How to recognise and treat fungal nail infections

Fungal nail infections affect approximately 50% of the population, while fungal skin infections, otherwise known as tinea pedis (or more commonly, athlete's foot), affect 30% of the population.

Tinea pedis and onychomycosis form a vicious cycle, where the infection on the nail constantly affects the skin and vice-versa.

Being able to recognise the different kinds of tinea pedis is most valuable because this is as contagious as fungal nail infections.

What is onychomycosis? 

It is a fungal infection of the nail plate and or matrix (nail root) by a fungal pathogen (i.e. dermatophyte, mould or yeast), which produces an enzyme that digests nail keratin.

What causes fungal nail infections?

Anyone of any age can contract this infection but there are certain factors that contribute to the likelihood: 

• Wearing tight, closed shoes especially with no socks
• Walking barefoot in public areas, especially in bathroom facilities and showers
• History of nail trauma
• Constantly wearing nail polish and using false nails, etc
• Warm water foot soaks. This creates an environment for any fungal infection present, whether on the skin (Athletes foot /Tinea Pedis) or on the nails to spread more widely and easily
• Diabetes
• Neglect and ignorance
• Medical conditions ie: exposure to certain medications, immunocompromised conditions, and many more.

How can I recognise a fungal nail infection?

• Subungual hyperkeratosis (debris under the nail)
• Nail plate thickening
• Brittleness
• Changes in the shape of the nail
• Crumbling of the nail
• Discolouration (yellow, white, black, green, purple, brown)
• Onycholysis (detachment of the nail plate).

In clinical practice, samples of the nail are often sent to the laboratory to identify the exact causative pathogen. It’s important to note that there are many other nail conditions that can look like a fungal infection but are not, these include psoriasis, lichen planus, onychogryphosis and nail trauma.

How do you treat a fungal nail infections?

There are two main treatments for fungal nail infections.

1. Prescription oral tablets which can only be prescribed by a doctor; the duration of treatment is between 3 and 6 months. Such tablets have side-effects and these must be discussed in detail between the practitioner and the patient.

2. Laser treatment. This is a very effective treatment option and it bypasses the systemic system, as treatment is directed to the site of infection. It has very limited side-effects, if none at all.
The efficacy rate of both the laser treatment and the oral tablets is the same. However, do remember that laser treatment has no side-effects whereas oral tablets carry the risk of many side-effects. Neither treatment can give the patient a guaranteed outcome. Many factors will determine this and should be discussed with the patient.

A prescribed topical treatment is mandatory. This is applied to all the nails, even those not infected from the time of diagnosis until at least two years after there are no signs of fungal infection at all. Fungal nail infections have a very high recurrence rate.

When discussing treatment, we must discuss prevention from all possible sources of further contamination and spread of infection.

Who should diagnose and treat infected nails? 

Nails and skin fall under the care of a dermatologist. However, specific to the feet it would fall under the care, diagnosis and treatment of a podiatrist.

Only once a diagnosis has been made can an appropriate course of treatment be determined. The choice of treatment depends on many factors. To mention a few: underlying medical conditions; medication the patient is on; history; how many nails are involved; and what percentage of nail plate is infected.

When should I refer a client to the podiatrist?

Clients should be referred to a podiatrist as soon as the nail technician or therapist notices that the nail, or any part of the nail, does not look like a normal nail should.

This is to safeguard both therapist and client as the therapist is exposed to contracting the fungal infection themselves, especially if they are doing a pedicure without gloves. This would also apply to infected fingernails.

Equipment used by therapists (e.g. nail nippers, files, orange sticks etc) will all be contaminated after being used on a client’s infected nails and skin. It is therefore vitally important that at this stage we talk about sterilisation and disinfection. These are both decontamination processes.

While disinfection is the process of eliminating or reducing harmful microorganisms from inanimate objects and surfaces, sterilisation is the process of killing all microorganisms. Fungal infections are very difficult infections to eliminate and can only be prevented from spreading with the use of registered sterilisation techniques.

Fungal infections are not to be ignored and cause other complications. They are contagious so the sooner the correct diagnosis is made and appropriate treatment started, the better the prognosis.

Andy Blecher is a member of PASA (Podiatry Association of South Africa) and has served on the committee for the Diabetic Foot Working Group of South Africa. She has a special interest in the diabetic foot, paediatrics, the treatment of ingrowing toenails and verrucae (warts), and specialised laser treatment for onychomycosis.