Onychomycosis(Nail fungus) is a fungal infection of the nail plate and its surrounding structures: nail folds, matrix (growth part of the nail) and nail bed. It is manifested by deformation and thickening of the nails, a change in their color - the nails become white or yellow.
This disease is quite common. The prevalence of onychomycosis among Europeans, according to some data, is 10-12%, exceeding the known indicators of the last decade. It occurs 1. 5 times more often in men, but they go to the doctor 2 times less often than women. Older people become ill more often, children very rarely.
The main problem in treating the disease is that patients come to the dermatologist long after the first symptoms appear. For this reason, the pathological fungus covers a large area and treatment is delayed.
Pathogenic fungi can only be transmitted from a sick person. Very often, a fungal infection occurs within the family because the cause is not recognized in a timely manner and adequate preventative measures are not taken.
Causes of the disease:most often direct contact with the patient or with the items he uses (shoes, clothes, 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 mycoses can also occur with concomitant diseases of the endocrine system (diabetes mellitus, obesity, hypothyroidism), vascular diseases of the extremities (venous insufficiency, lymphostasis), immune disorders, as well as when taking antibiotics, corticosteroids, etc. cytostatics. As a result of the above diseases, blood microcirculation in the nail area is disrupted and natural immunity is weakened, 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;
- Molds.
Depending on the type of pathogen, the penetration of the fungal infection and the clinical picture differ, which is why the therapeutic approaches also differ.
Toenails are ten times more likely to be affected by fungus than fingernails. In most cases, the fungus is caused by dermatophytes (e. g. Trichophyton rubrum). The remaining cases are most often caused by non-dermatophytic molds (Aspergillus, Scopulariopsis, Fusarium).
If you notice similar symptoms, contact your doctor. Do not self-medicate - it is dangerous to your health!
In addition to nail fungus, athlete's foot 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 that is accompanied by itching. In severe lesions, against a 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 advent of modern antimycotics has improved the epidemiological situation, but mycosis of the feet remains one of the biggest problems in dermatovenereology. The use of some medications is restricted for older people and patients with chronic illnesses.
Routes of infection
The risk of fungal infection is particularly high in public places with high humidity. These are saunas, swimming pools, gyms, public pools, etc. The most common routes of infection:
- direct contact with an infected person. Here the fungus migrates from its habitat to healthy areas, causing an infection;
- Household wise. In this case, infection occurs when the patient uses personal items: shoes, personal hygiene items, etc.
Risk factors
The incidence of onychomycosis increases with 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 (distant) parts of the body, that is, the fingers and toes.
Other risk factors for the development of nail fungus include:
- diabetes mellitus;
- varicose veins;
- injuries to nails and adjacent tissue;
- HIV and other immunodeficiency diseases;
- long-term use of antibiotics;
- weakened immune system;
- Vascular and skin diseases, dermatitis, diaper rash;
- Disturbances in the blood supply to the extremities;
- inadequate hygiene.
Symptoms of onychomycosis (nail fungus)
The longer the disease lasts, the more pronounced its symptoms become. The main signs of onychomycosis include:
- Dyschromia – a 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 nail bed;
- change in the thickness of the nail plate;
- Hapalonychia – a decrease in the thickness of the plate and its softening;
- Koilonychia – the nail looks concave, in the shape of 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 in the surface of the nail plate: pits, grooves, ridges;
- Changes in the nail fold and the surrounding skin (paronychia – inflammation of the proximal nail fold).
It is important to note that none of the symptoms are pathognomonic, that is, clearly suitable for a specific pathogen, therefore it is not possible to determine them based on the symptoms - additional examinations are required.
Pathogenesis of onychomycosis (nail fungus)
The pathogenesis of the disease depends on how the fungus got on 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 area, the infection spreads over the free edge of the nail into the nail 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.
Surface white type:If whitish lesions form on the surface of the nail, over time the fungus affects the entire nail plate. The nail becomes thicker, crumbles and takes on a gray-brown color. 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. In the area of the hole and the nail bed, spots form on the nail and the nail plate detaches. There is no significant inflammation of the nail bed or nail 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.
Existsbiophysical concept of the pathogenesis of onychomycosis, which states that during the disease there is a confrontation between two forces: the fungal colony growing 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 in the course of onychomycosis - the faster the nail grows, the faster healing occurs. Perhaps this explains 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;
- superficially white;
- proximal subungual;
- completely dystrophic.
According to Arievich's classification (1970):
- normotropic: In the thickness of the nail there are yellowish and whitish stripes, 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 and has jagged edges;
- dystrophic:The nail plate thins and detaches from the nail bed, forming cavities.
Complications of onychomycosis (nail fungus)
Long-term onychomycosis increases the risk of developing itdiabetic foot(formation of trophic ulcers on the legs) andgangreneif the patient suffers from diabetes mellitus or vascular diseases of the lower extremities.
In immunosuppressive diseases (primary and secondary immunodeficiency), fungi can spread to the skin and internal organs and cause allergy in the body. This can manifest itself in skin rashes or even the development of bronchial asthma.
If the course is uncomplicated, the disease causes the symptoms typical of the fungus, which only cause severe discomfort in humans. But without treatment, onychomycosis can lead to complications. Most often they manifest themselves in addition to a bacterial infection.
Sometimes onychomycosis is very acute and blisters, ulcers and weeping spots appear on the skin next to the nail. In severe cases, the disease takes a generalized form. This means that nail fungus spreads to internal organs and systems and then the patient requires emergency hospitalization.
Diagnosis of onychomycosis (nail fungus)
Before studying the methods of diagnosing onychomycosis, it is necessary to explain how to correctly collect the material for research (the patient does this independently or prepares the nails before the diagnosis). Before collecting material for research, the nail plate must be treated with 70% alcohol to avoid contamination with other bacteria.
The method of obtaining material varies depending on the form of onychomycosis:
- Surface shape- scrape the nail plate;
- distal form- It is necessary to scrape both from the nail bed and a piece of the nail plate;
- proximal subungual form- The material is collected with a drill, a nail biopsy is performed, or a scraping from the nail bed is performed.
The fastest method for determining pathological fungi in the nail ismicroscopy. Technique: The material to be examined is treated with an alkaline solution to dissolve the keratin. In order to make the fungal threads more visible, ink is added to the lye. Next, the resulting preparation is examined under a microscope.
This research method is the fastest and most objective. The sensitivity is up to 80%. The disadvantages of the method include the fact that when using it it is not possible to determine the type of pathogen.
Bacteriological culture: is an additional method for diagnosing onychomycosis. The material is sown on a special substrate and the result is evaluated under the microscope after 2-3 weeks. This method allows you to determine the type of pathogen - this helps to determine treatment tactics and select drugs based on sensitivity. However, the disadvantage of the study is that it takes a lot of time and its sensitivity is only 30-50%.
biopsy: The nail and nail bed are cut off with a scalpel and under anesthesia. The material is dipped in a formaldehyde solution and sent to the laboratory for histological examination. The advantages of this method are that it is very sensitive and makes it possible to detect the presence of a pathological fungus in the material.
Disadvantages: It is impossible to identify the pathogen and determine the viability of microorganisms, the method is expensive and labor-intensive.
Genetic diagnostics: Molecular biology 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 diagnostics in medical institutions that have PCR laboratories. However, the introduction of test systems for identifying dermatophytes and molds is currently only planned in laboratories. This method allows you to determine the type of pathogen. The sensitivity is between 80 and 90%. Disadvantages: high cost, inaccessibility, lack of technology standards and complexity of implementation.
Doctors are increasingly being introduced into practiceDermoscopy. This method allows you to assess changes in the color and structure of the nail, as well as the condition of the surrounding structures. Dermoscopic examination allows for a more accurate assessment of the depth of the nail plate and a more correct calculation of the onychomycosis severity index (KIOTOS).
First, the patient is sent for microscopy to determine the presence of the pathogen. In the future, it is necessary to determine its type in order to choose the right treatment for toenail fungus. In 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 the affected tissue. To do this, it is placed in an artificial culture medium in which the pathogen is cultured to determine its type;
- Polymerase chain reaction (PCR) method for detecting pathogen DNA in a sample of affected tissue.
When should you see a doctor?
Many who have experienced onychomycosis know that the disease develops slowly and is incredibly difficult to treat. That is why it is very important to see a doctor at the first signs of the disease. In our clinic in the center of Moscow, a dermatologist treats onychomycosis of nails. The specialist will advise you competently and accompany you until you fully recover.
Preparing for the doctor's visit
Before visiting a dermatologist, it is important not to treat the affected areas of the nails with anything, i. e. H. Do not use medications, including iodine and brilliant green. The use of creams and ointments against fungi should also be avoided. At your appointment, you should complete all tests that have already been carried out, including for other diseases. Affected nails should not be cut for 3-4 days before the consultation.
Treatment of onychomycosis (nail fungus)
There are different types of treatment for onychomycosis:
- Local therapy.
- Systemic therapy.
- Combination therapy.
- Corrective therapy.
Local therapyMedication is applied 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 to the prescription of systemic drugs: hypersensitivity, liver disease, renal dysfunction, pregnancy, breastfeeding.
The advantage of this therapy is that high concentrations of the therapeutic agent form on the nail surface and do not enter the bloodstream. There are no side effects when taking antifungal drugs – nausea, loss of appetite, abdominal pain. The disadvantage of the method is that the drug does not always reach the pathogen's habitat, especially if the fungi are in the nail bed or nail matrix. This in turn can lead to treatment failure. This type of treatment is very labor-intensive because the affected part of the nail must be removed before using the medicine.
Methods for removing affected nails:
- Mechanical removal with files, pliers or drills.
- Use of keratolytic patches. Before applying a keratolytic patch, the skin around the nail is sealed with a plaster, a plaster mass (urea with salicylic acid) is applied to it and sealed with an adhesive plaster. 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 can be damaged, which leads to the regrowth of deformed nails.
After removing the affected nail plate, local antifungal drugs are used.Antifungalsdifferentiated according to location:
- applied to the nail: varnishes;
- applied to rollers: creams, ointments, solutions.
The most studied drug for topical use is1% naftifine solution, which has an evidence base for treatment effectiveness based on a Cochrane meta-analysis. This product is water-based, which allows better penetration of the antifungal substance into the affected area. Varnishes, the active ingredients of which 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 varnishes to be unsatisfactory and increasingly prefer water-based products.
To achieve results from local therapy, it is necessary to adhere to 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 to reach the lesion site via the bloodstream, even if the nail bed and nail matrix are affected. A high concentration of the drug remains in the affected area long after use has stopped. The disadvantages of this type of treatment are associated with the risk of side effects and toxic effects.
Indications for systemic therapy:
- Common forms of nail plate damage.
- Lack of effect of local therapy (i. e. after six months of treatment of onychomycosis of the hands and 9-12 months of treatment of onychomycosis of the feet, healthy nails did not grow back).
To determine treatment tactics, KIOTOS (Clinical Index for Assessing the Severity of Onychomycosis by Sergeev) is used, published in 1999 by A. Yu. Sergeev was suggested. It is used as a standard of care in various countries around the world.
Medicationfor 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 when no other antifungals are present;
- multi-component - in addition to the antimycotic, they also contain other active ingredients, such as anti-inflammatory drugs.
Prescription regimens:
- Standard - daily intake of medication 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 correspond 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 by active ingredient:
- triazoles;
- allylamines;
- others (third generation drugs).
Currently used for systemic therapyonly third generation drugs.
With combination therapyLocal and systemic treatment are carried out simultaneously. Combination therapy is used when it is necessary to increase the effectiveness of systemic therapy and shorten the treatment time.
Corrective therapy(Treatment of concomitant diseases): To select a treatment regimen, it is necessary to assess the general somatic condition of the body. Diseases such as circulatory disorders in the extremities can make it difficult for the antifungal to reach the lesion. Therefore, drugs that improve tissue trophism are prescribed.
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 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 are removed. Next, treat the nails and skin between the fingers with iodine, place them in a bath with soda solution for 20-30 minutes and dry thoroughly.
- Vinegar. For 3 liters of water take 1 tbsp. Add apple cider vinegar and a little potassium permanganate. Soak your feet in the bath for 20 to 30 minutes and then dry them thoroughly.
- Hydrogen peroxide. After thoroughly steaming your feet, remove the affected areas of the nail plates. Place cotton pads soaked in hydrogen peroxide on top, wrap them with a bandage and leave for half an hour.
Myths and dangerous misconceptions when treating nail fungus
One of the most important and dangerous myths is that nail fungus is not a serious disease. In fact, progressive onychomycosis can have serious consequences, including deformation and complete rejection of the nails from the nail bed.
In addition, an infected person poses a daily danger to their relatives, as they also risk getting sick when they are around them. That is why it is important to know how to cure nail fungus in a timely manner.
Forecast. prevention
The sooner a patient sees a doctor when there are signs of a fungal nail infection, the faster the disease can be cured and the nail plate can be restored. With long-term processes affecting the entire nail, treatment of onychomycosis can be lengthy, but if all recommendations are followed, recovery often occurs. If there are contraindications to systemic therapy, long-term maintenance therapy with local medications is required.
For preventionIt is necessary to observe the rules of personal hygiene and reduce the possibility of re-infection:
- Try to wear comfortable and high-quality shoes (to prevent excessive sweating of the feet).
- It is recommended to change socks and tights daily;
- Only use single shoes. For patients undergoing onychomycosis treatment, shoes must be treated at the beginning of treatment, at least once a month throughout the entire period of treatment and after its completion;
- Use foot antiperspirants if necessary.
- Use an individual nail care kit (scissors, files).
- Use antifungal topical agents (sprays, creams and sticks) before and after visiting public places (swimming pool, bathhouse, gym).
- Identify the source of the fungal infection in the family and get treatment at the same time.
It is recommended to periodically carry out antifungal treatment on personal items, shoes, bathtubs, floors and carpets. For these purposes, you can use a 40% acetic acid solution, a 1% alcoholic chlorhexidine solution (prescribed by a doctor) and disinfectant solutions. Linen can be boiled in a 1-2% soap-soda solution for 20-30 minutes and ironed at maximum temperature.