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Fungal Nails

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Have you noticed your toenails thickening and turning yellow? Have you noticed itchy, red, peeling skin between your toes or on the soles of your feet? You guessed it, there’s a “Fungus Among Us!”

Fungus or dermatophytes are slow growing micro-organisms, related to mold. They are present on moist surfaces everywhere and feed off of epidermal cells that are in moist, dark places, i.e., your feet! Fungus grows from spores that can remain dormant for weeks during dry conditions. Once it grows, it can bloom into an itchy, painful red rash on the feet and between the toes. When fungus on the skin becomes “chronic”, the itch may go away, but the skin remains flaky and red. People may think that it is dry skin, but it chronic fungus, instead.

Fungal nails are nails that have fungal elements feeding off of the nail bed, the skin just underneath the nail plate. Over many years, fungus slowly causes the nail bed to thicken with flaky, yellow debris and will spread from one nail to the next until many or all toenails are yellow/orange, flaky and extremely thick and brittle.

Fungus generally starts under a nail that has been damaged by a single traumatic event (“a horse stepped on my toe”) or by repeated nail trauma of tight-fitting shoes or aggressive pedicures where there has been digging under the nails.

How is it treated?

First let’s talk about the skin. In order to successfully manage athlete’s foot, one must control moisture or heavy perspiration. The simplest way to do this, is to use an antiperspirant spray, daily, on the feet, wear moisture-wicking socks, air out the feet whenever possible in sandals, avoid wearing sneakers or synthetic material shoes which trap moisture on the skin. Finally, use an over-the-counter (OTC) antifungal cream daily for one full month, when fungus develops on the skin. If all of this fails, see your podiatrist for prescription strength topical or oral antifungal products and management instructions.

Now, let’s discuss fungal toenails or onychomycosis. Fungus that lives UNDER the nail plate is nearly impossible to reach with any topical antifungal product, whether it is OTC or prescription. No topical product can penetrate deeper than 1 mm of thickness. Most fungal nails are easily > 1 mm thick and can reach as much as 7 mm in thickness. That’s why there is a 95% failure rate from topical products alone. Many disappointed patients come to my office with old bottles and tubes of “failed” antifungal products which they had been instructed to use by a friend or a doctor.

One way to facilitate use of a topical product, is for your podiatrist to surgically remove (temporarily) the toenail, then apply the topical antifungal product while the nail is re-growing, for many months.

Another treatment option is to use prescription oral antifungal medications. There are several different ones available. All require periodic blood testing to monitor liver enzymes, similar to cholesterol medications, which can cause temporary elevation of these enzymes. With proper monitoring, these medications are safe and can be highly effective. Of course, your podiatrist can determine if you are the right candidate for these medications. Someone with liver disease, taking multiple medications, or a heavy alcohol consumer, would not be an appropriate candidate.

Recently, some doctors have been using laser treatments on fungal nails. The treatment, while not covered by any medical insurance, can be quite costly. If you obtain success initially, the fungus usually re-grows again in about 2 years, requiring re-treatment. Re-treatment may or may not be successful.

Another treatment option, not as dramatic or horrifying as it might first sound, is a PERMANENT removal of all affected nails, or only the worst ones. While the nail will never re-grow, it’s cosmetically more attractive than the original fungal toenails, is much more comfortable than having a thick toenail that gets pressed by shoes, and once healed, it is forever maintenance- free. It also prevents further spread of the fungal infection to other unaffected nails or skin. For some, who are unable or unwilling to take oral medication, this is an excellent treatment. Patients will often ask if they need the nail for protective reasons and what it will look like, when the nail is no longer there. My answers are as follows: the thick, painful hard-to-trim fungal toenail is not offering any protection for the toe. On the contrary, it is doing the opposite, sometimes causing a secondary bacterial infection under the nail. And, with the nail gone, the remaining nail bed will look like your “outside” skin, but maybe a little thicker. Many of my patients will polish the nail bed along with their remaining nails.

Finally, a combination of the above treatments can be provided, depending on patient circumstances.

Why not schedule an appointment for an evaluation and treatment care plan for your specific conditions?

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