Fungal Toenails

What is a fungal toenail?

Toenail fungus is also known as onychomycosis and is typically caused by dermatophytes, moulds or yeasts infecting the nail bed, matrix and plate of the nail. These fungal infections can present in a number of different ways, affecting your nail shape, colour and overall appearance.

But there’s no need to be alarmed, as although a fungal nail infection can look physically unappealing, it is one of the most prevalent nail conditions. It rarely has pain associated with it and will not have any major impact on your quality of life. In saying that, fungal nail infections are not self healing and should be treated to avoid spread and worsening of the infection. 

Causes

A fungal nail infection occurs when a fungal infection penetrates your nail. You can acquire this fungi from a number of sources including public swimming pools, unsterilised nail equipment, coming into contact with someone who has a fungal infection, and any other moist environments. 

Fungal nail infections are seven times more likely to occur on the toenails than on the fingernails as the inside of a shoe, where it’s dark, warm and moist, is the perfect environment for fungi to thrive.

The different types

A fungal nail infection can present itself in many ways. In fact, there are five core patterns of fungal nail infections that are categorised by their physical appearance.

  1. Distal lateral subungual onychomycosis is the most prevalent form of a fungal nail infection. This fungus starts from the surrounding skin and gets into the lower side of the nail plate through the free edge of the nail, then continues to spread to the nail matrix. When this occurs, thickening of the skin known as subungual hyperkeratosis develops and lifts the nail plate, usually associated with yellowish discoloration.
  2. Superficial onychomycosis, formerly known as superficial white onychomycosis, is a less common fungal infection. This form of fungus localises on the dorsum of the nail plate and forms colonies. Although usually superficial, this type of fungal infection can infiltrate the nail plate and spread to the proximal nail fold and cuticle. It usually presents with a whitish chalky appearance.
  3. Proximal subungual onychomycosis infiltrates deeper to the plantar aspect of the nail plate proximally and then spreads distally. This fungus forms a white patch or marking on the nail, and although uncommon, it can suggest the likelihood of a weakened immune system.
  4. Endonyx onychomycosis occurs when the fungus attacks the nail plate. With this form of fungal infection, the skin does not thicken between the nail and nail bed and will present as a milky white discolouration on the nail. 
  5. Total dystrophic onychomycosis is usually seen with long standing and untreated fungal infections. This results in a loss of nail structure and a thick and deformed nail. This form is highly prevalent in people with immunodeficiency from birth. 

Whilst fungal infections can usually be categorized into these 5 different types, it is not uncommon for people to have mixed patterned fungal infections. Due to these various patterns, a fungal nail infection can often be mistaken for other nail conditions or simply a discoloured and thickened toenail.

Who's at risk

Fungal nail infections can be acquired at all ages and ethnicities however are more often present in men rather than women and in adults more so than children. 

Although being common in such a diverse group, there are certain risk factors that heighten your chance of acquiring it. These include:

  • Being over the age of 65
  • Frequent use of shellac as the nail does not have time to break and it can become weakened and susceptible to infections 
  • Recurrent use of unsterilised equipment, especially if it has been in contact with other nails. 
  • Public swimming pools and change rooms 
  • Tight fitting footwear
  • Current nail injuries
  • Foot deformities
  • Certain sporting activities e.g. running or swimming
  • Existing medical conditions such as diabetes, HIV or tinea pedis (fungus on the skin of the foot)
  • Being immunocompromised or peripheral arterial disease
  • Obesity
  • Smoking 

Symptoms

Clinical appearance of the nail will usually alert your podiatrist to the presence of a fungal infection. They will be assessing or looking for:

  • Nail discoloration; usually yellowy whitish colour 
  • Nail deformities (thickening or brittle) with debris under the nail 
  • Nail detachment which is lifting 
  • Nail trauma
  • Malodour present 
  • Moisture in footwear

Even though these features are common for fungal infections, it must not be mistaken for other nail conditions such as a psoriatic nail condition, which have very similar appearance!

Our qualified podiatrists will perform a physical examination and if required, use diafactory tinea unguium diagnostic testing which has a 95-99% accuracy of all common dermatophytes. Therefore we can then confidently diagnose your fungal infection and begin treatment.

Treatment

It is important to consult your podiatrist for advice and preferred treatment plans as there are multiple factors that must be considered before starting a treatment pathway to resolve your fungal infection. These can include the type of fungal present, predisposition to antifungal drugs, comorbidities, drug interactions whether with medication or adverse effects, diet, age, compliance and cost.

1. PACT

Photodynamic Antimicrobial Therapy (PACT) is a safe and reliable treatment pathway for fungal nails. This treatment uses light interaction with photosensitive agents to penetrate the microorganism's cell wall. PACT kills off these cells without causing harm to the healthy tissues and usually only takes 3 sessions. 

A study conducted by Figueriredo et al. 2016 showed a 100% success rate in mild to moderate fungal infections and a 63.5% success rate for severe infections.

Consult 1

  1. Diagnosis with Diafactory fungal test
  2. Intensive debridement (chemical and mechanical)
  3. General foot care if required
  4. Dispense urea and dressing to the client to use at home daily for 3 days prior to the first PACT therapy.
  5. Dispense of Tinea cream or spray
  6. Provide in regards to fungal nail infection and education in treating contributing environmental factors. 
Consult 2 - 4 ( 1 week apart)
  1. Mechanical debridement
  2. Apply gel for 10 mins
  3. PACT laser for 9.5 mins per toenail
  4. Dispense urea and dressing to the client to use at home daily for 3 days prior to each PACT therapy.
  5. Advise to continue other implemented treatment and healthy foot habits
  6. Shoe zap can be done at these appointments
Consult 5

    Review 4-12 weeks after last PACT treatment to review the progress of the fungal nail infection and to ensure healthy nail is growing out. 

    2. Oral Medications

    Systemic or oral treatments can be used for all types of fungal infections. These oral medications are prescription medication and it is important to discuss your complete medical history and the common adverse reactions and side effects with your GP first. Doctors commonly order a blood test to check liver function and it will be monitored every 12 weeks for those at risk of adverse effects such as liver disease.

    Oral treatments can be taken for months until results are achieved in respect to the individuals liver and heart function and/or their resistance to the medication or adverse drug effects. This form of treatment has approximately an 85% success rate, however there can be many side effects ranging from; dizziness, headaches and skin rashes etc.

    3. Topical Nail Paints

    Local or topical treatments are over-the-counter medications and include ciclopirox nail lacquer, amorolfine nail lacquer (Loceryl) and Canesten. Topical treatments can be used as long as there is no involvement of the nail matrix. The dosal nail is filed down and painted with the chosen lacquer, which allows the active ingredient to diffuse into the unhealthy nail. 

    The efficacy rate is approximately 8-10% and can take upwards of 6 to 24 months to treat or notice a visible change at all. 

    In addition to this, it is recommended that you have podiatry treatments approximately every six (6) weeks during this time, so we can use sterile instruments (that limit the risk of cross contamination and re-infection) and mechanically de-bride the nail back so the topical agents are more effective. 

    Prevention

    Although a fungal infection may seem daunting, with these simple tips we can all stay fresh and fungal free. 

    • Dry your feet thoroughly after you shower or bath.
    • Keep your showers and floors clean.
    • Avoid having your nails painted all the time, give them time nail polish free. 
    • Avoid having regular shellac treatments. 
    • Wear thongs in communal showers or swimming facilities.
    • Keep your shoes dry and clean by airing them regularly. 
    • Avoid sharing shoes, socks and nail clippers.
    • Sweaty feet? Change your socks regularly.
    • Wear appropriate fitting shoes to minimise trauma to the nail.
    • Fungus dies in temperatures over 60 degrees — warm washing cycles for socks are the way to go!

    Additionally, if you get a pedicure at a nail salon, remember to ask the staff how they disinfect their equipment and how often they do it. 

    If you notice a change in your nail, consult your podiatrist as we want to start treatment straight away before the infection spreads to other nails or people.

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