Download ONYCHO… WHAT?

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