What is NAIL FUNGUS?
Nail fungus (onychomycosis) is a fungal infection of the fingernails and toenails. - These fungal
infections usually cause discoloration, thickening and often softening of the nails. - Nail fungus is a
difficult condition to treat and may often cause permanent damage to the nails and possibly nail loss.
Types of NAIL FUNGUS:
- Distal subungual onychomycosis (DSO): site of invasion is the distal nail bed and progression is
distal to proximal.
- Proximal subungual onychomycosis (PSO): site of invasion is the proximal nail bed. This
condition is quite rare in people with intact immune systems.
- White superficial onychomycosis (WSO): characterized by white discoloration on the surface of
the toenail which can be easily scraped away.
Common causes of NAIL FUNGUS
- Nail fungus infections are caused by dermatophyte fungi (tinea unguium), yeasts such as Candida
albicans, and non-dermatophyte molds. - Factors that may increase the development of nail fungus
include humidity, heat, trauma, diabetes mellitus, and underlying tinea pedis (athlete’s foot).
Symptoms of NAIL FUNGUS:
- Other than appearance, nail fungus generally has no symptoms. In some rare cases, nail fungus
may cause pain, limit mobility, and interfere with manual dexterity. - DSO: yellow-brown
discoloration with eventual crumbling and disintegration of the nail plate. - PSO: white or yellow
discoloration on the surface of the nail plate beginning at the proximal nail fold and extending
distally. - WSO: white discoloration on the surface of the toenail which can be easily scraped away
Your body hosts millions of microscopic organisms, some harmful, some hurtful. Fungi are one type
of tiny, plant-like organism that lives on your body or inside it. Unlike plants, they have no
chlorophyll, a chemical which turns sunlight into food. To survive, fungi absorb nutrients from other
living or dead things. They thrive in warm, moist places, like underneath your toenails.
It is estimated that around 36 million people in the United States have onychomycosis, a fungal nail
infection. Fungal nail infections are more common in toenails, but they also occur in fingernails.
They are more likely in adults and often follow a fungal foot infection, like athlete's foot.
When the nail is infected with fungi, it becomes yellowish, dry and brittle. The nail also becomes
thicker, as layers of fungi grow and bloom. The nail may even separate from the skin, slightly rising
off the toe.
Locker rooms, public pools and gym showers can all be sources of fungal infections. Fungi love
these hot, damp environments. Nail salons can also be a source of fungal infection. If the foot tub is
not properly cleaned after a pedicure, fungi can live there, infecting the next person that puts their
feet in tub.
Perhaps the best way to prevent a fungal toenail infection is not to go barefoot at public pools or
locker rooms. When you go to the nail salon, be sure the equipment is properly cleaned.
Although they may not hurt, it is best to treat fungal infections early. Untreated fungal infections can
become very painful, making it difficult to walk and uncomfortable to wear shoes.
Doctors prescribe topical ointments or oral medication depending on how much the fungus has
grown. Fungal nail infections are not life threatening. It can take years before the infection becomes
large enough to cause pain or difficulty walking.
Nail Problems
This page relates to three of the most common nail problems:
* Ingrown nails
* Fungal nails
* Psoriatic nails.
If you're interested in the structure of the nail and medical terms relating to the nail, visit our web
page on nail anatomy and glossary of nail conditions. We have another page that discusses some
basic surgical nail procedures.
Ingrown Toenail
An ingrown toenail is probably the most common abnormality involving the nail, and we see this
problem in our office on a daily basis. Simply put, an ingrown nail is a condition in which the nail
is growing into the flesh.
The condition may involve one border or both, and is accompanied by redness, warmth, swelling,
and quite frequently, infection.
The amount of pain the patient experiences varies, depending upon one's age, gender, circulation,
and general medical condition. As a rule, smokers will have more pain than non-smokers.
While the problem is often dismissed as inconsequential (at least by those who have never
experienced the problem), it should not be taken lightly. Just a couple generations ago, in the era
before antibiotics, an ingrown toenail that developed into an infection could kill people. Even
today, if the patient has compromised circulation or diabetes, the condition may frequently lead to
loss of a limb.
Ingrown toenail may be caused by:
* Improperly trimmed nails (Trim then straight across, not longer than the tip of the toes. Do not
cut down the corners.)
* Heredity
* Shoe pressure; crowding of toes in poorly-fitting shoes.
* Repeated trauma to the feet from normal activities.
The most common treatment a patient attempts to perform for this condition is so-called "bathroom
surgery". This is where the patient attempts to remove a portion of nail, himself. Unfortunately,
this will often worsen the condition and can make proper treatment more difficult.
We suggest that you may clean the foot in a warm (not hot) salt water soak, or a basin of soapy
water, then apply an antiseptic and bandage the area. You should then schedule an appointment
with a podiatrist as soon as possible. He or she can diagnose the problem, the prescribe medication
or other appropriate treatment. People with diabetes or circulatory disorders are especially sensitive
to infections and serious problems and need to seek podiatric medical care as soon as possible.
Antibiotics will usually address the infection-portion of this complaint, but they do nothing for the
actual problem of the nail digging into the flesh. So most podiatrists will resect the ingrown portion
of the nail and may prescribe a topical or oral medication to treat the infection as an adjunctive
treatment.
If ingrown nails are a chronic problem or severe enough, we can perform a simple procedure to
permanently prevent ingrown nails. This procedure consists of removing the problematic nail border
and killing or removing the root of the nail in some way so that it never regrows. This is a very
common procedure, one that we perform every day. And the procedure very rarely hurts.
For more information on some of the types of surgical procedures used for ingrown nails, please
click on the following link for Permanent Nail Procedures.
Fungal Nails
Fungal infections of the nail, (also known as tinea unguium or onychomycosis), usually develop as a
result of spread from a fungal infection of the skin (tinea pedis or athlete's foot).
In contrast to athlete's foot, which is often itchy or even painful, fungal nails are frequently painless,
and so are often ignored for years. Early fungal disease is characterized by a slow but progressive
change in a toenail's quality and color.
While many patients believe the infection lies beneath the nail plate, it usually involves all layers of
the nail--on top of the nail plate, beneath it, and within it.
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As time progresses and becomes more advanced, the nail will often worsen, becoming more and
more discoloured, thickened, and difficult to cut. There is frequently a foul odour associated with
the condition.
The infection may also spread to other toenails, the skin, or even the finger nails.
As the thickened nails deteriorate, they may become ingrown (discussed above) and painful.
Pain may also develop because the thicker nails are difficult to trim and make walking and wearing
shoes uncomfortable.
Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are
especially vulnerable around damp areas where people are likely to be walking barefoot, such as
swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more
susceptible to all types of infection, including fungal infection. The elderly and those who suffer
from chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are
especially prone to fungal nails. Other contributing factors may be a history of athlete's foot and
excessive perspiration.
Prevention
* Proper hygiene and regular inspection of the feet and toes are the first lines of defense against
fungal nails.
* Clean and dry feet resist disease.
* Washing the feet with soap and water, remembering to dry thoroughly, is the best way to
prevent an infection.
* Shower shoes should be worn when possible in public areas.
* Shoes, socks, or hosiery should be changed more than once daily.
* Toenails should be clipped straight across so that the nail does not extend beyond the tip of the
toe.
* Wear shoes that fit well and are made of materials that breathe.
* Avoid wearing excessively tight hosiery, which promote moisture.
* Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks.
* Disinfect instruments used to cut nails.
* Disinfect home pedicure tools.
* Don't apply polish to nails suspected of infection—those that are red, discolored, or swollen, for
example.
Treatment of Fungal Nails
Treatments may vary, depending on the nature and severity of the infection. A daily routine of
cleansing over a period of many months may temporarily suppress mild infections. White markings
that appear on the surface of the nail can be filed off, followed by the application of an over-thecounter liquid antifungal agent. However, even the best over-the-counter treatments may not prevent
a fungal infection from coming back.
A podiatric physician can detect a fungal infection early, culture the nail, determine the cause, and
form a suitable treatment plan, which may include prescribing topical or oral medication, and
debridement (removal of diseased nail matter and debris) of an infected nail.
Newer oral antifungals, may be the most effective treatment. They offer a shorter treatment regimen
of approximately three months and improved effectiveness. Podiatrists may also prescribe a topical
treatment for onychomycosis, which can be an effective treatment modality for fungal nails.
In some cases, surgical treatment may be required. Temporary removal of the infected nail can be
performed to permit direct application of a topical antifungal. Permanent removal of a chronically
painful nail, which has not responded to any other treatment, permits the fungal infection to be
cured, and prevents the return of a deformed nail.
Trying to solve the infection without the qualified help of a podiatric physician can lead to more
problems. With new technical advances in combination with simple preventive measures, the
treatment of this lightly regarded health problems can often be successful.
Psoriatic Nails
Psoriasis is a chronic skin disorder affecting about 2% of the population. It is non-contagious and
appears to have a genetic origin, though episodes may be triggered by stress and trauma.
Psoriasis may be rather mild, involving occasional bouts of non-painful, silver-white scales on a
small area of the skin with varying degrees of redness (inflammation) surrounding it (see diagram to
the right), or it may be severe, involving uncomfortable blisters over large portions of skin
throughout the body.
While psoriasis may be found anywhere on the body, the classic areas of involvement are the
elbows, knees, hands, feet, scalp, ears, and the genital region.
Some 50% of individuals with psoriasis may develop the condition in their nails. This condition
causes some combination of pitting in the nails (see diagram A below), yellow-white discoloration
and dystrophy (degeneration) mimicking fungal involvement (see diagram B below), and
onycholysis, where the nail slowly becomes detached and loose from the nail bed (see diagram C
below). The nails are usually painless, but may become painful in some cases.
When an ingrown nail, fungal nail, psoriatic nail, or other uncomfortable nail pathology does not
respond to conservative care, an attempt may be made at a permanent correction of the problem
through surgical means. Surgical nail procedures have improved greatly over the years, and they
may be designed to temporarily or permanently correct ingrown nail conditions. Listed below are
some of the most common procedures.
Temporary Nail Procedures
At first glance, it may seem nonsensical to attempt a temporary nail procedure. After all, why
would anyone wish to temporarily fix a nail condition when you could do it permanently?
Well, there are a couple reasons it may make sense to try this sort of procedure. First, if there is
nothing really wrong with the nail, but the ingrown nail was caused by a one-time trauma, by cutting
the nail improperly or by some other one-time event, it may be quite reasonable to address the acute
problem temporarily in such a way that once the tissues heal, the problem may not be likely to
return.
A couple examples of procedures that fall into this category are listed below:
Wedge Resection This procedure simply aims to remove the offending portion of the ingrown nail
without touching the remainder non-problematic nail. Depending upon the severity of the problem,
this procedure may be performed with or without anesthesia.
Granuloma Excision This procedure aims at removing the portion of skin that often grows up and
over the nail plate when ingrown nails are present. This abnormal growth of skin is known as a
Granuloma or Proudflesh, and usually appears red, angry-looking (though they may be painless) and
very bloody. While a granuloma excision may performed as an isolated procedure, it is frequently
performed along with a permanent nail procedure.
Skin Plasties Skin plasties are techniques that primarily address an abnormal component of skin that
may be the cause of the problem. For example, a portion of skin may be excessively large and the
nail may continually grow into the skin. Again, this may be performed as an isolated procedure or
in conjunction with a permanent nail procedure.
Permanent Nail Procedures
There are three families of procedures that permanently address nail conditions--"sharp" procedures,
chemical procedures, and miscellaneous procedures.
procedures are known by that name because they all have in common the use of a scalpel to excise a
portion of the nail root. Because the nail root is being cut out, or "excised", this family of
procedures is properly known as known as matrixectomy procedures, with the suffix "-ectomy"
meaning "excision". A matrixectomy may either be a partial matrixectomy, when only a portion of
the nail root is removed, or a total or complete matrixectomy, when the entire nail root is removed.
Compared to chemical procedures, sharp procedures have the advantage of looking better
immediately after the procedure, and they typically have less drainage.
While sharp procedures are still performed frequently by other medical professionals, it's probably
safe to say that In the podiatric profession they are performed much more infrequently today than in
years past because of their down side. First, there is cutting involved, so they may create more scar
tissue than other types of procedures, they may have a more noticeable post-operative appearance,
they may hurt more and they physically remove the nail root from the bone, potentially increasing
the odds of a bone infection.
Suppan This procedure involves freeing the skin behind the nail and removing the nail, then peeling
away the root of the nail.
Zadik Procedure This procedure involves an incision that is angled at about 45 degrees from the
nail border, and excising just the nail root.
Frost Procedure One of the older "sharp" procedures, the Frost involves making an "L"-shaped
incision behind the nail plate, peeling back the soft tissues to expose and excise the nail root and any
abnormal soft tissue associated with it.
Winograd The Winograd procedure involves a "D"-shaped excision of the nail root and overlying
soft tissues. Not so aggressive as the Kaplan procedure, the Winograd may be a good choice when
sharp procedures are considered.
Kaplan The Kaplan procedure may be the most well documented nail procedure in the literature. It
involves an "H"-shaped incision and requires the excision of both the nail root and the nail bed (the
soft tissue upon which then nail rests). This procedure may still be indicated in cases where the
bone underlying the nail is involved, but this procedure is more aggressive then necessary for the
vast majority of ingrown nails.
Terminal Syme The Terminal Syme procedure is basically an amputation of the tip of the toe. I'd
like to say this procedure is rarely done any longer for routine ingrown nails, but from time to time, I
still see people who have had this done. There are very few indications for this procedure to be
performed.
Chemical Procedures
Simply put, chemical procedures attempt to permanently resolve an ingrown nail by chauterizing the
nail root through the application of a strong chemical. Because the root of the nail is not actually
removed, chemical procedures are not really matrixectomies, though they are often referred to as
being so.
In theory, any chemical strong enough to chauterize the root of the nail without adversely affecting
the patient could be used, but the most common chemical techniques are listed below.
The advantage of chemical procedures are that they are known for being relatively painless; there is
typically no scalpel used in these procedures, so there is little scarring, and so they also tend to look
very nice after they are completely healed; and chemical procedures don't denude the covering from
the underlying bone, which diminishes the odds of a post-operative bone infection.
The downside to these procedures is that they create a minor chemical burn in the area, so they tend
to drain. Soaking and bandage changes are usually prescribed.
The most common names you might hear?
Phenol The phenol procedure involves applying an acidic chemical known as phenol to the root of
the nail. (See diagram to the right for an image of phenol's chemical structure.) This is probably the
most common chemical procedure used today.
P&A The P&A procedure is short for "Phenol and Alcohol", because alcohol is commonly used at
the end of the phenol procedure to wash away any remaining phenol. So a P& A is the same as a
phenol procedure.
Phenol
Sodium Hydroxide The second most common chemical method involves using the base known as
Sodium Hydroxide. Some practitioners believe it creates less drainage than phenol procedures.
NaOH Those of you who have studied chemistry may recall that NaOH is the chemical
abbreviation for sodium hydroxide, so the NaOH procedure is the same as the Sodium Hydroxide
procedure.
Miscellaneous Procedures
In addition to sharp procedures and chemical procedures, other techniques exist to address ingrown
nails. The two most common are listed below:
Laser Lasers can also permanently resolve nail problems. Proponents suggest there is less postoperative discharge and less pain involved when lasers are used, but it has been my experience that
when performed correctly, there is very little pain involved with most other procedures anyway. In
Canada, lasers are used relatively infrequently for this indication because of their high cost.
Radiosurgery Radiosurgical techniques can also be used to permanently resolve nail problems.
Much less expensive than lasers, radiosurgery offers the same benefit, namely less discharge
postoperatively.