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Causes and Symptoms

Onychomycosis (tinea unguium) is a fungal infection of the nail or nail bed of fingernails and toenails. It is most commonly caused by the organisms Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton interdigitale, and Epidermophyton floccosum. Less commonly, it can be caused by the yeast Candida albicans, although this is more common for fingernail infections. While not deadly, it can be painful and unsightly, as well as embarrassing.

Onychomycosis may begin as superficial white or yellowish patches at the corner of the nail. In more severe cases involving the nail bed, the nail becomes thick and cloudy, and yellow--to-dark in color. The nail also becomes very hard and difficult to cut. Although usually painless, it can be uncomfortable, especially if it results in associated conditions, such as in-grown toenails, making the area more susceptible to bacterial infections.

Onychomycosis occurs in about 1.3% of people ages 16-34, and the incidence increases with age to nearly 5% of people age 55 and older. Infection of toenails occurs more frequently than that of fingernails.

Infection usually begins by bloodborne exposure. Typically, this is due to a combination of poor hygiene and cutting nails too short, causing them to bleed, and having the exposed area come into contact with a fungus-contaminated surface. Contamination most frequently occurs in humid areas shared by many individuals, such as gyms, locker rooms, and bathrooms, or by using contaminated grooming appliances, such as nail clips. Most reputable manicurists and pedicurists, professional groomers who work exclusively in nail care, have procedures in place for the proper sterilization of grooming tools. Check with the local Health Department to make sure there are no prior complaints against one of these facilities prior to making an appointment.

Treatment Options
It is important to get a firm diagnosis from a doctor prior to embarking on any treatment plan, since other nail disorders may produce similar symptoms. Once the initial diagnosis has been made, there are several treatment options, each having varying degrees of success, largely dependent upon the severity of the infection, and, most importantly, the willingness of the patient to adhere to the treatment regimen. Whatever the treatment plan, the nail should be trimmed to the thinnest point possible in order to maximize chances for treatment success.

1. Over-the-counter (OTC) Topical Medications
The wording on the packaging for OTC treatments carefully states that it is effective in treating nail fungus only on exposed portions of infected nails. This means that while it may be effective for superficial nail fungus, it is unlikely to be effective against nail fungus deep down under the nail. Therefore, if the entire fingernail or toenail is infected, and a topical dose is applied to the affected area, it is unlikely that any of the medication will reach the infection. It may, however, prevent an infection from spreading to the entire nail, if used regularly.

Miconazole nitrate and clotrimazole are antifungal agents effective against T. rubrum, T. mentagrophytes, and yeast, and are available in topical creams, sprays, and brush-on liquids. Since most are indicated 2 times per day for 3-18 months to be most effective, the success rate is low due to low patient compliance to the daily regimen.

Betadine (10% povidine iodine) has been found to be 82% effective in superficial fungal nail infections. Again, this treatment would be unlikely to be effective against an infection of the entire nail bed.

2. Surgery
Surgery, or removal of the entire nail may be indicated in instances where the complete nail is infected, or if it is causing pain or secondary bacterial infections resulting from such conditions as in-grown toenails. This is usually done as an in-office procedure using a local anesthetic. The doctor may prescribe an oral antibiotic to be taken for the next 7-10 days to prevent a secondary bacterial infection of the wound. The wound should be carefully cleaned with an anti-bacterial solution, such as betadine, and rebandaged daily. Once healing has begun, the nail bed should be treated twice per day with a topical antifungal to prevent re-infection of the new nail. Vigilant use of the antifungal is key, as this type of infection can be quite stubborn, and re-infection is very common.

3. Oral Prescription Medication
A group of doctors treating patients for intestinal parasites found as a side-effect that previously fungus–infected nails in study patients began to grow clear after 3 months of treatment, and that nails were completely fungus-free between 6 months to one year later. This led to the use of griseofulvin as the first effective oral treatment of nail fungal infections. However, clinical studies indicated that reoccurrence was common with this treatment because of undesirable side effects, such as nausea, headache, sensitivity to light, and gastrointestinal intolerance, which caused patients to stop taking their medication.

A more recent study found that 82% of patients taking oral Lamasil (250 mg) daily reported clear nail growth within 12 weeks, and were completely cured within 9 months, with no significant side-effects.

When it comes to prevention, there are several simple ways to avoid infection or re-infection.
1. Always thoroughly clean nail-grooming devices before and after use with a disinfecting solution.
2. Only frequent reputable manicurists and pedicurists.
3. Wear clean shower shoes with rubber soles when using public or shared facilities like gyms or swimming pools.
4. Wash feet thoroughly every day with an anti-bacterial soap.
5. Dry feet thoroughly after bathing or showering, especially between the toes.
6. Do not wear the same pair of shoes everyday, and spray shoes with a disinfectant between wearing.