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ONYCHO… WHAT? By Jeffrey W. Watkins D.P.M. nychomycosis is the medical term used to describe a fungal infection of the toenails. It is the most common condition diagnosed and treated by podiatrists in the United States. It is estimated that nearly 13% of the United States has onychomycosis and that nearly every person who wears shoes will have a toenail infection at some point in their lives. O In general, onychomycosis is rare in children but incidence does increase with age. There tends to be a higher incidence in males over females, which is considered to be due to occupational reasons. With the increase moisture of shoes and heavy hosiery, it creates the dark, damp, and warm environment that is very inviting to fungal organisms. The type of fungus that typically causes onychomycosis in the United States is called a dermatophyte. These fungi have an affinity for skin, hair, nails, horns, and feathers. They can spread through contact with soils, locker rooms, and bathrooms. Onychomycosis can also be caused by yeasts, molds, and nondermatophyte fungi. Initially, onychomycosis is more of a cosmetic nuisance. If left untreated, however, the fungal infection can spread to other toes. It can become very painful due to the thickening of the nails. It can also lead to impaired activity, limited shoe wear, decreased self –esteem, heightened self-consciousness, and possible secondary bacterial infections. Diagnosing the condition can usually be done through clinical evaluation. The toenails will start to show evidence of being discolored (yellow to brownish), thickened, rough, or splitting. As the condition progresses, there may even be evidence of the toenails loosening. Laboratory tests can also be performed, as well as biopsies and cultures. Typically, the changes will begin at the tip or the edge of the toenail. The fungus enters under the nail and infects the skin layer of the nail bed. The fungus is then protected by the nail itself and this creates the preferred environment for fungal growth. The fungus can then spread throughout the nail bed and toenail until in reaches the nail root. At this level, all newly formed toe nail will be infected until the entire nail is involved. Treatment of onychomycosis is multi-faceted. The mainstay in any treatment regimen must include aggressive debridement. Not only should the nail be trimmed at its tip, it should also be aggressively filed to thin it as much as possible. Although direct to consumer marketing has encouraged the use of systemic oral anti-fungal medications, many topical anti-fungals appear to work with much less risk. There are numerous creams and gels made for treatment of fungal infections. These can be either overthe-counter or prescription. There is a common feeling among podiatrists that topical gels penetrate the nail better. However, Onychomycosis: Chronic fungal toenail infection causing deformity and discoloration. Photographs courtesy of Loyola University Chicago Stritch School of Medicine many of the over-the-counter creams work well and are more readily available. Several of these creams once were available only by prescription. One of the major advantages of topical medications is that they can be directly applied to the affected area and have a lesser chance of causing an adverse drug reaction. Most combine an active anti-fungal ingredient with a mixture of urea ointment to soften the nail. This allows for easier debridement of the nail, which in turn allows for better penetration of the medication. Most topical medication protocols report an average cure rate of approximately 42 weeks. Oral anti-fungal medications have become increasingly popular due to increased advertising by the companies that manufacture them. These medications are reported to have a shorter duration of therapy. However, they are also known to have a greater number of side-effects and drug interactions. Most insurance companies do not cover these medications because they are of the opinion that onychomycosis is only a cosmetic problem. The cost of these medications can range from $750-1200 for the recommended 3 month supply. These medications have a reported success rate of 70-80%. Therefore, in the appropriate patient population, they are an effective treatment option. There are a couple of alternative treatment options that have proven very effective in recent years. One is Tea Tree Oil. This is a natural, over-the-counter product that can be found in many health food stores. The other is Vapo-rub. This treatment has become very popular and is routinely used in podiatric practices and has actually become the author’s initial treatment and should be done in conjunction with aggressive toenail debridement. If these conservative treatments fail to resolve the fungal infection, total nail removal can be performed. The toenail can be either permanently removed or removed temporarily and treated with topical medications as the new toenail returns. Despite the treatment chosen to cure the onychomycosis, one must keep in mind the resolution of the infection can take months to resolve. However, with a little patience and diligent treatment with aggressive debridement and appropriate medication (topical or oral), onychomycosis can be eliminated and allow for growth of normal, clear toe nails. ■ www.castleortho.com 23