The eyes may be the windows to our soul, but our nails are a reflection of our overall sense of style, general health and grooming habits. That is why the mere hint of nail changes suggestive of a nail fungus frequently leads one to hide their hands (or toes) in shame.

Nail fungus is rampant and doesn't discriminate in choice of its next host. While contagious, it's comforting to realize that developing a nail fungus is not necessarily a reflection of our cleanliness.

Nail fungus is a contagious infection caused by several members of the "true fungus" (dermatophyte) family. Other organisms also likely to infect the nails are yeast and bacteria. Neither are members of the dermatophyte family; think of them as cousins. It's fairly common for the public to overgeneralize the entire category "nail fungus", however the appearance of the infection and the therapeutic options differ between these two categories. In fact, this distinction is often the reason many people do not respond to treatment as they mistakenly select the incorrect option.

THERE'S A FUNGUS AMONGST US!

Fungi are ubiquitous. They literally hang out everywhere. However, fungi are most likely to thrive in warm, moist environments like bathrooms, locker rooms, gyms, and poolside as well as other places one hangs out barefoot such as yoga and Pilates studios.

How do you pick up a nail infection? Unsanitary nail grooming is one way. The accidental spread of fungus can occur when using a contaminated manicure or pedicure tool. Simply by filing an infected nail and then moving on to an uninfected nail is a common mistake that easily spreads a fungal infection.

Simple exposure is another. So many times our skin, nails and cuticles have microscopic cuts and abrasions through which fungi can enter. Protection and the use of preventative antifungal treatments in high risk environments can reduce this risk.

People who wear artificial nails are at a higher risk for developing fungal or yeast infections of the nail due to the microscopic damage that arises to the nail plate. Fastidious practices by the nail technician go a long way to help cut down on the development of these infections.

Finally, there are those individuals who simply are more prone to becoming infected with fungal infections, often due to a hereditary lack of immunity to the organism. That's not so unusual. Think of all the people who struggle with recurrent sinus infections, Strep throat or warts. Typically their systems simply are a genetic set-up to "pick up" these infections. While one doesn't have to simply give in to fate, those prone to nail fungus frequently become reinfected after successful treatment.

EENIE MEANIE MINEY MOE

How do you know you have an infection and exactly which one is it?

Yellow, thickened, splitting nails often signals the presence of a true nail fungus. Loosening (onycholysis) is frequently due to a fungal infection of the nail plate. The nails may become brittle or peel. Thick debris often seems to collect under these thickening nails (aka subungual debris) as they lift away from the nail bed, but it's really fungi happily proliferating. Nail plates may further discolor as they detach, frequently due to bacteria taking advantage of the situation.

Yeast and bacterial infections on the other hand rarely cause the nail plate to thicken or have debris build beneath the nail. Instead in the case of a yeast infection the nails typically begin to develop a white discoloration beginning at the tip of the nail and moving back towards the cuticle. Bacterial infections frequently cause black or greenish discoloration of the nail plate.

A nick at the manicurist, a paper cut, or any trauma or injury to the cuticle can set you up for an infection called paronychia. Rather than an infection primarily arising in the nail itself, paronychia begins with a yeast or bacterial infection of the skin around the cuticle. This area may appear red, swollen and oozing unpleasant fluid. Occasionally a paronychia can be the open portal for infection of the nail. In either case, treatment of the paronychia is important for both health and comfort concerns.

THERAPY OPTIONS FOR FUNGI

True fungus and yeast infections of the nails may sound similar, but they are entirely different organisms, which respond to entirely different therapy. Plus, it's vital to understand that no treatment for nail yeast, bacteria or fungal infections is going to change the appearance of an altered nail plate. What they will do is stop the infection and prevent further spread. Lots of time is needed to grow out an affected nail and allow a healthy nail to grow in its place. Fingernails typically require at least six months; toe nails twelve to twenty four! And the more mature one gets, the longer it takes to grow a new healthy nail.

The main treatments available for nail fungus are three systemic RX anti-fungal medications and one prescription topical therapy. Unfortunately, there aren't any topical OTC medications that can penetrate the nail plate and cure a fungal infection. But the most recent entry into the categoryLamisil (terbinafine)is, in my opinion, far superior to the others.

Griseofulvin

The original prescription oral medication for treating a true nail fungus is Griseofulvin. Known by various brand names such as Grispeg, Grifulvin V, and Fulvicin, this medication while highly effective, does not remain in the nail bed, where the fungus resides. As fingernails typically take approximately 6-12 months to grow out from back to front, and toenails take even longer (as much as 1-2 years!), this medication has to be taken daily until the nail fully grows out and the fungal infection is gone. Griseofulvin, similar to other oral antifungal agents, has a low risk of bone marrow and liver damage, so blood work is done approximately every 3 months (in addition to a screening panel performed prior to beginning treatment) while on the medication. The most common side effects include nausea/vomiting, headaches, increased sunburn potential and diarrhea.

Sporonox

Sporonox (itraconazole) was the next systemic medication to hit the market for the treatment of true fungal infections. I was honestly never personally impressed with Sporonox for my patients as it is effective only 50% of the time and has several serious drug interactions. Medications including terfenadine, astemizole and cisapride may not be taken with Sporonox, as serious heart arrhythmias may arise. Also, medications such as lovastatin and simvastatin must be discontinued during therapy. There are several other drugs that may not be taken with Sporonox. I highly recommend you make your physician and pharmacist aware of all medications you are on, especially if you will be taking this drug. Sporonox is typically given in 2 pulse doses of 200mg twice daily for one week and again 3 weeks later for fingernail fungal infections with a 47% cure rate. Toenail infections are treated with 200mg daily for 12 weeks with up to a 54% cure rate. Side effects include GI disorders, rashes, elevated liver enzymes, headaches and dizziness.

Lamisil

Lamisil (terbinafine) has been the most recent entry into the systemic nail fungus medication category. Oral Lamisil, (it does come in cream form, Lamisil AT, for treating fungal infections of the skin), has been far superior, in my opinion, to other options of treatment. Lamisil remains in the nail bed, significantly reducing the time of therapy. The medication is taken once a day, and the dose is constant at 250mg. Toenails require 3 months, while fingernails require only 6 weeks of treatment. Remember, while treatment time is vastly reduced with Lamisil, it still takes that 6-12 months for fingernails and 1-2 years for healthy toe nails to fully grow out. While Lamisil is considered safe, it also has a low potential risk of systemic problems such as depression of the bone marrow and liver damage. For the safety of my patients, I still perform screening blood work, and will repeat blood work during therapy. Typically this is at 3 weeks for fingernails, and every month for toenail therapy. I have seen occasional patients experience diarrhea, and I have seen one drug reaction to it, but it has basically been a well- tolerated drug.

Penlac

Penlac (ciclopirox) 8% solution remains the sole prescription topical antifungal therapy effective for nail fungus. Penlac works best for containing and treating very early nail fungus limited to a very few nail plates. Consistent daily application and immaculate nail grooming are necessary to maximize results.

DOLLARS AND SENSE

Unfortunately, oral antifungal therapy doesn't come cheap. And in this world of insurance ruling the practice of medicine, standards of care are rapidly changing. It used to be that the patient with suspected nail fungus would have a fungal culture done prior to beginning treatment. This was because there are some skin diseases, such as psoriasis, that may mimic the appearance of nail fungus. Certainly in patients with obvious athlete's foot, or other general fungal infections, this diagnosis was straightforward. I would routinely (and still do, for the safety of my patients), run screening blood work to make certain a patient was healthy enough to tolerate the systemic medication. However, insurance companies typically (not always, but the vast majority) refuse to pay for the fungal cultures, as well as the screening blood work for nail fungus, and are actually refusing to pay for the therapy, calling nail fungus a "cosmetic" condition. Be aware that the cost of therapeutic medication alone may run approximately $250-400.00 (Lamisil).

Diabetics however are typically covered for nail fungus therapy. The fungus causes microscopic breaks in the skin through which bacteria can enter which can result in a significant skin infection of the lower legs called cellulitis. Diabetics are far more prone to developing this condition that otherwise healthy patients fighting nail fungus. The costs associated with oral antifungal therapy are a vast savings over potential hospitalization.

THERAPY OPTIONS FOR YEAST INFECTIONS OF THE NAILS

Medications such as Diflucan and oral Nizoral (Ketoconazole), are not meant for true fungal infections, but they do treat yeast infections. I can't tell you how many patients I see who have been to primary care physicians and "failed" treatment for their true nail fungus who have been on Diflucan. It's a great drug, but the wrong use. In addition, oral Ketoconazole carries a much higher risk of liver damage, so I am hard pressed to consider this medication for routine yeast infections of the nails.

Thymol

I used to have to write a prescription for the pharmacist to mix up a treatment called thymol in order to treat yeast and bacterial infections of the nail. Now there is Amoresse Thymola mixture of 4% thymol in alcohol and it is excellent for yeast and bacterial infections of the nails. Use it twice daily, until the affected area has grown out. I also advise patients that diminishing exposure to water or soil can help significantly in both their treatment and prevention.

THERAPY OPTIONS FOR PARONYCHIA

Keep the area clean, and speed healing by allowing hydrogen peroxide to bubble up the bacteria in the area followed by the application of Polysporin First Aid Antibiotic Ointment, an over-the-counter bacterial preparation. Separately, apply Amoresse Thymol twice a day. The extension of redness or development of pus signals the possible need for a round of oral antibiotics. Call your doctor if you see these signs.

PREVENTION

Let's face it; it's easier to prevent a nail fungus that it is to clear it up. To me, prevention makes a lot of sense, especially for diabetics. I always recommend to my diabetic patients the use of a preventative antifungal cream like Lamisil AT Cream for Athlete's Foot, DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream or Spectazole. By applying to the feet and toenails daily, this helps reduce the rate of developing a fungal infection of the foot or nails in the first place and of course thus reduces the risk of developing cellulitis.

If you're headed out to exercise barefoot, apply an antifungal cream to your feet before you go, or carry it in your gym bag to apply immediately after showering. By simply applying a dab or DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream or a spritz of Lamisil AT Continuous Spray for Athlete's Foot, you can make a preemptive strike against infection.

Headed to the pool? Try wearing those new water shoes or at least take a pair of flip-flops and reduce your barefoot time. Again, once you've come home and cleaned up, consider applying an antifungal cream to your feet.

Finally, nail grooming is important. Cut or file healthy nails first, followed by infected ones. Use a metal nail file such as Diamancel Diamond Nail File #2 that you can easily disinfect (along with the clippers) in a solution of dilute ammonia or bleach, or by using rubbing alcohol. These procedures will go a long way in preventing the spread of the infection to other nails. A good anti-fungal cream will also help contain but not clear the infection within the affected nail.

Have no fear; having a fungal infection (or a fungal cousin) of the nail is not insurmountable. Putting in the time and effort can indeed reward you with beautiful healthy nails.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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