Onychomycosis, also known as tinea unguium, is a
fungal infection
Fungal infection, also known as mycosis, is disease caused by fungi. Different types are traditionally divided according to the part of the body affected; superficial, subcutaneous, and systemic. Superficial fungal infections include common ti ...
of the
nail
Nail or Nails may refer to:
In biology
* Nail (anatomy), toughened protective protein-keratin (known as alpha-keratin, also found in hair) at the end of an animal digit, such as fingernail
* Nail (beak), a plate of hard horny tissue at the tip ...
.
[ Symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed.] Toenail
A nail is a claw-like plate found at the tip of the fingers and toes on most primates. Nails correspond to the claws found in other animals. Fingernails and toenails are made of a tough protective protein called alpha-keratin, which is a polymer. ...
s or fingernail
A nail is a claw-like plate found at the tip of the fingers and toes on most primates. Nails correspond to the claws found in other animals. Fingernails and toenails are made of a tough protective protein called alpha-keratin, which is a polymer. ...
s may be affected, but it is more common for toenails.[ Complications may include ]cellulitis
Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...
of the lower leg.[
A number of different types of fungus can cause onychomycosis, including ]dermatophyte
Dermatophyte (from Greek '' derma'' "skin" (GEN ''dermatos'') and ''phyton'' "plant") is a common label for a group of fungus of ''Arthrodermataceae'' that commonly causes skin disease in animals and humans. Traditionally, these anamorphic (as ...
s and ''Fusarium
''Fusarium'' is a large genus of filamentous fungi, part of a group often referred to as hyphomycetes, widely distributed in soil and associated with plants. Most species are harmless saprobes, and are relatively abundant members of the soil mi ...
''.[ Risk factors include ]athlete's foot
Athlete's foot, known medically as ''tinea pedis'', is a common skin infection of the feet caused by a fungus. Signs and symptoms often include itching, scaling, cracking and redness. In rare cases the skin may blister. Athlete's foot fungus m ...
, other nail diseases
A nail disease or onychosis is a disease or deformity of the nail. Although the nail is a structure produced by the skin and is a skin appendage, nail diseases have a distinct classification as they have their own signs and symptoms which may re ...
, exposure to someone with the condition, peripheral vascular disease
Peripheral artery disease (PAD) is an abnormal narrowing of arteries other than those that supply the heart or brain. When narrowing occurs in the heart, it is called coronary artery disease, and in the brain, it is called cerebrovascular diseas ...
, and poor immune function
Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse reacti ...
.[ The diagnosis is generally suspected based on the appearance and confirmed by laboratory testing.][
Onychomycosis does not necessarily require treatment.][ The ]antifungal medication
An antifungal medication, also known as an antimycotic medication, is a pharmaceutical fungicide or fungistatic used to treat and prevent mycosis such as athlete's foot, ringworm, candidiasis (thrush), serious systemic infections such as crypt ...
terbinafine
Terbinafine, sold under the brand name Lamisil among others, is an antifungal medication used to treat pityriasis versicolor, fungal nail infections, and ringworm including jock itch and athlete's foot. It is either taken by mouth or applied to ...
taken by mouth appears to be the most effective but is associated with liver problems
Liver disease, or hepatic disease, is any of many diseases of the liver. If long-lasting it is termed chronic liver disease. Although the diseases differ in detail, liver diseases often have features in common.
Signs and symptoms
Some of the sig ...
.[ Trimming the affected nails when on treatment also appears useful.][
There is a ]ciclopirox
Ciclopirox (sometimes known by the abbreviation CPX) is a synthetic antifungal agent for topical dermatologic treatment of superficial mycoses. It is most useful against tinea versicolor. It is sold under many brand names worldwide.Drugs.coInt ...
-containing nail polish
Nail polish (also known as nail varnish or nail enamel) is a lacquer that can be applied to the human fingernail or toenails to decorate and protect the nail plates. The formula has been revised repeatedly to enhance its decorative properties ...
, but there is no evidence that it works. The condition returns in up to half of cases following treatment. Not using old shoes after treatment may decrease the risk of recurrence.
Onychomycosis occurs in about 10 percent of the adult population, with older people more frequently affected.[ Males are affected more often than females.][ Onychomycosis represents about half of nail disease.][ It was first determined to be the result of a fungal infection in 1853 by ]Georg Meissner
George Meissner (19 November 1829 – 30 March 1905) was a German anatomist and physiologist born in Hanover.
He studied medicine at the University of Göttingen, where he worked closely with Rudolf Wagner (1806–1864). In 1851 he accompan ...
.
Etymology
The term is from Ancient Greek
Ancient Greek includes the forms of the Greek language used in ancient Greece and the ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Dark Ages (), the Archaic peri ...
' "nail", ' "fungus", and the suffix ''ōsis'' "functional disease".
Signs and symptoms
The most common symptom of a fungal nail infection is the nail becoming thickened and discoloured: white, black, yellow or green. As the infection progresses the nail can become brittle, with pieces breaking off or coming away from the toe or finger completely. If left untreated, the skin underneath and around the nail can become inflamed and painful. There may also be white or yellow patches on the nailbed or scaly skin next to the nail,[NHS Choices: Symptoms of fungal nail infection]
/ref> and a foul smell. There is usually no pain or other bodily symptoms, unless the disease is severe. People with onychomycosis may experience significant psychosocial
The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is ...
problems due to the appearance of the nail, particularly when fingers – which are always visible – rather than toenails are affected.
Dermatophytids
Dermatophytids are fungus-free disseminated skin lesions resulting from induced sensitization in patients with ringworm infections.
See also
* Candidid
Candidid is a skin condition, an id reaction, similar to dermatophytids.
See also
* Cand ...
are fungus-free skin lesions
A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. The major function of this sy ...
that sometimes form as a result of a fungus infection in another part of the body. This could take the form of a rash
A rash is a change of the human skin which affects its color, appearance, or texture.
A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch, become warm, bumpy, chapped, dry, cr ...
or itch
Itch (also known as pruritus) is a sensation that causes the desire or reflex to scratch. Itch has resisted many attempts to be classified as any one type of sensory experience. Itch has many similarities to pain, and while both are unpleasant ...
in an area of the body that is not infected with the fungus. Dermatophytids can be thought of as an allergic reaction
Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic derma ...
to the fungus.
Causes
The causative pathogens
In biology, a pathogen ( el, πάθος, "suffering", "passion" and , "producer of") in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a germ ...
of onychomycosis are all in the fungus kingdom
A fungus ( : fungi or funguses) is any member of the group of eukaryotic organisms that includes microorganisms such as yeasts and molds, as well as the more familiar mushrooms. These organisms are classified as a kingdom, separately from th ...
and include dermatophyte
Dermatophyte (from Greek '' derma'' "skin" (GEN ''dermatos'') and ''phyton'' "plant") is a common label for a group of fungus of ''Arthrodermataceae'' that commonly causes skin disease in animals and humans. Traditionally, these anamorphic (as ...
s, '' Candida'' (yeast
Yeasts are eukaryotic, single-celled microorganisms classified as members of the fungus kingdom. The first yeast originated hundreds of millions of years ago, and at least 1,500 species are currently recognized. They are estimated to constitut ...
s), and nondermatophytic mold
A mold () or mould () is one of the structures certain fungus, fungi can form. The dust-like, colored appearance of molds is due to the formation of Spore#Fungi, spores containing Secondary metabolite#Fungal secondary metabolites, fungal seco ...
s.[ Dermatophytes are the fungi most commonly responsible for onychomycosis in the temperate western countries; while ''Candida'' and nondermatophytic molds are more frequently involved in the tropics and subtropics with a hot and humid climate.]
Dermatophytes
When onychomycosis is due to a dermatophyte infection, it is termed tinea unguium. ''Trichophyton rubrum
''Trichophyton rubrum'' is a dermatophytic fungus in the phylum Ascomycota. It is an exclusively clonal, anthropophilic saprotroph that colonizes the upper layers of dead skin, and is the most common cause of athlete's foot, fungal infectio ...
'' is the most common dermatophyte
Dermatophyte (from Greek '' derma'' "skin" (GEN ''dermatos'') and ''phyton'' "plant") is a common label for a group of fungus of ''Arthrodermataceae'' that commonly causes skin disease in animals and humans. Traditionally, these anamorphic (as ...
involved in onychomycosis. Other dermatophytes that may be involved are '' T. interdigitale'', ''Epidermophyton floccosum
''Epidermophyton floccosum'' is a filamentous fungus that causes skin and nail infections in humans. This anthropophilic dermatophyte can lead to diseases such as tinea pedis (athlete's foot), tinea cruris, tinea corporis and onychomycosis. Diagn ...
'', ''T. violaceum'', ''Microsporum gypseum
''Microsporum gypseum'' is a soil-associated dermatophyte that occasionally is known to colonise and infect the upper dead layers of the skin of mammals. The name refers to an asexual "form-taxon" that has been associated with four related biolo ...
'', '' T. tonsurans'', and '' T. soudanense''. A common outdated name that may still be reported by medical laboratories is ''Trichophyton mentagrophytes
''Trichophyton mentagrophytes'' is a species in the fungal genus ''Trichophyton''. It is one of three common fungi which cause ringworm in companion animals. It is also the second-most commonly isolated fungus causing tinea infections in humans, ...
'' for ''T. interdigitale''. The name ''T. mentagrophytes'' is now restricted to the agent of favus
Favus (Latin for "honeycomb") or tinea favosa is the severe form of tinea capitis, a skin infectious disease caused by the dermatophyte fungus ''Trichophyton schoenleinii.'' Typically the species affects the scalp, but occasionally occurs as onyc ...
skin infection of the mouse
A mouse ( : mice) is a small rodent. Characteristically, mice are known to have a pointed snout, small rounded ears, a body-length scaly tail, and a high breeding rate. The best known mouse species is the common house mouse (''Mus musculus' ...
; though this fungus may be transmitted from mice
A mouse ( : mice) is a small rodent. Characteristically, mice are known to have a pointed snout, small rounded ears, a body-length scaly tail, and a high breeding rate. The best known mouse species is the common house mouse (''Mus musculus' ...
and their dander
Dander is material shed from the body of humans and other animals that have fur, hair, or feathers. The term is similar to dandruff, when an excess of flakes becomes visible. Skin flakes that come off the main body of an animal are dander, while th ...
s to humans, it generally infects skin and not nails.
Other
Other causative pathogens
In biology, a pathogen ( el, πάθος, "suffering", "passion" and , "producer of") in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a germ ...
include ''Candida'' and nondermatophytic mold
A mold () or mould () is one of the structures certain fungus, fungi can form. The dust-like, colored appearance of molds is due to the formation of Spore#Fungi, spores containing Secondary metabolite#Fungal secondary metabolites, fungal seco ...
s, in particular members of the mold genus ''Scytalidium
''Scytalidium'' is a genus of fungi in the Helotiales order. The relationship of this taxon to other taxa within the order is unknown (''incertae sedis''), and it has not yet been placed with certainty into any family. This genus of anamorphic ...
'' (name recently changed to ''Neoscytalidium
Neoscytalidium is a genus of fungi in the Botryosphaeriaceae
The Botryosphaeriaceae are a family of sac fungi (Ascomycetes), which is the type representative of the order Botryosphaeriales. According to a 2008 estimate, the family contains 2 ...
''), ''Scopulariopsis
''Scopulariopsis'' is a genus of teleomorph, anamorph and holomorph, anamorphic fungi that are saprobic and pathogenic to animals. The widespread genus contains 22 species. ''Scopulariopsis'' belongs to the group Hyphomycetes. These species are c ...
'', and ''Aspergillus
' () is a genus consisting of several hundred mold species found in various climates worldwide.
''Aspergillus'' was first catalogued in 1729 by the Italian priest and biologist Pier Antonio Micheli. Viewing the fungi under a microscope, Miche ...
''.
''Candida'' species mainly cause fingernail onychomycosis in people whose hands are often submerged in water. ''Scytalidium'' mainly affects people in the tropics
The tropics are the regions of Earth surrounding the Equator. They are defined in latitude by the Tropic of Cancer in the Northern Hemisphere at N and the Tropic of Capricorn in
the Southern Hemisphere at S. The tropics are also referred to ...
, though it persists if they later move to areas of temperate climate
In geography, the temperate climates of Earth occur in the middle latitudes (23.5° to 66.5° N/S of Equator), which span between the tropics and the polar regions of Earth. These zones generally have wider temperature ranges throughout t ...
.
Other molds more commonly affect people older than 60 years, and their presence in the nail reflects a slight weakening in the nail's ability to defend itself against fungal invasion.
Nail injury and nail psoriasis can cause damaged toenails to become thick, discolored & brittle.
Risk factors
Advancing age (usually over the age of 60) is the most common risk factor for onychomycosis due to diminished blood circulation
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
, longer exposure to fungi, nails which grow more slowly and thicken, and reduced immune function increasing susceptibility to infection. Nail fungus tends to affect men more often than women and is associated with a family history of this infection.
Other risk factors include perspiring heavily, being in a humid or moist environment, psoriasis
Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by raised areas of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small, localized patches to complete ...
, wearing socks and shoes that hinder ventilation and do not absorb perspiration, going barefoot in damp public places such as swimming pools, gyms and shower rooms, having athlete's foot
Athlete's foot, known medically as ''tinea pedis'', is a common skin infection of the feet caused by a fungus. Signs and symptoms often include itching, scaling, cracking and redness. In rare cases the skin may blister. Athlete's foot fungus m ...
(tinea pedis), minor skin or nail injury, damaged nail, or other infection, and having diabetes, circulation problems, which may also lead to lower peripheral temperatures on hands and feet, or a weakened immune system.
Diagnosis
The diagnosis is generally suspected based on the appearance and confirmed by laboratory testing.[ The four main tests are a potassium hydroxide smear, ]culture
Culture () is an umbrella term which encompasses the social behavior, institutions, and norms found in human societies, as well as the knowledge, beliefs, arts, laws, customs, capabilities, and habits of the individuals in these groups.Tyl ...
, histology
Histology,
also known as microscopic anatomy or microanatomy, is the branch of biology which studies the microscopic anatomy of biological tissues. Histology is the microscopic counterpart to gross anatomy, which looks at larger structures vis ...
examination, and polymerase chain reaction
The polymerase chain reaction (PCR) is a method widely used to rapidly make millions to billions of copies (complete or partial) of a specific DNA sample, allowing scientists to take a very small sample of DNA and amplify it (or a part of it) t ...
.[ The sample examined is generally nail scrapings or clippings.][ These being from as far up the nail as possible.][
Nail plate ]biopsy
A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...
with periodic acid-Schiff stain
Periodicity or periodic may refer to:
Mathematics
* Bott periodicity theorem, addresses Bott periodicity: a modulo-8 recurrence relation in the homotopy groups of classical groups
* Periodic function, a function whose output contains values tha ...
appear more useful than culture or direct KOH examination. To reliably identify nondermatophyte molds, several samples may be necessary.
Classification
There are five classic types of onychomycosis:
* Distal subungual onychomycosis is the most common form of ''tinea unguium''[ and is usually caused by '']Trichophyton rubrum
''Trichophyton rubrum'' is a dermatophytic fungus in the phylum Ascomycota. It is an exclusively clonal, anthropophilic saprotroph that colonizes the upper layers of dead skin, and is the most common cause of athlete's foot, fungal infectio ...
'', which invades the nail bed and the underside of the nail plate
A nail is a claw-like plate found at the tip of the fingers and toes on most primates. Nails correspond to the claws found in other animals. Fingernails and toenails are made of a tough protective protein called alpha-keratin, which is a polymer. ...
.
* White superficial onychomycosis (WSO) is caused by fungal invasion of the superficial layers of the nail plate to form "white islands" on the plate. It accounts for around 10 percent of onychomycosis cases. In some cases, WSO is a misdiagnosis of "keratins granulations" which are not a fungus, but a reaction to nail polish that can cause the nails to have a chalky white appearance. A laboratory test should be performed to confirm.
* Proximal subungual onychomycosis is fungal penetration of the newly formed nail plate through the proximal nail fold. It is the least common form of ''tinea unguium'' in healthy people, but is found more commonly when the patient is immunocompromised.[
* Endonyx onychomycosis is characterized by ]leukonychia
Leukonychia (or leuconychia) is a medical term for white discoloration appearing on nails.Freedberg, et al. (2003). ''Fitzpatrick's Dermatology in General Medicine''. (6th ed.). McGraw-Hill. pp. 658–59. . It is derived from the Greek words ''l ...
along with a lack of onycholysis
Onycholysis is a common medical condition characterized by the painless detachment of the nail from the nail bed, usually starting at the tip and/or sides. On the hands, it occurs particularly on the ring finger but can occur on any of the fingern ...
or subungual hyperkeratosis
Hyperkeratosis is thickening of the stratum corneum (the outermost layer of the epidermis, or skin), often associated with the presence of an abnormal quantity of keratin,Kumar, Vinay; Fausto, Nelso; Abbas, Abul (2004) ''Robbins & Cotran Patholo ...
.
* Candidal onychomycosis is '' Candida'' species invasion of the fingernails, usually occurring in persons who frequently immerse their hands in water. This normally requires the prior damage of the nail by infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
or trauma
Trauma most often refers to:
* Major trauma, in physical medicine, severe physical injury caused by an external source
* Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event
*Traumatic i ...
.
Differential diagnosis
In many cases of suspected nail fungus there is actually no fungal infection, but only nail deformity.[. Which cites:* ][
To avoid misdiagnosis as nail psoriasis, ]lichen planus
Lichen planus (LP) is a chronic inflammatory and immune-mediated disease that affects the skin, nails, hair, and mucous membranes. It is not an actual lichen, and is only named that because it looks like one. It is characterized by polygonal, fla ...
, contact dermatitis
Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are ...
, nail bed tumor
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s such as melanoma
Melanoma, also redundantly known as malignant melanoma, is a type of skin cancer that develops from the pigment-producing cells known as melanocytes. Melanomas typically occur in the skin, but may rarely occur in the mouth, intestines, or eye ( ...
, trauma
Trauma most often refers to:
* Major trauma, in physical medicine, severe physical injury caused by an external source
* Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event
*Traumatic i ...
, or yellow nail syndrome
Yellow nail syndrome, also known as "primary lymphedema associated with yellow nails and pleural effusion", is a very rare medical syndrome that includes pleural effusions, lymphedema (due to under development of the lymphatic vessels) and yellow d ...
, laboratory confirmation may be necessary.[
Other conditions that may appear similar to onychomycosis include: ]psoriasis
Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by raised areas of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small, localized patches to complete ...
, normal aging, yellow nail syndrome
Yellow nail syndrome, also known as "primary lymphedema associated with yellow nails and pleural effusion", is a very rare medical syndrome that includes pleural effusions, lymphedema (due to under development of the lymphatic vessels) and yellow d ...
, and chronic paronychia
Paronychia is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium '' Staphylococcus aureus'', or gradually when it is commonly caused by the fungus ''Candida albicans''. The term is fr ...
.
Treatment
Medications
Most treatments are with antifungal
An antifungal medication, also known as an antimycotic medication, is a pharmaceutical fungicide or fungistatic used to treat and prevent mycosis such as athlete's foot, ringworm, candidiasis (thrush), serious systemic infections such as crypto ...
medications, either topically or by mouth.[ Avoiding use of antifungal therapy by mouth (e.g., ]terbinafine
Terbinafine, sold under the brand name Lamisil among others, is an antifungal medication used to treat pityriasis versicolor, fungal nail infections, and ringworm including jock itch and athlete's foot. It is either taken by mouth or applied to ...
) in persons without a confirmed infection is recommended, because of the possible side effects of that treatment.
Medications that may be taken by mouth include terbinafine (76% effective), itraconazole
Itraconazole, sometimes abbreviated ITZ, is an antifungal medication used to treat a number of fungal infections. This includes aspergillosis, blastomycosis, coccidioidomycosis, histoplasmosis, and paracoccidioidomycosis. It may be given by mouth ...
(60% effective), and fluconazole
Fluconazole is an antifungal medication used for a number of fungal infections. This includes candidiasis, blastomycosis, coccidiodomycosis, cryptococcosis, histoplasmosis, dermatophytosis, and pityriasis versicolor. It is also used to prevent ...
(48% effective).[ They share characteristics that enhance their effectiveness: prompt penetration of the nail and nail bed, and persistence in the nail for months after discontinuation of therapy. ]Ketoconazole
Ketoconazole, sold under the brand name Nizoral among others, is an antiandrogen and antifungal medication used to treat a number of fungal infections. Applied to the skin it is used for fungal skin infections such as tinea, cutaneous candid ...
by mouth is not recommended due to side effects. Oral terbinafine is better tolerated than itraconazole. For superficial white onychomycosis, systemic rather than topical antifungal therapy is advised.
Topical agents include ciclopirox
Ciclopirox (sometimes known by the abbreviation CPX) is a synthetic antifungal agent for topical dermatologic treatment of superficial mycoses. It is most useful against tinea versicolor. It is sold under many brand names worldwide.Drugs.coInt ...
nail paint, amorolfine
Amorolfine (or amorolfin), is a morpholine antifungal drug that inhibits Δ14-sterol reductase and cholestenol Δ-isomerase, which depletes ergosterol
Ergosterol (ergosta-5,7,22-trien-3β-ol) is a sterol found in cell membranes of fungi and pr ...
, and efinaconazole
Efinaconazole, sold under the brand name Jublia among others, is a triazole antifungal medication. It is approved for use in the United States, Canada, and Japan as a 10% topical solution for the treatment of onychomycosis (fungal infection of t ...
. Some topical treatments need to be applied daily for prolonged periods (at least one year). Topical amorolfine is applied weekly.
Efinaconazole
Efinaconazole, sold under the brand name Jublia among others, is a triazole antifungal medication. It is approved for use in the United States, Canada, and Japan as a 10% topical solution for the treatment of onychomycosis (fungal infection of t ...
, a topical azole antifungal
An antifungal medication, also known as an antimycotic medication, is a pharmaceutical fungicide or fungistatic used to treat and prevent mycosis such as athlete's foot, ringworm, candidiasis (thrush), serious systemic infections such as crypto ...
, led to cure rates two or three times better than the next-best topical treatment, ciclopirox. In trials, about 17% of people were cured using efinaconazole, as opposed to 4% of people using placebo.
Topical ciclopirox results in a cure in 6% to 9% of cases. Ciclopirox when used with terbinafine appears to be better than either agent alone.[ Although eficonazole, P-3051 (ciclopirox 8% hydrolacquer), and tavaborole are effective at treating fungal infection of toenails, complete cure rates are low.
]
Other
Chemical (keratolytic
Keratolytic () therapy is a type of medical treatment to remove warts, calluses and other lesions in which the epidermis produces excess skin. In this therapy, acidic topical medicines, such as Whitfield's ointment or Jessner's solution, are ap ...
) or surgical debridement
Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy.
In p ...
of the affected nail appears to improve outcomes.[
As of 2014 evidence for ]laser treatment
A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The fir ...
is unclear as the evidence is of low quality and varies by type of laser.
Tea tree oil
Tea tree oil, also known as melaleuca oil, is an essential oil with a fresh camphoraceous odor and a colour that ranges from pale yellow to nearly colourless and clear. It is derived from the leaves of the tea tree, ''Melaleuca alternifolia'', ...
is not recommended as a treatment, since it is not effective and can irritate the surrounding skin.
Cost
United States
According to a 2015 study, the cost in the United States of testing with the periodic acid–Schiff stain
Periodicity or periodic may refer to:
Mathematics
* Bott periodicity theorem, addresses Bott periodicity: a modulo-8 recurrence relation in the homotopy groups of classical groups
* Periodic function, a function whose output contains values tha ...
(PAS) was about $148. Even if the cheaper KOH test
The KOH Test for ''Candida albicans'', also known as a potassium hydroxide preparation or KOH prep, is a quick, inexpensive fungal test to differentiate dermatophytes and ''Candida albicans'' symptoms from other skin disorders like psoriasis and e ...
is used first and the PAS test is used only if the KOH test is negative, there is a good chance that the PAS will be done (because of either a true or a false negative with the KOH test). But the terbinafine treatment costs only $10 (plus an additional $43 for liver function tests). In conclusion the authors say that terbinafine has a relatively benign adverse effect profile, with liver damage very rare, so it makes more sense cost-wise for the dermatologist to prescribe the treatment without doing the PAS test. (Another option would be to prescribe the treatment only if the potassium hydroxide test is positive, but it gives a false negative in about 20% of cases of fungal infection.) On the other hand, as of 2015 the price of topical (non-oral) treatment with efinaconazole
Efinaconazole, sold under the brand name Jublia among others, is a triazole antifungal medication. It is approved for use in the United States, Canada, and Japan as a 10% topical solution for the treatment of onychomycosis (fungal infection of t ...
was $2307 per nail, so testing is recommended before prescribing it.
The cost of efinaconazole treatment can be reduced to $65 per 1-month dose using drug coupon
A drug coupon is a coupon intended to help consumers save money on pharmaceutical drugs. They are offered by drug companies or distributed to consumers via doctors and pharmacists, and most can be obtained online. There are drug coupons for d ...
s, bringing the treatment cost to $715 per nail.
Canada
In 2019, a study by the Canadian Agency for Drugs and Technologies in Health
The Canadian Agency for Drugs and Technologies in Health, or CADTH, is a Canadian national organisation that provides research and analysis to healthcare decision-makers.
The organisation was established in 1989 by the country's federal governme ...
found the cost for a 48-week efinaconazole course to be $178 for a big toe, and $89 for an other toe.
Prognosis
Recurrence may occur following treatment, with a 20-25% relapse rate within 2 years of successful treatment. Nail fungus can be painful and cause permanent damage to nails. It may lead to other serious infections if the immune system is suppressed due to medication, diabetes or other conditions. The risk is most serious for people with diabetes and with immune systems weakened by leukemia or AIDS, or medication after organ transplant. Diabetics have vascular and nerve impairment, and are at risk of cellulitis
Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...
, a potentially serious bacterial infection; any relatively minor injury to feet, including a nail fungal infection, can lead to more serious complications. Infection of the bone is another rare complication.[
]
Epidemiology
A 2003 survey of diseases of the foot in 16 European countries found onychomycosis to be the most frequent fungal foot infection and estimated its prevalence at 27%. Prevalence was observed to increase with age. In Canada, the prevalence was estimated to be 6.48%. Onychomycosis affects approximately one-third of diabetics
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased app ...
and is 56% more frequent in people with psoriasis
Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by raised areas of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small, localized patches to complete ...
.
Research
Research suggests that fungi are sensitive to heat, typically . The basis of laser
A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The fir ...
treatment is to try to heat the nail bed to these temperatures in order to disrupt fungal growth. As of 2013 research into laser treatment seemed promising.[ There is also ongoing development in ]photodynamic therapy
Photodynamic therapy (PDT) is a form of phototherapy involving light and a photosensitizing chemical substance, used in conjunction with molecular oxygen to elicit cell death (phototoxicity).
PDT is popularly used in treating acne. It is used cl ...
, which uses laser or LED light to activate photosensitisers that eradicate fungi.
References
{{Disorders of skin appendages
Conditions of the skin appendages
Mycosis-related cutaneous conditions
Wikipedia medicine articles ready to translate