Are Your Nails Changing?

What you need to know to treat nail infections

By: John Kraft and Charles Lynde, MD, FRCPC

Nearly half of all nail changes are due to fungal infection. The term, onychomycosis refers to a fungal infections of the nail. Fungal infections of the nails are common around the world with men affected more often than women. Toenails are much more commonly affected than fingernails because fungus tends to become established in nails that grow slowly. More than one nail can be infected and a preceding fungal infection of the foot is common. Learn more on Fungal Guide.

What to Look For:

The disorder is can be more than just a cosmetic change. The infected nail can cause discomfort or pain, especially when cutting nails, and during athletic activities (i.e. walking, running, dancing).

The fungi live on keratin in the nail and multiply within the nail plate causing it to thicken and become yellow or white. There may also be opaque, crumbly, accumulations of hyperkeratotic debris below the nail and onycholysis (separation of the nail plate from the nail bed). With these changes, the nail environment becomes even more suited to fungal growth. Once infected, the nail may grow even slower, seldom requiring cutting.

What if it's Not a Fungal Infection?

Not every thickened nail is a fungal infection. The following diseases can also cause nails that look like fungal infections:

Skin diseases

Dermatitis
Lichen Planus
Psoriasis (See Psoriasis treatment and skincare patient portal)

Systemic diseases

Hyperthyroidism

External insults

Contact irritants
Ingrown toenails
Trauma

Your dermatologist may want to be sure of the diagnosis before deciding on treatment strategies. Nail clippings are taken for examination and culture.

At Home Treatment and Prevention:

There are things that can be done at home to help prevent onychomycosis, or prevent it from spreading to other nails or to the feet:

Regularly use antifungal or absorbent powders
Wear cotton socks with protective foot wear
Discard old footwear to prevent re-contamination.
Thoroughly dry your feet after bathing, especially between the toes. Sometimes the use of a blow-dryer can help.

Medical Treatment Options:

Treating onychomycosis is challenging to treat. Until recently, topical therapy has not usually sufficed as topical therapy has trouble penetrating the nail. A new formulation has been created that penetrates the nail (Penlac™ - drug name Ciclopirox). This lacquer that you paint on your nails, has been shown effective in the early stages of fungal infection and as conjunctive therapy with systemic medications.

Systemic antifungals (i.e. terbinafine, itraconazole, ketoconazole, fluconazole) are the most effective options for treating onychomycosis. However, these medications are prescribed with caution as they can have serious effects on the liver and can interact with other medications. Your dermatologist will ensure it is safe for you to take them, by knowing the contraindications, being aware of all your medications, and monitoring your liver function while taking these medications.
To learn more about anti-fungal drugs, click on fungalguide.ca/treatments/antifungal_drugs.html

Nail infections are particularly challenging and can be frustrating to treat. They often require long treatment periods and in spite of this, recurrence of toenail disease is relatively common.

About the authors:
Charles Lynde, MD, FRCPC is Assistant Clinical Professor, University of Toronto Canada. His special interests include paediatric dermatology, cosmetic procedures, contact dermatitis, skin cancer, psoriasis and clinical trials in acne, eczema, and psoriasis.
John Kraft, HBSc, is a fourth year medical student at the University of Toronto, with an interest in dermatology.