Fungal Toenails

What's the Problem?

Toenail fungus is an unsightly infection of the nails, causing thickened, brittle, yellow, discolored and sometimes painful nails. It is very difficult to cure.

It is caused by one of several microscopic organisms, similar to those that cause Athlete’s foot (dermatophytosis) These are plant-like organisms that thrive in dark, warm, moist environments, such as within shoes and stockings. They grow in the nail bed, beneath your nails, and live off keratin, the protein in the nail.

The condition usually begins toward the far end of the nail and may cause white or yellow-white areas that appear to be rotten or dead. If the infection continues to the base of the nail, it can invade the nail root (matrix) and cause the nail to grow thickened and deformed. Many people complain of a foul odor associated with this condition. It can also spread to other nails. The fungus often spreads to the adjacent skin surrounding the nail.

How Does it Feel? 

Fungal ToenailsIt may not be painful in the beginning, and may only look slightly different than the normal nails. Later, the nail may begin to show small patches of white or yellowish-tan color and may become brittle and split.

As it progresses, the nail becomes thicker and deformed and may begin to grow at an angle and become an ingrown nail. Pain develops, due to the ingrown or thickened nail deformity, and becomes aggravated by pressure applied by shoes. Inflammation can develop due to this pressure and a secondary bacterial infection may occur, leading to more pain. Even without inflammation, shoe pressure on the fungal nails can cause pain, making it difficult to walk or stand for periods of time. This can also influence one’s involvement in day to day activities.

Let's Do a Test! 

Correct evaluation and diagnosis is important, as other common medical conditions, such as psoriasis, can look like fungal nails. Your doctor may make this decision by examination alone. He may also examine scrapings from the nail under the microscope or send these scrapings to the lab for accurate identification, to determine if the condition is a fungus and what type of fungus is responsible.

How Did This Happen? 

Many types of fungus are common in our environment. Among them are the dermatophytes, a group of opportunistic parasitic plant organisms, similar to molds or mildew that, lacking chlorophyll, do not require sunlight for growth. Sweaty tennis shoes and moist socks create the perfect conditions for them. The fungi thrive in a warm, moist, dark environment and they eat the protein keratin that our skin produces.

Although fungi may be present in the skin around the nails, one may not develop a nail infection without history of injury, such as bruised nails from short shoes, inflammation from an ingrown nail, or from cutting the nails incorrectly or too short. In other words, the organisms do not invade intact, healthy, normal skin or nails. Other contributing factors would be excessive perspiration and tinea pedis (athlete’s foot), which is caused by similar fungi.

Some individuals appear to be more susceptible to infection. These would include those with medical conditions such as diabetes, poor circulation and HIV. For that reason, even if treatment is successful in eliminating the condition, the susceptible person may become re-infected in the future.

What Can I Do for It? 

Topical medications are ineffective in most cases, because the infection starts growing under the nail. No topical medicines penetrate deep enough into and through the nail to treat the living organisms under the nail plate. Any clearing of the nail surface is eventually overtaken by infected nail replacing it from underneath. Unfortunately, in this condition, any self-treatment is, at best, temporary. Use of a topical antifungal medicine may, at best, prevent spread of the fungus to as-yet unaffected nails or the surrounding skin.

What Will my Doctor Do for It? 

First of all, the doctor will perform a physical examination to determine if there is a fungus present and not some other kind of medical condition. After determining the type of fungus, treatment may range from topical solutions to oral, systemic medications. The nails may be trimmed and reduced with an electric grinder periodically, and you may be asked to participate in some way at home. Surgical and/or laser treatment may address removal of part or all of the nail with additional medications to prevent recurrence as the new nail grows.

Fortunately, oral medications are now available that have proven very effective in curing these difficult infections. These medicines reach the nail through the bloodstream and create a barrier between the old infected nail and the newly formed nail, effectively killing all living fungus organisms.

The medications are taken for about three months. During that time, they penetrate and saturate the growing part of the nail. Even after you stop taking the medicine, the medicine that has gotten into the nail continues to treat the nail from inside for another six to nine months, until a healthy nail has completely grown out. The medicines seem expensive initially, but in the long run, they are more economical than previous long-term treatments, and they offer a good chance of a cure.

Although these medications are safe, there are some side effects in a small percentage of patients and they require a blood test to monitor blood levels. Your doctor will discuss the advantages and disadvantages of oral therapy and other alternatives with you to determine the most appropriate treatment in your situation

Can I Prevent From It Happening Again?

You may be asked to treat the insides of your shoes, which have become contaminated by the fungus. This is to make sure that the new healthy nail doesn’t become contaminated by any fungus hiding in the shoe.

To prevent the fungus infection from coming back, the best offense is a good defense. We must control moisture and create a drier environment for your feet. Use powder in shoes to absorb perspiration. Avoid synthetic or nylon socks that trap, rather than absorb, perspiration. Cotton socks absorb moisture and wick it away from the skin and nails.

Keeping your feet dry and protected from injury is essential to avoid any fungus infections. If you have been cutting your nails too deeply, or treating an ingrown nail on your own, this may have allowed the fungus to grow under the nail. If shoes have become contaminated while you had the condition, they may be sanitized by spraying them with a topical antifungal spray, to prevent a recurrence of the fungal nail condition.

Since fungal nails are usually more resistant and more difficult to treat than athlete’s foot, topical or oral antifungal medications may be prescribed. Permanent nail removal is another possible form of treatment for fungal nails.

After a fungal nail infection has cleared up, you can take steps to prevent the infection from coming back. Keeping the fungus under control will help prevent a fungal infection of the skin from re-infecting the nail. Before bed, thoroughly wash and dry your feet, and apply a nonprescription anti-fungal cream to the entire foot from the ankle down. Use the cream every night, then gradually apply it less often. Keep your feet dry. Dry feet are less likely to become infected. Apply powder to your dry feet after you take a shower or bath.

Other tips: 

  • Don’t share nail clippers or nail files with others.
  • Don’t share shoes or socks with others.
  • Try not to injure your nail, such as by cutting it too short (trauma to the nail may lead to infections).
  • Wear dry cotton socks, and change them two or three times per day if necessary.
  • Wear dry shoes that allow air to circulate around your feet (tight, enclosed, moist shoes contribute to fungal toenail infections).
  • Wear shower sandals or shower shoes when you are at a public pool or shower.

Prevention

Follow basic foot care guidelines and you more than likely can head off most common foot fungus problems.