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Fungal Nails (Onychomycosis)
Fungal Nails
(Onychomycosis) "Tho the world may be a jungle,
Not all funny nails are fungal."
Anonymous
People find funny-looking nails embarrassing, at least in part because everyone, from doctors to manicurists, more or less automatically calls them "fungus" (fungal nails). This makes them sound contagious and as if they are caused by poor hygiene.
The first thing to realize about fungal nails, therefore, is that if you think you have them, there is a fair-to-middling chance you don't.
What other conditions can be mistaken for fungal nails?
Here are some other conditions you may have instead of fungal nails: - Lines and ridges -- These are common and may be considered normal.
- Whitish or yellowish nails -- due to onycholysis. This means separation of the nail from the nail bed. The color you see is air. The treatment is to trim the nail short, don't clean under it, polish if you want to hide the color, and wait 2 to 3 months.
- Red or black nails -- due to a hematoma, or blood under the nail, usually from trauma (like wacking yourself on the thumb with a hammer). Goes away by itself.
- Green nails -- caused by pseudomonas bacteria, which live silently under many nails minding their own business. This bacteria grows under a nail that has partially separated from the nail bed, thereby producing a green pigment. No antibiotics are needed. The treatment is to trim the nail short, don't clean it, polish if you want to hide the color, and wait 2 to 3 months.
- Pitted nails -- May be associated with psoriasis or other skin problems that affect the nail matrix, the area under the skin just behind the nail. This is the area from which the nail grows.
- Swelling and redness of the skin around the nail -- called paronychia. This condition occurs when yeast infects a damaged cuticle. Applying a topical anti-yeast cream (such as one containing clotrimazole , miconazole , and terbinafine , which are available over-the-counter) for 2 months or so will usually work.
What do fungal nails look like?
There are many species of fungi that can affect nails. By far the most common, however, is called Trichophyton rubrum. This type of fungus that has a tendency to infect the skin (dermatophyte) and shows itself in the following specific and even peculiar ways, which are as striking as they are hard to explain. - The "moccasin" distribution. Fungal toenails are almost always accompanied by fine scaling which extends a little ways up the sides of the foot, like a little fungal bootie. Many people ignore this as "dry skin," which leads to the ironic situation that while some people think they have fungus when they don't, others think they don't have fungus when they do!
- Feet first! For some reason, fungus rarely affects the hands unless the feet are involved first.
- Two feet - one hand. Even stranger is the striking tendency of fungus to affect only one hand at a time. If one or more nails are yellowish and crumbly on one hand but not on the other -- and both feet are involved -- fungus is likely. Otherwise, this fungus is less likely to be the culprit.
Where does fungus come from?
So entrenched is the belief that you catch fungus from shower floors, locker rooms, swimming pools, and the unhygienic people who use them, that it seems almost a shame to point out that to a large extent it isn't so. Fungi are everywhere -- in the air, the dust, and the soil. The fungi carried on the coats of pets, like cats and dogs, don't often cause nail fungus. Hygienic measures such as spraying socks and footgear sound sensible and perhaps these measures can even help a little bit. However, avoiding tight, non-breathing shoes, or steering clear of athletic floors may very well be more trouble than they're worth. Wearing white socks also does not help. Daily washing of the feet and drying between the toes can help to prevent nail fungus.
One thing is sure, though: once fungus gets a foothold, so to speak, it hangs around indefinitely and often recurs even after successful treatment. Even people who usually resist infections quite well have an immunologic "Achilles Heel," which allows fungus to become entrenched.
Is nail fungus contagious?
No. Nail fungus is so common that finding more than one person in a household who has it is hardly more than a coincidence.
How is nail fungus treated?
Creams and other topical medications are usually not effective against nail fungus. This is because nails are too hard for external applications to penetrate. However, a new medicated nail lacquer ciclopirox (Penlac) Topical Solution 8% has been approved to treat finger or toenail fungus that does not involve the white portion of the nail (lunula) in persons with normal immune systems.
Oral medications that are effective against nail fungus include: - Griseofulvin (Fulvicin, Gifulvin, Gris-Peg). This drug has been the mainstay of oral antifungal therapy for many years. Although this drug is safe, it is not very effective against toenail fungus. Newer agents have largely supplanted it.
- Terbinafine (Lamisil). This drug is taken daily for 8 weeks for fingernail fungus and for 12 weeks for toenail fungus. The drug is safe, effective, and produces few side effects.
- Itraconazole (Sporanox). This is often prescribed in "pulse doses" -- one week per month for 2 or 3 months. It can interact with some commonly used drugs such as the antibiotic erythromycin or certain asthma medications.
- Fluconazole (Diflucan). May be given once a week for several months. The dosing of this drug may needed to be modified if the patient has impaired kidney function or is taking it simultaneously with certain other medications.
Are oral medications for nail fungus toxic?
Old reputations for toxicity die hard. Although many people still have the impression that antifungal pills are "bad for the liver," the newer drugs are really very unlikely to cause any liver problems at all, even minor and temporary ones.
What about the cost of oral medications?
A further consideration is cost. Because newer oral antifungal agents are very expensive, some insurance companies balk at paying for what they consider a "cosmetic issue," unless nail fungus causes pain or other functional symptoms.
Conclusion
Before treating fungal nails, be sure you really have them. If you do, though, you may no longer have to live with them if you don't want to.
Last updated on 07/19/2008
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