Onychomycosis, also known as tinea unguium, is an infectious fungal infection of the nail. Affect toenails or fingernails. Toenail infections are particularly common. Recent studies reveal approximately 20- 30% of the population have at any one time fungal infected nails. Incidence rates increase considerably with age with weakening immunity. Children are less susceptible to infection.

It is the most common disease of the nails and constitutes about half of all nail abnormalities and can be very hard to treat. It can be identified by thickened, discoloured toenails that become brittle, painful and loose. It retards nail growth and destroys nail plate structures.

The formation of a fungal biofilm makes treating an infection harder. We recommend a combined treatment approach involving surgery and laser therapy. Please refer to Blogs.

A healthy skin has an acidic pH 4.5 which keeps in check small amounts of fungus found all over the body. If the skin becomes damaged or compromised due to poor health then fungus can start to colonise in dark, warm, moist areas like the groin, armpits and feet. Feet are a prime target as conditions are ideal when wearing socks and occlusive footwear. An Athletes Foot (Ring Worm) condition can develop. This is highly infectious and can be transferred into the nails if the nail plate’s structure is damaged or cross-infect from others in communal areas, during pedicures, nail bars or simply trying on shoes.

A healthy skin microbiome is important. If there is an imbalance of the skin’s commensals this can lead to a dysbiosis.

The majority of onychomycosis infections are caused by parasitic dermatophytes that are specific to humans. They are closely related to fungus. There are 2 common dermatophytes:

• Trichophyton rubrum
• Trichophyton mentagrophytes

Onychomycosis can also be a mixed infection involving non-dermatophyte fungi such as moulds and yeast. In one study, the causative fungal agents were found to be 68% fungus, 29% yeasts and 3% moulds.  (Bayer)

It is the fungal spores that are the real cause of infections spreading. One infected shed skin cell contains 1000s of microscopic spores which can live on a dry surface for approximately 20 months and on damp surfaces up to 50 months!

There are five primary types of fungal nail infection with Distal Lateral Subungual Onychomycosis (DLSO), representing 80-90% of infections. It is characterised by infection of the nail bed. Fungal infections are harboured in the nail plate layer just above the nail bed.

Fungal infections can progress very slowly in younger and healthier individuals and exponentially increase with age. Initially there may be a small insignificant disruption of the white free edge of the nail; a streak that progresses inwards or a white patch, flecks on the top of the nail plate which are noticed after removing nail varnish. These get more pronounced.

General Signs of Onychomycosis:

• Thickened nail
• Crumbly or brittle nail
• Slow nail growth, growing upwards, but not outwards
• Nail distorted in shape
• Nail with no lustre or shine
• Streaks or patches increasing in size
• A white, yellow or brown coloured nail, caused by debris build up

Redness and swelling next to the nail (possibly pus) could also be an indication. This a secondary bacterial infection caused by the presence of dermaphytes.

It is very important to diagnose if the presenting nail has a fungal nail infection or there is another cause:

• Bacterial infection especially Pseudomonas aeruginosa, which turns the nail black or green
• Psoriasis
• Eczema or dermatitis
• Lichen planus
• Viral warts
• Onycholysis (nail plate lifting, splitting)
• Onychogryphosis (nail thickening and scaling under the nail), common in the elderly

At Compleet Feet we will always undertake a thorough diagnostic consultation to determine whether there is a fungal infection present. If we are not sure we will take a specimen culture test.

Most major medical insurance companies and GPs consider onychomycosis to be a cosmetic condition, but it should be considered as a more serious dermatological condition. It can cause sufferers huge psychological stress. Onychomycosis is a destructive disease which can permanently damage nail beds, distorts and thicken nail plates leading to pain and discomfort. It is very infectious leading to multiple infected nails. Suffers become more prone to ingrowing toenails and secondary bacterial infections. Bacterial infections can lead to cellulitis or bone infection. Although, this is not common this presents a concern if an individual is immune-compromised, has diabetes or poor peripheral circulation it is thus important to treat fungal nail infections or at least control the condition to reduce unwanted complications.

Information from a study by Bayer

Having a fungal foot infection leads to low level inflammatory stress within the body which can impair overall systemic health. It should not be ignored as it can have an impact on the immune system. It is considered by many to be more of a health issue than a cosmetic one.

Topical treatments are usually applied as a lacquer to the surface of the nail plate. Their effectiveness is poor for medium to high grade infections, but have some benefit when treating new infections affecting the free edge of the nail and can help to control some infections as part of a podiatry treatment programme. The main reason why they have reduced efficacy on badly infected nails is that they simply cannot penetrate the hard keratin of the plate to reach source of infection. Think of a nail plate being made up of many layers like plywood. The infection is  harboured in the bottom layer near to the nail bed. Often valuable time is lost whilst individuals try to treat their infections with topicals, having spread further into the plate.

• Tea Tree products have been recommended as an alternative treatment for fungal nail infections for many years. There is no clinical evidence to support their effectiveness other than to have a mild antimicrobial action and to be applied as an astringent for hygiene purposes.
• pH modulating agents e.g. vinegar and Vicks Vapour rub. The aim of these products is to change the skin’s pH from alkaline to acidic. Fungus does not like an acidic environment. There is little clinical evidence to support changing PH can inhibit fungal dermaphyte activity, but can in effect make it worse, more entrenched.
• Do not use spirits or astringents on the skin as can make the infection worse.

Oral antifungal agents used to treat onychomycosis include; Itraconazole and Terbinafine. Special  consideration must be made before prescribing and taking a course of anti-fungal drugs due to the possibility of systemic side effects, patients must be good health. Liver function tests are required. The drugs can potentially effect the liver, causing hepatic damage.

When taking a drug it is absorbed into skin, nail and hair. Nails do not have direct blood vessels, so the drug is absorbed through the blood stream over time. It cannot be controlled. The drugs will need to be taken for the time it takes for the nail infection to grow out or success rate is reduced. A toenail plate only grows 1mm per month so a long  course of medication is required for a big toenail if it is badly infected.

Antifungal drugs can play a role if there is a recalcitrant Athlete’s Foot skin infection that cannot be controlled with conservative methods.

Clearanail is a very effective treatment for recent singular mild to moderate infections. If the nail has a small area of infection then minute holes are introduced around and through it to allow the penetration of Terbinafine Hydrochloride 1%. High concentrations of the drug build up in the nail plate to treat the infection. Results are seen within 2-8 weeks. It is less effective on multiple, older more severe infections.

A photograph will be taken as a record of presenting condition. The nail plate will be debrided or drilled to reduce thickness of nail. Multiple minute holes will be introduced into nail plate and Lamisil Spray, Terbinafine Hydrocholoride 1% will be applied. General advice will be given on home care. A review appointment will be made.

Usually 1 -2 treatments are all that are required depending on severity of infection. It is always important to treat any accompanying Athlete Feet infection and sanitise footwear for infectious spores.

1 Treatment 30 minutes From: £120

Includes x1 Lamisil Spray

It is very important to diagnose if the presenting nail has a fungal nail infection or there is another cause:

• Bacterial infection especially Pseudomonas aeruginosa, which turns the nail black or green
• Psoriasis
• Eczema or dermatitis
• Lichen planus
• Viral warts
• Onycholysis (nail plate lifting, splitting)
• Onychogryphosis (nail thickening and scaling under the nail), common in the elderly

At Compleet Feet we will always undertake a thorough diagnostic consultation to determine whether there is a fungal infection present. If we are not sure we will take a specimen culture test.

Most major medical insurance companies and GPs consider onychomycosis to be a cosmetic condition, but it should be considered as a more serious dermatological condition. It can cause sufferers huge psychological stress. Onychomycosis is a destructive disease which can permanently damage nail beds, distorts and thicken nail plates leading to pain and discomfort. It is very infectious leading to multiple infected nails. Suffers become more prone to ingrowing toenails and secondary bacterial infections. Bacterial infections can lead to cellulitis or bone infection. Although, this is not common this presents a concern if an individual is immune-compromised, has diabetes or poor peripheral circulation it is thus important to treat fungal nail infections or at least control the condition to reduce unwanted complications.

Information from a study by Bayer

Topical treatments are usually applied as a lacquer to the surface of the nail plate. Their effectiveness is poor for medium to high grade infections, but have some benefit when treating new infections affecting the free edge of the nail and can help to control some infections as part of a podiatry treatment programme. The main reason why they have reduced efficacy on badly infected nails is that they simply cannot penetrate the hard keratin of the plate to reach source of infection. Think of a nail plate being made up of many layers like plywood. The infection is  harboured in the bottom layer near to the nail bed. Often valuable time is lost whilst individuals try to treat their infections with topicals, having spread further into the plate.

• Tea Tree products have been recommended as an alternative treatment for fungal nail infections for many years. There is no clinical evidence to support their effectiveness other than to have a mild antimicrobial action and to be applied as an astringent for hygiene purposes.
• pH modulating agents e.g. vinegar and Vicks Vapour rub. The aim of these products is to change the skin’s pH from alkaline to acidic. Fungus does not like an acidic environment. There is little clinical evidence to support changing PH can inhibit fungal dermaphyte activity, but can in effect make it worse, more entrenched.

Oral antifungal agents used to treat onychomycosis include; Itraconazole and Terbinafine. Special  consideration must be made before prescribing and taking a course of anti-fungal drugs due to the possibility of systemic side effects, patients must be good health. Liver function tests are required. The drugs can potentially effect the liver, causing hepatic damage.

When taking a drug it is absorbed into skin, nail and hair. Nails do not have direct blood vessels, so the drug is absorbed through the blood stream over time. It cannot be controlled. The drugs will need to be taken for the time it takes for the nail infection to grow out or success rate is reduced. A toenail plate only grows 1mm per month so a long  course of medication is required for a big toenail if it is badly infected.

Antifungal drugs can play a role if there is a recalcitrant Athlete’s Foot skin infection that cannot be controlled with conservative methods.