How to Diagnose and Treat Discoloured Thick and Fungal Nails

Onychomycosis literally means nail (onycho) fungal (myco) disease (osis) and it refers to the common fungal infections of the nails that lead to their discolouration, thickening and splitting.

The fungus that is most commonly involved in nail disease is “Trichophyton rubrum”, which belongs to the group “dermatophyte” (derma = skin), a name that reflects their involvement in skin infections as well.

Yeasts and moulds may also lead to nail infections.

How is one infected?

Fungi are microscopic organisms that thrive in moist and warm environments, away from sunlight. Public swimming pools and showers are a likely place to acquire a fungal nail infection. Skin cuts, even minute ones, provide a portal of entry. Fungi can also breach through any gaps between your nails and nail beds.

Walking barefoot in public showers, pools or communal bathing areas, or sharing your towels or nail clippers increases the likelihood of acquiring a fungal nail infection.

Walking barefoot in public showers, pools or communal bathing areas, or sharing your towels or nail clippers increases the likelihood of acquiring a fungal nail infection.

Fingernails are more frequently washed, while toenails often remain confined in warm, dark, sweaty shoes – all the elements required for fungal growth.

Being at the very end of the body may place them at a greater risk of infection because of decreased blood circulation.

Who is more prone to developing fungal nails?

Age does play a role, and people over 60 are at a greater risk of acquiring fungal infections, not just of the nails.

Immunosuppression: HIV, leukaemia, use of immunosuppressant drugs (after organ transplantation) or any immune system disorder.

Diabetes compromises both the peripheral circulation and immune response of the body. The condition is seen in about 65% of diabetics.

Fungal skin infection: about a third of people with a pre-existing fungal skin infection such as athlete’s foot may develop fungal nails.

Psoriasis is an immune-mediated disease characterised by redness and irritation of the skin and an increased risk of developing fungal nails.

Poor general health or a positive family history

Wearing closed shoes most of the time or working in a hot, humid environment.

The first symptoms

The infection mostly starts at the end of the nail, spreads towards the cuticle, and is termed “distal subungual onychomycosis”. It occurs in about 90% of cases. Initially it starts as a discoloured spot at one corner of the toenail, and then spreads towards the cuticle, undermining the nail, which becomes thick and flaky.

The infection may remain confined to the superficial layers of the nail plate, leading to the appearance of chalky white patches on the nail. It is called “white superficial onychomycosis”, is found in about 10% of cases, and is often misdiagnosed.

In about 3% of cases, especially in immunocompromised individuals, the infection starts from the cuticle and spreads towards the end of the nail. This is termed “proximal subungual onychomycosis”.

The infection leaves the nails dull, discoloured, brittle and ragged.

The nails become thick, distorted and lose their surface shine.

The nails may separate from the nail bed (onycholysis).

The area is painful and may become smelly. Walking or standing for long periods becomes painful, and it interferes with wearing shoes.

The infection if not treated properly may damage the nail bed permanently.

Candida onychomycosis is caused by the yeast Candida. It is probably the most common fungal infection of the fingernails, especially in individuals who have a previous infection or trauma. It leads to thickened yellow, brown or white nails.

Can it spread?

Fungal infection may spread from one nail to another, from nails to skin and vice versa.

It does not spread easily from one person to another. It takes constant very intimate contact for a fungal infection to spread.

Complications:

Fungal infections can harbor serious consequences, especially for immunocompromised individuals, such as those suffering from leukemia, AIDS or those using immunosuppressive drugs. The body fails to limit the fungus, which then spreads to other parts of the body, further deteriorating health and predisposing to other, more serious infections.

How to diagnose fungal nails:

A conclusive history, overall health and an already existing condition all point toward the condition. For further confirmation, a portion of clipped nail or scraping of the debris from under the nail is sent to the lab for microscopic examination or lab cultures.

Treatment:

Treating fungal nails is difficult, takes a long time, and may not always yield results and, to top it all, it may recur. The infection is embedded under the nail and therefore hard to reach and eliminate. A fungal fingernail may take six months to eliminate, while a fungal toenail may require a year of treatment for complete healing.

The different treatment regimens include:

Oral antifungal drugs:

The ones most commonly prescribed oral antifungals include Itraconazole (Sporanox) and Terbinafine (Lamisil). These are prescribed for a period of six weeks to several months until the infection is completely removed. Early discontinuation of oral drug therapy may lead to recurrence.

Topical antifungal ointments:

These contain ciclopirox and amorolfine and, though not as effective as oral antifungals, they do help in mild cases or may be used as an adjunct to oral therapy. For the treatment of superficial fungal infections, oral antifungals are necessary.

Surgery:

In severe cases, the nail may need to be removed surgically. A new nail grows in its place, but may take a year.

Laser therapy:

Some podiatrists are also using lasers to treat fungal nail infections. There is, however, not much scientific data to prove their efficacy.

Alternative Medicines:

Australian tea tree oil and grapefruit seed extract are also considered beneficial in the treatment of fungal nails.

Snakeroot leaf extract is also used for the treatment of superficial onychomycosis.

All these treatments lack sufficient scientific data to verify their medicinal value.

Some home remedies:

Soaking your feet in diluted vinegar (one part vinegar to two parts warm water) for about twenty minutes at a time, four to seven times a week, may also help in treating mild infections or preventing new ones.

Fungal nails are unsightly, painful and may lead to serious complications. Keep your nails short and clean and your feet dry. As with every disease, prevention is always better than cure.