Fungal Nail Infections (Tinea Unguium)
Fungal infection of nails particularly toe nails is fairly common, it is less common in fingernails. The infection causes thickened and unsightly nails which sometimes become painful. Prescription medication often works well to clear the infection but you will need to take medication for several weeks.
Who develops fungal nail infection?
This type of infection is more common in people aged over 60 and in the younger population where there is sharing of communal showers areas, such as swimmers, athletes and sportsmen and women.
Are there any tests for fungal nails?
Other nail conditions can sometimes look like a fungal infection. Your Chiropodist Podiatrist will be able to confirm if there is a fungal infection. Your doctor will usually require a nail clipping and send it off for testing.
How does fungal infection develop in the nail?
It could spread from a fungal skin infection. For example, athlete’s foot (tinea pedis) is a fungal skin infection of the toes. This may spread to the toenails if the skin infection is not treated early.
After a toenail infection has become established fingernail infection may occur.
It may spread to a finger if you scratch your itchy toes and toenail.
Fingernail infections are also more likely to occur for certain occupations where it is necessary to wash your hands frequently, or have them in water a lot. For example, if you are a cook or a cleaner. Constant washing may damage the protective skin at the base of the nail. A nail that has recently been damaged is also more likely to become infected.
You have an increased risk of developing a fungal nail infection if you have various other conditions -for example:
- Poor circulation.
- Poor immune system.
- A general poor state of health.
Nail infections are more common in people who live in hot or humid climates, less of a problem perhaps in the UK where we experience a moderate climate.
Smoking also increases the risk of developing a nail infection.
What are the symptoms of fungal nail infection?
At first the infection is usually painless, often the infection appears in just one nail but several may become affected over time if action isn’t taken. The nail may look discoloured (greenish-yellow or whitish-yellow) and show signs of thickening. In most cases this is all that occurs and it often causes no other symptoms other than looking unsightly.
Should the infection become worse, white or yellow patches may appear where the nail has come away from the skin under the nail (the nail bed). The nail may become soft and crumble. Bits of nail may fall off. Sometimes the whole nail comes away. The skin next to the nail may show signs of inflammation. If left untreated, the infection may eventually destroy the nail and the nail bed, and may become painful. Walking may become uncomfortable if a toenail is affected and there is restricted room in the footwear.
What is the treatment for fungal nail infection?
It is recommended that mild fungal infections should be self-treated by the patients using a paint treatment such as Loceryl or Emtrix these may help prevent spread of the fungus in mild infections. The antifungal medicines used for treatment need to be taken for 3-6 months.
Treatment is usually advised if:
- Symptoms are troublesome. For example, if walking is uncomfortable due to an affected nail.
- Abnormal-looking nails cause distress.
- You have diabetes, vascular disease or a connective tissue disorder (because of a higher risk for secondary bacterial infections and cellulitis).
- The nail infection is thought to be the source of a fungal skin infection on your body.
- You have, or are likely to develop, severe problems with your immune system. For example, if you are to have certain types of cancer treatment.
What Medication is there for fungal nail infection?
Antifungal tablets will often clear a fungal nail infection. The medication will also clear any associated fungal skin infection, such as athlete’s foot (tinea pedis). Your doctor will usually recommend one of the following two medicines. The one chosen may depend on the type of fungus causing the infection. Both of these medicines cause side-effects in a small number of people, so please read the packet that comes with the medicine for a full list of cautions and possible side-effects.
- Terbinafine The usual adult dose is 250 mg once a day; for between six weeks and three months for fingernails, and for three to six months for toenails. Visible improvement can be expected after the end of two months of treatment for fingernails and three months of treatment for toenails.
- Itraconazole This is usually given as pulsed treatment. That is, for an adult: 200 mg twice a day for one week, with subsequent courses repeated after a further 21 days. Fingernail infections require two pulsed courses and toenail infections require at least three pulsed courses.
Studies suggest that in about 5 in 10 cases the nail will look fully normal again after treatment. In about a further 2 in 10 cases the fungus will be cleared from the nail after treatment but the nail does not look fully normal again.
Fingernails tend to respond better to treatment than toenails do. One reason for treatment to fail is because some people stop their medication too early.
Are antifungal nail paint (nail lacquer) effective?
A nail lacquer that contains the antifungal medicine amorolfine is an alternative for most (but not all) types of fungi that infect nails. You can buy amorolfine nail lacquer from pharmacies as well as obtaining it on prescription. However, this tends not to work as well as medication taken by mouth. Your doctor will advise if it is a suitable option for your type of infection. For example, it may be useful if the infection is just towards the end of the nail. This treatment does not tend to work so well if the infection is near the skin, or involves the skin around the nail. The nail lacquer has to be put on exactly as prescribed for the best chance of success. You may need six months of nail lacquer treatment for fingernails and up to a year for toenails.
Tioconazole is another solution that can be applied to the nail. It is available on prescription, although research trials suggest it does not work as well as amorolfine.
Is nail removal applicable for fungal nails?
If other treatments have failed, there is the option to have the nail removed by a small operation done under local anaesthetic, this can be performed by your Chiropodist Podiatrist. This is combined with treatment with antifungal medication.
Are there any newer options available?
Research is looking at newer methods of treating fungal nail infections. These include laser treatment and ultrasound. Initial results are positive but more evidence is needed about the long-term results of the treatments.
What to look out for with treatment
It is important to remember that the fungi that are killed as a result of whichever treatment remain in the nail until the nail grows out.
The good news is that fresh, healthy nail growing from the base of the nail is a sign that treatment is working. After you finish a course of treatment, it will take several months for the old infected part of the nail to grow out and be clipped off. The non-infected fresh new nail continues growing forward. When it reaches the
end of the finger or toe, the nail will often look normal again. Fingernails grow faster than toenails, so it may appear they are quicker to get back to normal. It may take up to a year after starting treatment before toenails look completely normal again and six months for fingernails to look completely normal.
If there does not seem to be any healthy new nail beginning to grow after a few weeks of treatment it is recommended that you consult your doctor. However, the infection can still respond to treatment even after you finish a course of medication. This is because the antifungal medication stays in the nail for about nine months after you stop taking medication.
What can I do to help?
Take the medication as directed and do not give up without discussing this with your doctor.
Side-effects are uncommon in all but a small number of patients with modern medication but tell your doctor if you notice any problems with the treatment.
Tips on nail care if you have a nail infection, with or without taking medication, include the following:
- Keep your nails cut short and file down any thickened nail.
- Use a separate pair of scissors to cut the infected nail(s) to prevent contaminating the other nails.
- Do not share nail scissors or nail files with anyone else (for the same reason).
- Avoid injury and irritants to your nails. For example, if fingers are affected, use cotton and vinyl gloves for wet work. Use heavy cotton gloves for dry work.
- If toenails are affected, wear properly fitted shoes with a wide toe box.
- Keep your feet cool and dry as much as possible.
Preventing fungal nail infection (tinea unguium)
Studies suggest that in about 1 in 4 cases where the infection has been cleared from the nail, the infection returns within three years. One way to help prevent a further bout of nail infection is to treat athlete’s foot (tinea pedis) as early as possible to stop the infection spreading to the nail. Athlete’s foot is common and may recur from time to time. It is easy to treat with an antifungal cream which you can buy from pharmacies, or obtain on prescription. The first sign of athlete’s foot is itchy and scaling skin between the toes.
- Try to avoid injury to nails, which may increase the risk of developing a nail infection.
- Wear footwear such as flip-flops in public places, such as communal bathing/shower places, locker rooms, etc.
- Avoid towel sharing.
- Consider replacing old footwear, as this could be contaminated with fungal spores.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. We have used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
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