Fungal Nail Infections (Onychomycosis)
Toenails infected with a fungus are relatively common affecting between 3-10% of the UK population. The prevalence is higher in cooler damp regions where occlusive footwear is the norm and exposure to sunlight is relatively low, therefore the incidence of fungal nail infections in warmer drier regions is relatively low.
Although a fungal infected nail 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).
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 immune-compromised. Anyone with a history of chronic skin fungal infection of the foot (athletes foot) is also at a much greater risk of toenail fungal infection.
How is a fungal infected toenail diagnosed?
Visual inspection and clinical instinct will arouse suspicion however only testing will confirm the diagnosis definitively. The testing undertaken in our clinic is an Immunochromatographic test-taking just a few minutes. This testing is the most reliable form of testing available and eliminates the need to send clippings off to the pathology laboratories for microscopy and culture which are time-consuming and notoriously unreliable (high incidence of false negatives).
It is best practice that before any treatment regime begins (especially taking tablets) a positive test result should be obtained. NICE guidelines advise that oral medication given for fungal nail infections should only be prescribed once a positive test result is obtained.
What can fungal nail infection be mistaken for?
Some other nails conditions can look similar to a fungal nail including:- Psoriatic nails, thick damaged toenails, bruising under the nail, bacterial infection under the nail, Lichen planus, nails affected by eczema, Yellow Nail Syndrome.
A nail affected by any of the above would be susceptible to secondary fungal infection and therefore many of the above nail conditions can be seen in combination with fungal infection.
How do we treat fungal nail infection?
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, then treatment can be considered.
1 Topical treatment
(applying a medicated paint/lacquer/cream/gel, directly onto the nail)
There are a large variety of topical products available to buy at Pharmacies, many of which are marketed to create the perception that they are effective. The reality is often quite different, the efficacy of topical treatments for fungal nail infections is very poor (except for White Superficial fungal infection – see bottom right image below).
For extensive infections where most of the nail is involved (see top left image below), or there is multiple nail involvement (see top right & bottom left images below) then the use of topical preparations is futile.
There is no peer-reviewed quality research that can demonstrate significant efficacy for the use of ANY topical antifungal preparations when used on extensive fungal nail infections. However, where there is a minor infection (see centre image above) then their use would be appropriate.
If patients apply topical preparations frequently for long periods of time onto minor fungal nail infections, and if the nail is kept short and debrided (thinned), then there is a reasonable chance of a cure. Since there are a large and bewildering choice of topical products available, and in an attempt to simplify that choice, we therefore advise patients to consider either of the following:-
- Terbinafine cream to be applied x2 daily to the affected nail
- Amorolfine lacquer to be applied x1 weekly to the affected nail
When using topical preparations for fungal nail infection it is essential that the following measures are adhered to diligently for as long as the preparations are used, failure to do so will dramatically reduce efficacy.
- The above preparations should be applied for at least a year.
- The affected nail(s) are cut back as short as possible regularly, particularly if the nail is loose/partially detached as is common with fungal infected nails.
- If the affected nails are thick they should be debrided by a Podiatrist regularly.
2 Oral treatment (Medication/Tablets)
( Terbinafine or Itraconazole )
Where topical preparations prove unsuccessful or are not indicated (e.g. multiple toenail fungal infections), the use of prescribed oral medication can be considered for some patients.
Research reviewed by the Cochrane library indicates that these tablets are generally well tolerated and safe although medication should be considered carefully as in some rare cases they can cause harmful side effects and consequently, blood testing is often conducted during treatment to assess any signs of adverse effects on the liver.
The incidence of relatively minor and transient side effects such as gastrointestinal upset, nausea and sensitivity rashes are not uncommon.
The protocol adopted at our clinic when advising patients to consider oral medication is to discuss the possibility of undesirable side effects, highlight the necessity for blood testing before and during treatment (when taking Terbinafine tablets), and consider the patient's age and general health. Healthy individuals with an unremarkable medical history who are particularly affected by significant fungal nail infection may then be advised to consider oral medication after we have confirmed the diagnosis with chairside Immuno-chromatographic testing.
There is good quality peer-reviewed research (available to see on Cochrane Library) that demonstrates Terbinafine or Itraconazole tablets provide the best chances of a cure. The library indicates that these tablets will provide average cure rates of 60% and are regarded by clinicians as the ‘Gold Standard’ for the treatment of fungal nail infection.
3 Combination treatment (oral & topical)
Topical treatments can be used (as directed above) in addition to taking tablets although there is only limited research available that compares the efficacy of combination therapy (oral and topical) to just oral medication. However, it would be logical to assume that using topical treatments in addition to oral medication would contribute to increased efficacy and is therefore a treatment regime we would encourage.
4 Laser treatment
Our advanced laser is a Podylas s30 1065nm class 4 medical laser. It causes a controlled thermal effect on the tissue which treats fungal infections safely & painlessly. The efficacy of all Laser treatments is the subject of some debate, a study in 2014 undertaken by the University of Barcelona involving 150 patients reported a ‘cure rate’ of 78% using the above Laser, and although we have invested in this technology it is our opinion that its effectiveness on well established extensive fungal nail infections is poor and hence we still regard oral medication as the ‘gold standard’ for extensive fungal nail infection.
For relatively minor infections, however, our Podylas medical Laser is more effective and therefore we advise its use for some minor fungal nail infections. The Laser treatment regime involves several sessions over a period of a few months.
5 Palliative treatment
(make the nails look as presentable as possible)
When patients decide that the cosmetic appearance doesn’t justify adopting any of the treatment regimes previously discussed then they can consider a palliative option where a Podiatrist will shape and debride (if thick) the nail to create a better looking & manageable toenail.
Although palliation can dramatically improve the appearance of unsightly fungal nails (see before & after images below) many patients will also choose Nail Reconstruction (see next page) which disguises the affected nail and creates the appearance of a normal-looking toenail.
6 Nail Reconstruction
Nail reconstruction is a wonderful way of making an unsightly nail appear normal (see above images) and will last for several weeks (often many months). It will not make an unsightly nail grow ‘normally’ again, but it does disguise it exceptionally well.
The affected nail is trimmed and debrided if necessary, then a malleable resin is added onto the affected nail and shaped to mimic the appearance of a healthy nail. When it sets a few minutes later the resulting ‘nail’ can be painted and shaped and will look the same as a healthy nail. This is particularly popular for patients where their toes are likely to be exposed during summer holidays, or at swimming pools, saunas, weddings, etc).
Nail reconstruction is safe, non-invasive, painless, and perfect for thickened/fungal nails that are unsightly.
Sarah Sharman (Podiatrist) is our Nail Reconstruction practitioner and she will assess the nail and advise patients if the toenail is suitable for Nail Reconstruction. If your nail is suitable for Nail Reconstruction and it is the source of embarrassment then this is the perfect solution for you.
If you suspect that you have a fungal infected toenail and are not sure what to do then why not consult one of our Podiatrists. This is the most common foot pathology that presents in our clinic, you will receive treatment/advice from a practitioner who is very familiar with the best way it can be treated and/or disguised.