Fungal Nail Infections (Onychomycosis) | Hollinshead & Associates

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Fungal Nail Infections (Onychomycosis)


Toenails infected with a fungus are relatively common affecting between 3-10% of the UK population.

Although a fungally infected toenail does not cause any pain/discomfort, many patients regard the cosmetic appearance as unacceptable. Typically the nail will become thickened, crumbly and discoloured (yellow/brown) often exposing the nail bed.

Normally the infection is predisposed by trauma to the nail, particularly repeated trauma and hence is more prevalent in hill walkers, footballers etc. The condition is also more common in people with poor peripheral circulation and who are immuno-compromised.

Anyone with a history of chronic skin fungal infection of the foot (athletes foot) is also at much greater risk of toenail fungal infection. Since a nail is an appendage of the skin, it is perhaps not surprising that the two fungi (T.Rubrum & T.Mentagrophytes) responsible for the majority of skin fungal infections of the foot (athletes foot), are also responsible for the majority of toenail fungal infections.

How is a fungally infected toenail diagnosed?        

The definitive means of diagnosis is to take nail clippings and send them for culture and microscopy, however there is often a high incidence of false negative results and thus only a positive result can be relied upon. An experienced practitioner can confidently offer a diagnosis based on visual inspection in the majority of cases.

Differential diagnosis would include :-  Psoriatic nails, thick damaged toe nails, bruising under the nail, bacterial infection under the nail, lichen planus, nails affected by eczema, or a combination of any of these conditions.

How do we treat fungally infected toe nails?

Many patients with relatively minor fungal nail infections are happy to ignore the problem and this is an approach we would encourage. However when the cosmetic appearance becomes unacceptable to the patient, or if the nail becomes thickened to such an extent that it rubs inside the toe box of a shoe, then treatment can be considered.

1 Topical treatment (applying a paint/lacquer /cream directly onto the nail)

The use of topical preparations is usually limited to 2-3 nails only. There are a variety of products available to use topically for fungal nail infections.

Research suggests the most efficacious topical preparations are products containing Amorolfine at 5% concentration (Curanail or Loseryl). However, even the use of Amorolfine based preparations rarely clears the infection (particularly where the infection has progressed to the matrix/root area of the nail), although with prolonged use it may improve the appearance of the nail.

In order to aid the effectiveness of topical treatments it is ESSENTIAL that the infected area of the nail and any loose ‘debris’ underneath is debrided (paired down) meticulously and regularly by a Podiatrist every 6-8 weeks for as long as the preparation is being applied. This will expose the infected nail bed area, thus facilitating the absorption topical cream/paint.

In addition to topical treatments demonstrating poor rates of cure, they have to be applied regularly for at least 18 months. In most cases a modest improvement in the aesthesis of the nail is the most realistic outcome of treating fungally infected toe nails with topical treatments.  

The exception to this rule would be where a patient has a form of fungal nail infection known as white superficial’ onycomycosis (see above photo). White superficial fungal nail infection only affects the upper layers of the nail plate and can be treated topically even where there are several nails affected. This is the only type of fungal nail infection that responds well to topical treatment.

2 Oral Medication/Tablets  (Terbinafine, Itraconazole)

Where topical preparations prove unsuccessful, or are not indicated (e.g. multiple toe nail fungal infection), the use of oral prescribed medication can be considered.  

Research would suggest that tablets containing Terbinafine are perhaps the most effective and a patient with toe nail fungal infection would be expected to take one 200mg Terbinafine tablet daily for three months (one month for finger nails).

Oral Terbinafine will provide on average about a 60% chance of successfully treating fungally-infected toe nails.

3 Combination of Oral Medication/Tablets &  paints/lacquers

A treatment regime of 200mg Terbinafine tablets taken for at least three months, in combination with the weekly application of an Amorolfine based paint will achieve a higher rate of cure than just taking tablets alone.

The application of the paint begins when the tablets are first taken and must continue to be applied once weekly for at least 18 months after the tablets have been discontinued. Additionally, any affected nail must be kept short, and if thickened, must also be thinned regularly by a Podiatrist, thus maximising the effect of the paint.

Research has shown that if patients adhere diligently to this combined treatment regime of oral Terbinifine tablets and topical Amorolfine paint a cure rate of 70% can be achieved.

4 Laser Treatment

The use of Lasers for fungal toenail treatment involves raising the temperature of the nail bed to levels that kill the fungal hyphae without exposing the patient to any significant discomfort.

There has been much anecdotal evidence that suggested this form of treatment could produce marked improvements to the aesthesis of the nail. However, until recently there had been no quality research published that supported these claims. However a study in 2014 undertaken by the University of Barcelona involving 150 patients achieved a cure rate of 78%.

We have now invested in this technology and are pleased to be able to offer this treatment.

5 ‘Live with it’ and get the nails ‘tidied up’ occasionally.

Many people who have tried a variety of treatment regimes (even under the supervision of a proficient Podiatrist) may have to accept that their toe nail fungus cannot be cured. Where this occurs there is a lot we can do to ‘disguise’ the affected nail(s) and dramatically improve the appearance of such nails.

Many people choose to come to our surgery and have the nails ‘tied up’ occasionally. This would involve our Podiatrists drilling down any excess thickness of the nail, clearing any debris from under the nail. The nail is then filed into as much a normal shape as is possible.

Some patients choose (particularly before special occasions like holidays) to come to us for Wilde-Pedique Nail Reconstruction  which is a wonderful way of making an unsightly fungally infected toenail look normal and will last for several weeks (visit our website for more details).

Fungal Nail Infection is often difficult to cure and patients are strongly advised to consult a practitioner who has an intimate familiarity of all the possible treatments. You will therefore increase your chances of a better outcome dramatically by consulting ourselves BEFORE any treatment regime (if any) is chosen and commenced.

If you suspect that you have a fungally infected toe nail and are not sure what to do then why not consult one of our Podiatrists. This is one of the most common foot pathologies seen by Podiatrists and we can ensure that you will receive treatment from a practitioner who is very familiar with your problem.

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