Onychomycosis(nail fungus) is a fungal infection of the nail plate and its surrounding structures: nail folds, matrix (growing part of the nail), and nail bed. This is manifested by deformation and thickening of the nails, color change - the nails become white or yellow.
This disease is quite common. The prevalence of onychomycosis among Europeans, according to some data, reaches 10-12%, exceeding the known indicators of the previous decade. This occurs 1. 5 times more often in men, but they visit the doctor 2 times less often than women. Older people get sick more often, children very rarely.
The main problem in treating the disease is that patients consult a dermatologist long after the first symptoms appear. As a result, the pathological fungus covers a large area and treatment is delayed.
Pathogenic fungi can only be transmitted by a sick person. Very often, fungal infection occurs within the family, because the source is not identified in time and adequate preventive measures are not taken.
Causes of the disease:most often direct contact with the patient or with the objects he uses (shoes, clothing, bath mats, washcloths, manicure accessories). Infections often occur when visiting gyms, baths, saunas and swimming pools.
The development of the disease is facilitated by microdamage - cracks in the interdigital folds resulting from abrasion, excessive sweating, dry skin, poor drying after water procedures and flat feet.
Nail fungus 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), immune disorders, as well as when usingantibiotics, corticosteroids and cytostatic drugs. Due to the above diseases, blood microcirculation in the nail area is disrupted and natural immunity is reduced, which contributes to the development of 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, so therapeutic approaches also differ.
Toenails are affected by fungus 10 times more often than fingernails. In most cases, the fungus is caused by dermatophytes (eg Trichophyton rubrum). The remaining cases are most often caused by non-dermatophyte molds (Aspergillus, Scopulariopsis, Fusarium).
If you notice similar symptoms, consult your doctor. Do not treat yourself, it is dangerous for your health!
In addition to nail fungus, foot fungus can also develop. Mycosis of the feet (dermatophytosis, Tinea pedis) is a disease of the skin of the feet caused by pathogenic or opportunistic fungi. Skin changes on the feet are characterized by peeling accompanied by itching. In case of severe lesions, against the background of red and swollen skin, deep erosions and cracks appear on the soles and in the spaces between the toes, which are accompanied by pain and make walking difficult.
The emergence of modern antifungal drugs has improved the epidemiological situation, but foot mycosis still remains one of the most important problems in dermatovenerology. The use of certain medications is limited in older adults and patients with chronic illnesses.
Routes of infection
The risk of being infected by a fungus is particularly high in public places with high humidity. These include 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, thereby causing infection;
- domestic manner. In this case, infection occurs when using the patient's personal belongings: shoes, personal hygiene items, etc.
Risk factors
The incidence of onychomycosis increases from the age of 60. Currently, the probability of developing such an infection is 60%, which is explained by a slowdown in metabolism, especially in the distal (distant) parts of the body, such as 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 problems;
- long-term use of antibiotics;
- weakened immune system;
- vascular and skin diseases, dermatitis, diaper rash;
- blood supply disorders to the extremities;
- insufficient hygiene.
Symptoms of onychomycosis (nail fungus)
The longer the disease lasts, the more pronounced its symptoms. The main signs of onychomycosis include:
- dyschromia - a change in the color of the nail 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 - a decrease in the thickness of the plaque and its softening;
- koilonychia - the nail appears concave, shaped like a teaspoon;
- pachyonychia - thickening of the nail plate, enlargement of the nails;
- 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 in the surface of the nail plate: hollows, grooves, ridges;
- 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, they are suitable only for a specific pathogen, therefore it is impossible to determine it by the symptoms - additional examinations are required.
Pathogenesis of onychomycosis (nail fungus)
The pathogenesis of the disease depends on how the fungus penetrated the skin and nails.
Distal subungual type:if the fungus has penetrated the skin at the nail folds or in the distal area, the infection spreads through the free edge of the nail into the bed and further towards 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 invades the entire nail plate. The nail thickens, crumbles and acquires a gray-brown tint. In this case, the matrix and epithelium of the nail bed are not affected. There is no inflammation of the surrounding skin.
Proximal subungual type:the fungus can spread from the skin and periungual folds to the nail plate and further to the matrix, reaching the distal parts of the nail plate. Stains appear on the nail at the hole and nail bed, and the nail plate becomes loose. There is no significant inflammation of the nail bed or matrix.
Total dystrophic type:The entire nail is affected. The proximal parts 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, which specifies that during the disease there is a confrontation between two forces: the fungal colony developing towards the matrix, and the natural growth of the nail from the matrix to the distal edge. This is why the speed of nail growth is crucial during onychomycosis: the faster the nail grows, the faster healing will occur. This may explain the low prevalence of the disease in children, since 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 stripes 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 irregular edges;
- dystrophic:thinning and detachment of the nail plate from the nail bed occurs 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 suffers from 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 in skin rashes and even the development of bronchial asthma.
In a simple course, the disease causes traditional symptoms of the fungus, causing only severe discomfort in a person. But if left untreated, onychomycosis can lead to complications. Most often they manifest themselves with the addition of a bacterial infection.
Sometimes onychomycosis is very acute with the appearance of blisters, ulcerations and oozing areas on the skin near the nail. In severe cases, the disease takes a generalized form. This means that the nail fungus spreads to internal organs and systems, and the patient will then need to be hospitalized urgently.
Diagnosis of onychomycosis (nail fungus)
Before considering the methods of diagnosing onychomycosis, it is necessary to explain how to correctly collect research material (the patient does it 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 material varies depending on the form of onychomycosis:
- surface shape- scrape the nail plate;
- distal form- scraping of the nail bed and a piece of the nail plate are necessary;
- proximal subungual form- the material is collected with a drill, or a biopsy of the nail is performed, or scraping of the nail bed is performed.
The fastest method for determining pathological fungi in the nail ismicroscopy. Technique: the material studied is treated with an alkaline solution to dissolve the keratin. To make the mushroom threads more visible, ink is added to the alkali. Then, the preparation obtained is studied under a microscope.
This research method is the fastest and most objective. The sensitivity can reach 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 sown on a special support and the result is interpreted under a microscope after 2-3 weeks. This method allows you to determine the type of pathogen, which helps to determine treatment tactics and select drugs based on their 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 under anesthesia, the nail and nail bed are cut. The material is immersed in a formaldehyde solution and sent for histological examination to the laboratory. The advantages of this method are that it is very 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 to establish the viability of microorganisms, the method is expensive and labor-intensive.
Genetic diagnosis: research method in molecular biology (PCR). This is one of the new and very sensitive methods of diagnosing onychomycosis - it allows detecting the DNA of the causative agent of the disease. In our country, it is recommended to introduce this type of diagnostics in medical institutions with PCR laboratories, but at the moment it is planned to introduce only testing systems for identifying dermatophytes and mold in laboratories. The method allows you to determine the type of pathogen and its sensitivity ranges from 80 to 90%. Disadvantages: high cost, inaccessibility, lack of technological standards and complexity of implementation.
More and more doctors are introducing into their practicedermatoscopy. Using this method, you can assess changes in the color and structure of the nail, as well as the condition of the surrounding structures. Dermatoscopic examination allows a more accurate assessment of the depth of nail plate lesions and a more correct calculation of the onychomycosis severity index (KIOTOS).
First of all, the patient is sent for microscopy, which helps identify the presence of the pathogen. In the future, it will be necessary to determine its type in order to select the appropriate treatment for toenail 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 in order to determine its type;
- polymerase chain reaction (PCR) method for detecting pathogenic DNA in a sample of affected tissue.
When to consult a doctor
Many who have encountered onychomycosis know that the disease develops slowly and is incredibly difficult to treat. This is why it is very important to consult a doctor as soon as the first signs of the disease appear. A dermatologist treats nail onychomycosis in our clinic in the center of Moscow. The specialist will provide you with competent assistance and guide you until complete recovery.
Prepare to see the doctor
Before consulting a dermatologist, it is important not to treat the affected areas of the nails with anything, i. e. do not use medications, including iodine and brilliant green. You should also avoid the use of creams and ointments against fungus. At your appointment, you must have all previously performed tests, including those for other illnesses. The affected nails should not be cut 3 to 4 days before the consultation.
Treatment of onychomycosis (nail fungus)
There are several types of treatment for onychomycosis:
- Local therapy.
- Systemic therapy.
- Combined therapy.
- Corrective therapy.
Local therapyinvolves applying medications to the nail plate and nail folds. Indications for local treatment:
- Limited form of damage to the nail plate (according to KIOTOS).
- There are contraindications to the prescription of systemic medications: hypersensitivity, liver disease, renal dysfunction, pregnancy, breastfeeding.
The advantages of this therapy are that high concentrations of the therapeutic agent are formed on the surface of the nail, which does not enter the bloodstream. The use of antifungal drugs does not cause any side effects - nausea, loss of appetite, abdominal pain. The disadvantage of this method is that the drug does not always reach the habitat of the pathogen, especially if the fungi are in the nail bed or matrix. This in turn can lead to treatment failure. This type of treatment is labor intensive, because before applying the medication it is necessary to remove the affected part of the nail.
Methods for removing affected nails:
- Mechanical removal using files, pliers or a drill.
- Use of keratolytic patches. Before applying a keratolytic dressing, the skin around the nail is sealed with a bandage, a plaster mass (urea with salicylic acid) is applied to it and sealed with an adhesive bandage. The plaster mass 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 removing the nail plate, the growth zone may be damaged, which leads to the regrowth of deformed nails.
Local antifungal agents are used after removing the affected nail plate.Antimycoticsdistinguished by place of application:
- applied to the nail: varnish;
- applied to rollers: creams, ointments, solutions.
The most studied topical medication isNaftifine 1% solution, which has an evidence base for 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. Varnishes whose active ingredients are ciclopirox and amorolfine have a dehydrated base, which reduces the penetration of the drug into the deep layers. Dermatologists therefore consider the use of varnish to be unsatisfactory and are increasingly favoring water-based products.
To achieve results from local treatment, it is necessary to follow the treatment regimen, it is important that the patient is responsible, consistent and patient. The duration of treatment can be up to 12 months.
Systemic therapyallows the antifungal medication to enter the bloodstream to the site of injury, even if the nail bed and matrix are affected. A high concentration of the drug remains in the affected area for a long time after its use ends. The disadvantages of this type of treatment are linked to the risk of side and toxic effects.
Indications for systemic treatment:
- Common forms of damage to the nail plate.
- Lack of effect of local therapy (i. e. after six months of treatment for onychomycosis of the hands and 9 to 12 months of treatment for onychomycosis of the feet, healthy nails have notpostponed).
To determine treatment tactics, the KIOTOS (Clinical Index for Assessing the Severity of Onychomycosis by Sergeev), proposed by A. Yu. Sergeev in 1999, is used. It is used as a therapeutic standard in various countries around the world.
Drugsfor the treatment of onychomycosis can be classified as follows:
- antimycotics - have an antifungal effect;
- antiseptics - have both antifungal and antibacterial effects. They are rarely used, only if there are no other antifungal agents;
- multicomponent - in addition to the antifungal agent, they also contain other drugs, such as anti-inflammatories.
Prescription schemes:
- standard - taking medications daily during the prescribed treatment period;
- shortened - the duration of treatment is shortened, 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 drugs).
Currently used for systemic therapyonly third generation drugs.
With combined therapylocal and systemic treatments are carried out simultaneously. Combination therapy is used when it is necessary to increase the effectiveness of systemic therapy and reduce the duration of treatment.
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 access of the antifungal agent to the lesion. Therefore, drugs are prescribed to improve tissue trophism.
Due to the toxic effect of systemic antifungal drugs, it is necessary to exclude liver disease and, if necessary, prescribe hepatoprotectors.
Home remedies
Before using home remedies, you should consult your doctor. With permission, you can use the following recipes:
- iodine. Before use, the feet should be steamed, washed with laundry soap, and then the affected areas of the nail plates should be removed. Then treat the nails and skin between the fingers with iodine, soak them in a bath with soda solution for 20-30 minutes and dry thoroughly;
- vinegar. For 3 liters of water, take 1 tbsp. apple cider vinegar and add a little potassium permanganate. Soak your feet in the bath for 20 to 30 minutes, then dry them thoroughly;
- hydrogen peroxide. After thoroughly steaming your feet, remove the affected areas from the nail plates. Place cotton pads soaked in hydrogen peroxide on top, wrap them with a bandage and leave for half an hour.
Dangerous myths and misconceptions in the treatment of nail fungus
One of the biggest and most dangerous myths is that toenail fungus is not considered a serious illness. Indeed, onychomycosis, as it progresses, can lead to serious consequences, including deformation and complete rejection of the nails from the nail bed.
In addition, an infected person represents a daily danger for those close to them, since being in close proximity to them also risks getting sick. That is why it is important to know how to cure nail fungus in time.
Forecast. Prevention
The sooner a patient consults a doctor with signs of fungal nail infection, the sooner the disease can be cured and the nail plate restored. With long-term processes involving the entire nail, treatment of onychomycosis can be long, but if all recommendations are followed, healing often occurs. If there are contraindications to systemic treatment, long-term maintenance therapy with local drugs is necessary.
For preventionIt is necessary to follow the rules of personal hygiene and reduce the risk of reinfection:
- try to wear comfortable, high-quality shoes (to avoid excessive sweating of the feet);
- It is recommended to change socks and tights daily;
- use only individual shoes. For people undergoing treatment for onychomycosis, shoes should be treated at the start of treatment, at least once a month throughout the duration of treatment and after its end;
- if necessary, use antiperspirants for the feet;
- use an individual nail care kit (scissors, files);
- before and after visiting public places (swimming pool, public baths, gym), use external antifungal agents (sprays, creams and pencils);
- identify the source of the fungal infection in the family and be treated at the same time.
It is recommended to periodically carry out antifungal treatment of personal belongings, shoes, bathtubs, floors and carpets. For these purposes, you can use 40% acetic acid solution, 1% alcohol solution of chlorhexidine (prescribed by a doctor) and disinfection solutions. Linen can be boiled in a 1-2% solution of soap and soda for 20-30 minutes, ironed at maximum temperature.