Onychomycosis(nail fungus) is a fungal infection of the nail plate and surrounding structures: nail folds, matrix (growing part of the nail) and nail bed. It manifests itself as deformation and thickening of the nails, a change in color - the nails become white or yellowish.
This disease is quite common. The prevalence of onychomycosis in Europeans, according to some data, reaches 10-12%, exceeding the indicators known from the previous decade. It occurs 1. 5 times more often in men, but they go to the doctor 2 times less often than in women. Elderly people get sick more often, children very rarely.
The main problem in treating the disease is that patients seek a dermatologist long after the first symptoms appear. Because of this, the pathological fungus covers a large area and treatment is delayed.
Pathogenic fungi can only be transmitted by a sick person. Often, fungal infection runs within the family, as the source is not identified in time and adequate preventive measures are not taken.
Causes of the disease:most of the time, direct contact with the patient or the objects they use (shoes, clothes, bath mats, cloths, manicure accessories). Infections often occur when visiting gyms, baths, saunas and swimming pools.
The development of the disease is facilitated by microdamages - cracks in the interdigital folds that occur as a result of abrasion, excessive sweating, dry skin, poor drying after water procedures and flat feet.
Nail mycoses can also occur in the presence of concomitant diseases of the endocrine system (diabetes mellitus, obesity, hypothyroidism), vascular diseases of the extremities (venous insufficiency, lymphostasis), immunological disorders, as well as with the use of antibiotics, corticosteroids and cytostatic drugs. As a result of the above diseases, blood microcirculation in the nail area is disturbed and natural immunity is reduced, which contributes to the development of a secondary infection.
Onychomycosis is caused by the following types of fungi:
- dermatophyte;
- yeast-like fungi of the genus Candida;
- mold fungi.
Depending on the type of pathogen, the penetration of fungal infection and the clinical picture occur differently, therefore therapeutic approaches also differ.
Toenails are affected by fungus 10 times more often than fingernails. In most cases, the fungus is caused by dermatophytes (e. g. Trichophyton rubrum). The remaining cases are most often caused by non-dermatophyte molds (Aspergillus, Scopulariopsis, Fusarium).
If you notice similar symptoms, see your doctor. Do not self-medicate - it is dangerous to your health!
Along with nail fungus, foot fungus can also develop. Mycosis of the feet (dermatophytosis, Tinea pedis) is a skin disease of the feet caused by pathogenic or opportunistic fungi. Changes in the skin of the feet are characterized by peeling, accompanied by itching. In the case of serious injuries, against the background of red and swollen skin, erosions and deep cracks appear on the soles of the feet and in the spaces between the toes, which are accompanied by pain and make walking difficult.
The emergence of modern antifungals has improved the epidemiological situation, but foot mycosis still remains one of the most significant problems in dermatovenerology. The use of some medications is limited in the elderly and patients with chronic diseases.
Infection routes
The risk of fungal infection is especially high in public places with high humidity. These are saunas, swimming pools, gyms, public baths, etc. The most common routes of infection:
- direct contact with an infected person. Here the fungus moves from its habitat to healthy areas, thus causing an infection;
- domestic way. In this case, infection occurs when using the patient's personal belongings: shoes, personal hygiene items, etc.
Risk factors
The incidence of onychomycosis increases at age 60. At this time, the probability of developing such an infection is 60%, which is explained by a slowdown in metabolism, especially in the distal (remote) parts of the body, which are the fingers and toes.
Other risk factors for developing nail fungus include:
- diabetes;
- varicose veins;
- injuries to nails and adjacent tissues;
- HIV and other immunodeficiency conditions;
- prolonged use of antibiotics;
- weakened immune system;
- vascular and skin diseases, dermatitis, diaper rash;
- disturbances in blood supply to the extremities;
- insufficient hygiene.
Symptoms of onychomycosis (nail fungus)
The longer the disease lasts, the more pronounced its symptoms become. The main signs of onychomycosis include:
- dyschromia - change in nail color to yellow, black, green, gray or brown (the type of color depends on the type of fungus);
- onycholysis - separation of the nail plate from the bed;
- change in the thickness of the nail plate;
- hapalonychia - decrease in plaque thickness and its softening;
- koilonychia - the nail appears concave, shaped like a teaspoon;
- pachyonychia - thickening of the nail plate, nail hypertrophy;
- onychogryphosis - thickening, discoloration of the nail plate, curved in the form of a beak;
- change in the thickness of the nail bed (hyperkeratosis - thickening of the nail bed);
- changes on the surface of the nail plate: depressions, furrows, furrows;
- changes in the nail folds and surrounding skin (paronychia - inflammation of the proximal nail fold).
It is important to note that none of the symptoms are pathognomonic, that is, exclusively suitable for a specific pathogen, therefore it is impossible to determine it by symptoms - additional examinations are required.
Pathogenesis of onychomycosis (nail fungus)
The pathogenesis of the disease depends on how the fungus got into the skin and nails.
Distal subungual type:If the fungus has penetrated the skin in the area of the nail folds or in the distal region, the infection spreads along the free edge of the nail in the bed and further to the matrix. At first, the nail plate may not change, but later, due to hyperkeratosis, it gradually moves away from the nail bed and becomes yellowish. The nail plate may gradually thicken.
White surface type:If whitish lesions form on the surface of the nail, over time the fungus will take over the entire nail plate. The nail thickens, crumbles and takes on a grayish-brown hue. In this case, the matrix and epithelium of the nail bed are not affected. There is no inflammation in the surrounding skin.
Proximal subungual type:the fungus can spread from the skin and periungual folds to the nail plate and subsequently to the matrix, reaching the distal parts of the nail plate. Spots appear on the nail in the area of the hole and nail bed, and detachment of the nail plate occurs. There is no significant inflammation of the nail bed or matrix.
Total dystrophic type:The entire nail is affected. The proximal portions of the nail fold disappear or thicken so that the nail plate can no longer form or grow.
Existbiophysical concept of the pathogenesis of onychomycosis, who states that during the disease there is a confrontation between two forces: the growth of the fungal colony towards the matrix and the natural growth of the nail from the matrix to the distal edge. Therefore, the speed of nail growth is crucial during the course of onychomycosis – the faster the nail grows, the sooner healing will occur. Perhaps this is what explains the low prevalence of the disease in children, as their nails grow faster than those of adults and the elderly.
Classification and stages of development of onychomycosis (nail fungus)
There is the following classification of onchomycosis:
- distal subungual;
- superficial white;
- proximal subungual;
- total dystrophic.
According to Arievich’s classification (1970):
- normotrophic: in the thickness of the nail there are bands of yellowish and whitish color, but the shape of the nail plate does not change, there is no subungual hyperkeratosis;
- hypertrophic:the nail plate turns yellow, thickens due to subungual hyperkeratosis, becomes brittle, with uneven edges;
- dystrophic:thinning and detachment of the nail plate from the nail bed occur with the formation of voids.
Complications of onychomycosis (nail fungus)
Long-term onychomycosis increases the risk of developingdiabetic foot(formation of trophic ulcers on the legs) andgangreneif the patient has diabetes mellitus or vascular diseases of the lower extremities.
In immunosuppressive conditions (primary and secondary immunodeficiencies), fungi can spread to the skin, internal organs and cause allergization of the body. This can manifest itself as skin rashes and even the development of bronchial asthma.
In an uncomplicated course, the disease causes traditional fungal symptoms, causing only severe discomfort to the individual. But without treatment, onychomycosis can cause complications. Most often they manifest themselves as a bacterial infection.
Sometimes, onychomycosis is very acute, with the appearance of blisters, ulcerations and watery areas on the skin close to the nail. In severe cases, the disease takes on a generalized form. This means that the nail fungus spreads to internal organs and systems, and then the patient will need emergency hospitalization.
Diagnosis of onychomycosis (nail fungus)
Before examining the methods of diagnosing onychomycosis, it is necessary to explain how to correctly collect material for research (the patient does this independently or prepares the nails before diagnosis). Before collecting material for research, it is necessary to treat the nail plate with 70% alcohol to avoid contamination with other bacteria.
The method of collecting the material varies depending on the form of onychomycosis:
- surface shape- scrape the nail plate;
- distal form- a scraping of the nail bed and a piece of the nail plate is necessary;
- proximal subungual form- the material is collected with a drill, or a nail biopsy is performed, or the nail bed is scraped.
The fastest method for determining pathological fungi on the nail ismicroscopy. Technique: the material under study is treated with an alkaline solution to dissolve the keratin. To make the mushroom threads more visible, paint is added to the alkali. Next, the resulting preparation is studied under a microscope.
This research method is the fastest and most objective. Sensitivity is up to 80%. The disadvantages of the method include the fact that when using it it is impossible to determine the type of pathogen.
Bacteriological culture: is an additional method for diagnosing onychomycosis. The material is seeded in a special medium and the result is interpreted under a microscope after 2 to 3 weeks. This method allows you to determine the type of pathogen - this helps to determine treatment tactics and select medications based on sensitivity. But the disadvantage of the study is that it takes a long time and its sensitivity is only 30-50%.
Biopsy: Using a scalpel and applying anesthesia, the nail and nail bed are cut. The material is immersed in a formaldehyde solution and sent to the laboratory for histological examination. The advantages of this method are that it is highly sensitive and allows you to determine the presence of a pathological fungus in the material.
Disadvantages: it is impossible to identify the pathogen, as well as establish the viability of microorganisms, the method is expensive and laborious.
Genetic diagnosis: molecular biological research method (PCR). This is one of the new and highly sensitive methods for diagnosing onychomycosis - it helps to detect the DNA of the causative agent of the disease. In our country, it is recommended to introduce this type of diagnosis in medical institutions that have PCR laboratories, but at the moment it is only planned to introduce testing systems for identifying dermatophytes and fungi in laboratories. The method allows you to determine the type of pathogen and its sensitivity varies from 80 to 90%. Disadvantages: high cost, inaccessibility, lack of technological standards and implementation complexity.
Increasingly, doctors are introducing into practicedermoscopy. Using this method, you can assess changes in the color and structure of the nail, as well as the condition of the surrounding structures. Dermoscopic examination allows a more accurate assessment of the depth of damage to the nail plate and a more correct calculation of the onychomycosis severity index (KIOTOS).
First, the patient is referred for microscopy, which allows the presence of the pathogen to be identified. In the future, it is necessary to determine its type in order to select the correct treatment for nail fungus. At JSC "Medicine" (clinic of Academician Roitberg) in the center of Moscow, the most modern and widespread methods for diagnosing onychomycosis are practiced:
- cultural examination of a biological sample of affected tissue. To do this, it is placed in an artificial nutrient medium, where the pathogen is cultivated to determine its type;
- polymerase chain reaction (PCR) method for detecting pathogen DNA in an affected tissue sample.
When to see a doctor
Many who have encountered onychomycosis know that the disease develops slowly and is extremely difficult to treat. Therefore, it is very important to consult a doctor when the first signs of the disease appear. A dermatologist treats nail onychomycosis in our clinic in the center of Moscow. The specialist will provide competent assistance and guide you until complete recovery.
Preparing to visit the doctor
Before visiting a dermatologist, it is important not to treat the affected areas of the nails with anything, that is, do not use medications, including iodine and brilliant green. It is also necessary to avoid using creams and ointments against fungi. At the consultation, you must take all the tests previously carried out, including those for other diseases. Affected nails should not be cut 3-4 days before your appointment.
Treatment of onychomycosis (nail fungus)
There are several types of treatment for onychomycosis:
- Local therapy.
- Systemic therapy.
- Combined therapy.
- Corrective therapy.
Local therapyinvolves applying medication to the nail plate and nail folds. Indications for local therapy:
- Limited form of damage to the nail plate (according to KIOTOS).
- There are contraindications for prescribing systemic medications: hypersensitivity, liver disease, renal dysfunction, pregnancy, lactation.
The advantages of this therapy are that high concentrations of the therapeutic agent are formed on the surface of the nail, which does not penetrate the bloodstream. There are no side effects from using antifungal medications - nausea, loss of appetite, abdominal pain. The disadvantage of the method is that the medicinal substance does not always reach the pathogen's habitat, especially if the fungi are located in the nail bed or matrix. This, in turn, can lead to treatment failure. This type of treatment is very laborious, as before applying the medication it is necessary to remove the affected part of the nail.
Methods to remove affected nails:
- Mechanical removal with files, tweezers or drill.
- Using keratolytic patches. Before applying the keratolytic plaster, the skin around the nail is sealed with a plaster, a plaster mass (urea with salicylic acid) is applied on top and sealed with an adhesive plaster. The plaster putty is changed every 2-3 days. After each removal, the affected part of the nail is removed mechanically.
- Surgical. This operation is very painful and traumatic, because when the nail plate is removed, the growth zone can be damaged, which leads to the growth of deformed nails.
Local antifungal agents are used after removing the affected nail plate.Antimycoticsdifferentiated by location of application:
- applied to the nail: varnishes;
- applied in rollers: creams, ointments, solutions.
The most studied medication for topical use is1% naftifine solution, which has an evidence base of treatment effectiveness based on a Cochrane meta-analysis. This product is water-based, which facilitates better penetration of the antifungal substance into the affected area. The varnishes, whose active ingredients are ciclopirox and amorolfine, have a dehydrated base, which reduces the penetration of the medicine into the deep layers. Therefore, dermatologists consider the use of varnishes unsatisfactory and increasingly prefer water-based products.
To obtain results from local therapy it is necessary to follow the treatment regimen, it is important that the patient is responsible, consistent and patient. The duration of therapy can be up to 12 months.
Systemic therapyallows the antifungal medication to penetrate the bloodstream to the site of injury, even if the nail bed and matrix are affected. A high concentration of the medication remains in the affected area long after use has stopped. The disadvantages of this type of treatment are associated with the risk of side and toxic effects.
Indications for systemic therapy:
- Common ways of damage to the nail plate.
- Lack of effect of local therapy (i. e. after six months of treatment for onychomycosis on the hands and 9 to 12 months of treatment for onychomycosis on the feet, healthy nails did not grow back).
To determine treatment tactics, KIOTOS (Sergeev's Clinical Index for Assessing the Severity of Onychomycosis) is used, proposed by A. Yu. Sergeev in 1999. It is used as a therapeutic standard in several countries around the world.
Medicinesfor the treatment of onychomycosis can be classified as follows:
- antimycotics - have an antifungal effect;
- antiseptics - have antifungal and antibacterial effects. They are rarely used, only if there are no other antifungal agents;
- multicomponent - in addition to the antifungal, they also contain other medications, such as anti-inflammatories.
Prescription regimens:
- standard - taking medications daily during the prescribed treatment period;
- shortened - the treatment period is shortened, it can be carried out in regular doses or increased;
- intermittent - treatment is prescribed in several short courses, the intervals between courses are equal to the duration of the courses;
- pulse therapy - treatment is prescribed in several short courses, the intervals between courses are longer than the duration of the courses.
Antifungal drugs are divided according to the active substance:
- triazoles;
- allylamines;
- others (third generation medicines).
Currently used for systemic therapyonly third generation medicines.
With combined therapylocal and systemic treatment are carried out simultaneously. Combination therapy is used when it is necessary to increase the effectiveness of systemic therapy and reduce treatment time.
Corrective therapy(treatment of concomitant diseases): to select a treatment regimen, it is necessary to assess the general somatic state of the body. Diseases such as circulatory disorders in the extremities can reduce the antifungal's access to the lesion. Therefore, medications are prescribed that improve tissue trophism.
Due to the toxic effect of systemic antifungal drugs, it is necessary to exclude liver diseases and, if necessary, prescribe hepatoprotectors.
Home remedies
Before using home remedies, you should consult your doctor. With his permission, you can use the following recipes:
- iodine. Before use, the feet must be steamed, washed with laundry soap, and then the affected areas of the nail plates must be removed. Next, treat the nails and the skin between the fingers with iodine, immerse them in a bath with soda solution for 20-30 minutes and dry well;
- vinegar. For 3 liters of water take 1 tablespoon. apple cider vinegar and add a little potassium permanganate. Soak your feet in the bathtub for 20-30 minutes and then dry well;
- hydrogen peroxide. After steaming your feet well, remove the affected areas from the nail plates. Place cotton pads soaked in hydrogen peroxide on them, wrap them with a bandage and leave to act for half an hour.
Dangerous myths and misconceptions in the treatment of nail fungus
One of the most important and dangerous myths is that nail fungus is not considered a serious illness. In fact, onychomycosis, as it progresses, can lead to serious consequences, including deformation and complete rejection of the nails from the nail bed.
Furthermore, an infected person represents a daily danger to loved ones, as, being close to them, they also run the risk of becoming ill. That's why it's important to know how to cure nail fungus in time.
Forecast. Prevention
The sooner a patient sees a doctor with signs of a fungal nail infection, the faster the disease can be cured and the nail plate restored. With long-term processes involving the entire nail, treatment of onychomycosis can be time-consuming, but if all recommendations are followed, recovery often occurs. If there are contraindications to systemic therapy, long-term maintenance treatment with local medications is necessary.
For preventionIt is necessary to observe the rules of personal hygiene and reduce the possibility of re-infection:
- try to wear comfortable, good quality shoes (to avoid excessive foot sweat);
- It is recommended to change socks and tights daily;
- wear only individual shoes. For those undergoing treatment for onychomycosis, shoes must be treated at the beginning of treatment, at least once a month throughout the treatment period and after its end;
- if necessary, use foot antiperspirants;
- use an individual nail care kit (scissors, files);
- before and after visiting public places (swimming pool, bathhouse, gym) use external antifungal agents (sprays, creams and pencils);
- identify the source of fungal infection in the family and be treated at the same time.
It is recommended to periodically carry out antifungal treatment on personal belongings, shoes, bathtubs, floors and carpets. To do this, you can use a 40% acetic acid solution, a 1% alcoholic chlorhexidine solution (prescribed by your doctor) and disinfectant solutions. Laundry can be boiled in a 1-2% soap and soda solution for 20-30 minutes and ironed at maximum temperature.