Onychomycosis

A very common condition is fungal infections of the nails that concerns men and women. Onychomycosis accounts for 30% of cases of fungal infection on the skin’s surface.

Fungi are divided into 3 genera: Trichophytes, Epidermophytes and Microspores.

There are 4 clinical types of Onychomycosis:

1. Peripheral onychomycosis that begins by affecting the free edge of the nail and then extends underneath (to the subnail).

2. White surface onychomycosis with plaque rupture that becomes white and opaque.

3. Near sub-nail onychomycosis that starts with nail attack under the nail (cuticle).

4. Candidiasis onychomycosis where the responsible fungus is Candida albicans and nail lesions start from the proximal fold and the nail’s side and there may be inflammation with pain and edema in the perineum. Usually without treatment, the entire nail is affected.

In general, the nails that are affected by fungi show differences in their color (white, green, yellow, brown or black) which are sometimes indicative of the type of fungus. Also, the nails may show thickening, fragility or even onycholysis.

Usually one or two nails on each foot are affected, while the infection of all nails is either indicative of another condition (e.g. psoriasis, lichen, etc.) or occurs in exceptional cases where the patient has neglected the care of his/her nails. Sometimes, onychomycosis coexists with mycosis of the soles skin.

The diagnosis is performed by direct microscopy and culture of the fungus by scraping the affected area with the aim of isolating nail clippings containing enough fungal hyphae for culture.

Prior to the culture of the nail clippings, the patient should not have used antifungal creams, powders for several weeks. Oral antifungal treatment should have been stopped for at least 3 months before culture. The nails should not have been polished for at least 10 days before culture.

In initial conditions, the treatment can be applied with local antifungal products, usually in the form of lacquers (imidazoles, amorolphin, and allalamines) but the patient must consistently and persistently follow the treatment for 3-6 months and with a recurrence (relapse) rate of up to 50%.

In more advanced cases, it is necessary to administer oral antifungal treatment with different regimens. Usually we follow pulse treatment which last 6-9 months for the toenails and 3-4 months for the fingernails.

While on oral antifungal treatment, liver function should be checked. There are 3 categories of antifungal agents, the itraconazole, the terbinafine and the fluconazole.

The dermatologist should take into account the interactions between the drugs if the patient is taking other drugs (e.g. anticoagulants) at the same time.

Finally, there is a fungal treatment that is performed by a dermatologist with an Nd: Yag Laser at 1064 nm (S30 PODYLAS) and 3-4 treatments are required with an interval of 15 days on the affected nails.

The preventive measures one should take to prevent relapses are the following: the good foot hygiene with thorough drying, the avoidance of wearing synthetic socks and shoes. If there is dermatophytosis on the feet soles, it should be treated so that the nails are not affected afterwards.