What Causes Nail Fungus?
Fungal nail infections are usually caused by fungi called dermatophytes that infect the skin beneath the nail; yeast is another common culprit. Toenails are especially vulnerable to infection when your bare feet contact damp surfaces such as showers, swimming pools and locker rooms. Moreover, if you have a fungal infection on the skin of your foot, this can also transfer to your nails.
Wearing closed shoes for extended periods also can contribute to infection if your shoes and/or socks are damp from perspiration or heat. Moreover, if your shoes fit snugly enough to put pressure on your toes, they can damage the nail bed, making it more susceptible to infection.
People with chronic diseases, such as diabetes or circulatory problems, also may be more prone to toenail infections.
Common Symptoms of Nail Fungus
Although fungal nails are usually cosmetic concerns, some patients do experience pain and discomfort due to the thickness of the nails. These symptoms may be exacerbated by footwear, activity, and improper trimming of the nails.
There are many species of fungi that can affect nails. By far the most common, however, is called Trichophyton rubrum (T. rubrum). This type of fungus has a tendency to infect the skin (known as a dermatophyte) and manifests in the following specific ways.
There are different types of nail fungal infections:
- Starts at the ends of the nails and raises the nail up: This is called “distal subungual onychomycosis.” It is the most common type of fungal infection of the nails in both adults and children. Risk factors include older age, swimming, athlete’s foot, psoriasis, diabetes, family members with the infection, or a suppressed immune system. It usually starts as a discolored area at a corner of the big toe and slowly spreads toward the cuticle. Eventually, the toenails will become thickened and flaky. Sometimes, you can also see signs of a fungal infection in between the toes or skin peeling on the sole of the foot. It is often accompanied by onycholysis. The most common cause is T. rubrum.
- Starts at the base of the nail and raises the nail up: This is called “proximal subungual onychomycosis.” This is the least common type of fungal nail. It is similar to the distal type, but it starts at the cuticle (base of the nail) and slowly spreads toward the nail tip. This type almost always occurs in people with a damaged immune system. It is rare to see debris under the tip of the nail with this condition, unlike distal subungual onychomycosis. The most common cause is T. rubrum and non-dermatophyte molds.
- Yeast onychomycosis: This type is caused by a yeast called Candida and not by the Trichophyton fungus named above. It is more common in fingernails but can be present in toenails. Patients may have associated paronychia (infection of the cuticle). Candida can cause yellow, brown, white, or thickened nails.
- White superficial onychomycosis: In this nail condition, a Podiatrist can often burr off a white powdery material on the top of the nail plate. This condition is most common in tropical environments and is caused by a fungus known as Trichophyton mentagrophytes.
Here are some other conditions you may have instead of fungal nails:
- Lines and ridges: These are common and may be considered normal. They may worsen during pregnancy. A large groove down the center of the nail can be caused by nail biting. Some people may develop these changes following chemotherapy.
- Senile nails: As you age, the nails become brittle and develop ridges and separation of the nail layers at the end of the nail. To avoid this, try to clean solutions and don’t soak the nails in water.
- Whitish or yellowish nails can occur due to onycholysis. This means separation of the nail from the nail bed. The color you see is air beneath the nail. The treatment is to trim the nail short, don’t clean under it, polish if you want to hide the color, and wait two to three months. Persistent onycholysis can make the nails susceptible to fungal infection.
- Red or black nails due to a hematoma, or blood under the nail, usually occur from trauma. The discolored area will grow out with the nail and be trimmed off as you trim your nails. If you have a black spot under your nail that was not caused by trauma, you may want to see a dermatologist or a podiatrist if it involves a toenail to make sure it is not melanoma (a type of skin cancer associated with pigmented cells). A simple biopsy can rule out malignancy (cancer).
- Green nails can be caused by Pseudomonas bacteria, which grow under a nail that has partially separated from the nail bed. This infection may cause a foul odor of the nails. It is also advised to avoid soaking the nail in any sort of water (even if inside gloves) and to thoroughly dry the nail after bathing. If the problem continues, there are prescription treatments that your doctor may try.
- Pitted nails may be associated with psoriasis or other skin problems that affect the nail matrix, the area under the skin just behind the nail. This is the area from which the nail grows. Nails affected by psoriasis can also be tan in color.
- Swelling and redness of the skin around the nail is called paronychia. This is an infection of the skin at the bottom of the nail (cuticle). If the infection is acute (has a rapid onset), it is usually caused by bacteria. It may respond to warm soaks but will often need to be drained by a doctor. A chronic paronychia occurs when a cuticle becomes inflamed or irritated over time. Sometimes, yeast will take advantage of the damaged skin and infect the area as well. Therapy begins with keeping the skin dry and out of water. If the problem continues, a physician should be consulted. Antibiotics are not often used but may be necessary in severe infection.
- Chronic nail trauma, such as repeatedly starting and stopping, kicking, and other athletic endeavors, can cause damage to the nails that can look a lot like fungal nails. This sort of repetitive trauma can also occur with certain types of employment or wearing tight-fitting shoes. Some traumas may cause permanent changes that may mimic the appearance of fungal nails.
What to Look for in a Toenail Fungus Treatment
Toenail fungus, if left untreated, can become a tough problem to treat and will greatly influence what medications you need. If the toenails are thick, yellowed, and left untreated for a long time, that could indicate you need a prescription for oral medication.
Fungal infections can start on the nails and transfer to this skin, or start on the skin and transfer to the nails. It is important to treat both as they will continue to spread.
Zinc undecylenate and undecylenic acid are both FDA-approved ingredients to treat toenail fungus Also, if you seek help from a professional, they will likely prescribe medications in the “azole” family. This compound interferes with the synthesis of the fungal cell membrane, which essentially kills the fungus.
Toenail fungus treatments can come in a variety of forms, but oral, topical, and homeopathic medications are the most commonly used for treating toenail fungus.
- Oral: Oral medications have been proven effective, but they take time to work. But there are several conditions that can make people ineligible for oral antifungal medications. The same underlying comorbidities, including chronic renal failure (with dialysis) and renal transplant, immunodeficiency, diabetes, cancer, and peripheral arterial disease that make someone more susceptible to toenail fungus also make them more at risk for side effects when taking the drugs.
- Topical: Topical treatments (like amorolfine and ciclopirox) can help with minor toenail fungus. They cause fewer and less serious side effects. But, it’s difficult for them to penetrate the nail plate so treatment is longer and efficacy is low.
- Natural/Homeopathic: Natural preventative measures can be effective, but once fungus sets in, your best bet is a research-backed and FDA approved oral antifungal.
Is Nail Fungus Easily Treatable?
Toenail fungus infections often require diligent treatment to be successful. Early-stage toenail fungus may respond to home treatments, such as those listed below. Apply the treatment to the affected nail several times daily; you may need to treat for six months or more to clear the infection as it takes 6-12 months for a full nail to grow out.
- Tea tree oil: This oil has antifungal properties, and studies found they performed as well as some over-the-counter and prescription topical antifungal treatments.
- Baking soda: Researchers found that baking soda prevented fungal growth in 79 percent of the specimens tested. Apply a paste of baking soda and water directly to the affected nail and let it sit for at least 10 minutes before rinsing.
- Vinegar and hydrogen peroxide also are popular home remedies for toenail fungus, but have not been shown to be effective in clinical studies.
Over-the-counter treatments for toenail fungus include creams, ointments, sprays and liquids. Ask your pharmacist for a recommendation or look for these ingredients, and follow the directions carefully:
- Terbinafine (brand name: Lamisil)
Laser treatment for fungal nail infections is the newest treatment option, though it has now been available for many years. It has shown significantly higher success rates and has been the delight of many patients. It should be noted that there are two variations of laser available, hot and cold laser, and it’s important to know the difference.
Hot laser therapy uses heat to destroy nail fungus by heating up the affected nail plate. Cold laser therapy uses two cold laser beams to damage and destroy nail fungus, as well as improve your immune response and boost your circulation to clear the fungus.
Nail removal surgery
When medical treatments don’t work, another option is to remove the nail, either surgically or with chemicals. A new nail should grow back in its place. However if there is already damage to the nail bed, the nail may return the same.
Follow these guidelines to help keep your toenails healthy:
- Wash your feet with soap and water and dry them thoroughly after swimming.
- Wear shower shoes in locker rooms and public areas.
- Wear shoes that fit well and are made of breathable materials.
- Remove wet or damp socks or shoes as soon as possible and dry your feet.
- Disinfect nail clippers and home pedicure tools.
- Avoid applying polish to infected nails.
In addition to antifungal treatments, you can help manage a fungal nail infection (and prevent further infections from developing) by:
- keeping your nails short;
- filing down any thick areas;
- thoroughly drying your hands and feet, including between the fingers and toes, after washing; and
- using a separate pair of nail scissors for any infected nails.
When To See An Expert
If your symptoms do not get better with home treatment, make an appointment with your podiatrist.
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