Fungal nail infections, or onychochomysis, are common disorders of the nails. They are treatable.
However, the choice of treatment depends on the individual because the efficacy rates of anti-fungal medication are between 60 to 80% and often treatment may be needed for several weeks or months and even years.
The best and most ideal antifungal therapy should be broad spectrum (acting against all the possible causative organisms causing fungal nail infections).
It should be able to reach the nails and nail bed via blood and should be able to penetrate the thickened nails.
The drugs should be effective with high rates of clinical cure and cause a low rate of relapse of the infection.
The antifungal agents should be effective over shorter durations of use, have fewer side effects and should be cost effective as well. The available drugs do not fulfil all of these criteria.
Types of treatment for fungal nail infections
There are several options for treatment of fungal nail infections, these range from no treatment at all to the removal of the affected nail surgically. (1-6)
Leaving fungal nail infections untreated
Patients with mild form of the infection may not need therapy. However, this raises risk of worsening of the condition and also spread to other nails and skin.
Antifungal tablets of Terbinafine and Itraconazole are commonly prescribed. The drugs taken orally reach the blood stream. These can be very effective in the treatment of fungal infections.
These drugs may be needed for several weeks and even months for slow growing toe nail infections. Stopping the medication too early can raise the risk of recurrence of the infection in the same nail.
These drugs also help clear out the associated fungal skin infections like athlete’s foot.
There are two dosage regimens for itraconazole one is the continuous therapy of 100 mg a day for 12 weeks and the other is pulsed (intermittent) therapy of 200 mg twice a day for 7 days each month for 2 months (for fingernail infections) or 3 months (for toenail infections).
Pulsed therapy is at least as effective as continuous therapy and causes fewer side effects.
Dosage for Terbinafine is 250 mg daily for 12 weeks for toenail infections.
Common side effects of these drugs include loss of taste sensation, headache, nausea and diarrhea.
There may be intolerance to certain foods and other concomitantly taken drugs.
Pregnant women should not be given Itraconazole.
Older agents include Griseofulvin and Ketoconazole. They are not used much these days as the newer agents are more effective and better tolerated.
Antifungal nail paint
These nail paints, which contain anti-fungal agents, are prescribed to individuals not willing to take oral medications. Nail paint is not considered as effective as the tablets.
A fingernail usually requires around six months of treatment, and a toenail up to twelve months.
Agents used in nail paints include 5% amorolfine that is the best topical agent in terms of its ability to penetrate the affected nail.
Other options are 28% tioconazole and 8% ciclopirox. These can be all combined with oral Terbinafine for best results.
Other care during therapy
As the treatment starts to take effect healthy nail grows at the base of the affected nail. The old infected nail should begin to grow out and can be clipped away.
Feet should be kept cool and dry. Patients are advised to wear only clean cotton socks and avoid wearing trainers or sports and closed, tight shoes. Nails need to be clipped regularly, and for the infected nail a separate set of clippers should be sued to prevent spread of infection.
While using communal showed shower shoes or flip flops should be preferred. Old footwear should be discarded to get rid of fungal spores they may be harbouring.
Removal of the nail surgically
Some patients may need removal of the affected nail surgically. The affected nail may be clipped with clippers, or scraped off with a curette.
After surgical removal of the nail and/or the nail bed the remnant is subjected to chemical treatments of 40–50% urea solution for very thickened nails.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)