evans  EG.  Causative pathogens in onychomycosis and the possibility of treatment resistance: a review.  J Am Acad Dermatol.  1998;38(5 pt 3):S32–56.

15. Scher R K. Diseases of the nails. In: Conn H, editor. Current therapy. Philadelphia, Pa: The W. B. Saunders Co.; 1990. pp. 736–742.

16. Singal A, Khanna D. Onychomycosis: Diagnosis and management. Indian J Dermatol Venereol Leprol 2011;77:659-72

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Is it Nail Fungus or Psoriasis?

What Are They?

Nail Fungus and Psoriasis of the Nail are sometimes confused with one other, causing disappointment when treatments for one don’t work for the other.  Even with today’s technology and with the easy access to plentiful information, most people are not medical experts. Just because someone can look up a few symptoms on the Internet does not mean that he has the expertise or experience necessary in order to make a proper diagnosis. Doctors and other medical professionals still have problems diagnosing a host of different illnesses and conditions so an expert opinion should always be sought out whenever the case may warrant it.

Part of this problem is the fact that so many different diseases and medical issues can present themselves with similar symptoms and it takes a very skilled and trained eye to spot the difference. A good example of this is onychomycosis and psoriasis of the nail. Onychomycosis is a fungal infection which presents itself in the toenails as well as the fingernails. It comes in several different variants and can be caused by multiple types of dermatophyte fungi. One of the variants of nail fungus is known as white superficial onychomycosis and it shows up with similar symptoms to psoriasis of the nail. Psoriasis is a chronic skin disease which causes patches of red skin which also has silvery scales to appear on areas of the body such as the scald, torso, knees and elbows. However, it can also appear on the finger and toenails, resembling onychomycosis.

This similarity between the two diseases can cause some people to seek treatment or to purchase medication immediately without consulting with an expert and they can accidentally purchase the wrong one. While it is true that people with onychomycosis should start to use some sort of nail fungus treatment as soon as possible because it can take some time for it to have a full recovery, it is also important to be sure regarding the type of disease a person has before any form of treatment begins.

 nail-fungus-WSO-fixafungus  nail-psoriasis-fixafungus

Figure 1. White Superficial Onychomycosis.

Figure 2. Nail Psoriasis.

According to the American Academy of Dermatology and the National Psoriasis Foundation as many as half of the people that have skin psoriasis can also have nail psoriasis. However, only about 5% of the people that have nail psoriasis do not have the skin affliction as well[1]. That means that the potential for a misdiagnosis between the two similar conditions is possible only in 5% of the people that already suffer from nail psoriasis. However, medical records show that this kind of misdiagnosis happens on a regular basis for one of two reasons: either the patient does not consult with a dermatology expert or other areas of the body are not checked during consultation.

 The Symptoms of the Two

The main reason for the confusion caused between the two conditions is the fact that they both turn the nail white. That means that people that rush to a conclusion or simply those that are not aware of one of the conditions can mistake one for the other. However, they both present themselves with a lot more symptoms which can be used to make a clear distinction between the two.

The aspect of the conditions might be similar to the layman, but they should not be able to fool a trained professional. White onychomycosis causes the nails to look dystrophic (damaged) with subungual hyperkeratosis or scaling. At the same time, psoriasis can also makes the nails appear dystrophic but with pitting on the surface. While both ailments can be found in both finger and toenails, onychomycosis is usually more common in toes since it is a fungus which thrives in a wet or damp environment while psoriasis of the nail affects fingers more commonly. The dystrophy of the nails is a lot more pronounced in the case of onychomycosis which can lead to more discomfort and even pain. On the other hand, psoriasis can cause the nail to suffer from discoloration which comes in the form of oil spots. Lastly, the most telling symptom of each disease is the way in which it can affect other areas. Most cases of nail psoriasis also come with skin psoriasis on other parts of the body which causes silver scales to develop. At the same time, the toenail fungal infection which causes onychomycosis can spread to other areas such as the scalp or the groin.

There has been a study conducted which aimed to determine whether there is a link between the two illnesses. The study encompassed 561 patients that suffered from psoriasis who had their nails examined. Out of these, the number of people with onychomycosis was found to be 1.56 times higher than the average considering the age and gender of the study subjects[2].

Treatment of the Two Conditions

 Although the symptoms of the two diseases might seem similar at times, even enough to fool most people into making a wrong diagnosis, the treatments for them differ wildly. Onychomycosis can be treated with various different medications. Pills which are taken orally are the most common such as Lamisil. However, they require a long treatment period and can come with a lot of unpleasant side effects and even dangerous ones such as liver damage. For that reason, many people prefer to stay away from them. New advances in technology have allowed lasers to be used in order to treat this condition to somewhat mixed results. While it does prove to be efficient at dealing with fungal infections, its high expense and the high chance for relapse recommend more studies to be performed before pursuing that option.

The easiest and least expensive course of action for treating nail fungus involves using various topical ointments or lacquers which can be applied directly to the nail. It is important when using a topical treatment to make sure that the antifungal, like Fungicillin™ is able to eliminate the infection by multiple pathways or the fungus can become resistant to a single drug.  Even more important is that the product has incorporated a strong penetration enhancer like Keratrate™ that is able assist the antifungal in penetrating the nail plate to reach the affected area. Otherwise, the topical ointment is simply dispersed and while some may be absorbed into the skin surrounding the infected toenail, most of the medication will not have effect.

Psoriasis of the nail currently does not have a definitive cure which will eliminate the problem forever. The current treatments seek to improve the appearance as well as the function of the affected nails. These can include injections of steroids which are done directly into the nail bed, while some cases can benefit from systemic therapy using methotrexate or systemic retinoids[3]. These are all complemented by using ointments and creams which contain vitamins A or D and also contribute towards improving the overall appearance of the nails.

In more extreme cases of nail psoriasis a doctor can have the affected nail removed either surgically or chemically. They are both painless, as the surgical option uses a local anesthetic and the chemical alternative uses a lotion which causes the nail to fall off by itself without any bleeding in around 7 days. Additionally, a therapy known as PUVA has also shown to have good results. It uses a combination of exposure to ultraviolet lights together with prescription drugs in order to drastically reduce the effect which the disease has on the nail. The type of treatment used will differ from case to case depending on whether the patient also has signs of psoriasis in other areas of the body.

 


[1] Alai, N. Cole, G. Shiel, W. “Psoriasis”. MedicineNet

[2] Gupta AK et. al. “A Higher Prevalence of Onychomycosis in Psoriatics Compared with Non-Psoriatics”. Journal Watch Dermatology.

[3] Stollery, N. “Onychomycosis VS Nail Psoriasis” GPOnline

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