Onychomycosis "Fungal Nail Infections" (Tinea Unguium): Causes, Symptoms, Diagnosis And, Treatment.

What is Onychomycosis

Define onychomycosis

Onychomycosis (nail fungus, toenail fungus, Tinea Unguium) is a fungal infection of the toenails or hands that affects any component of the nail complex, including the base, bed, or plate. The disease can be accompanied by pain, discomfort, a change in the appearance of the nails, which in some cases leads to serious physical and professional restrictions, the patient's anxiety, and a decrease in the quality of their life.

According to medical estimates, more than 15% of the world's population suffers from it, although this pathology is diagnosed much less often (in 2% of people).

In the United States, nail onychomycosis occurs in about 2-13% of the population, in Canada - in 6.5%, in England, Spain, and Finland - in 3-8%. According to a systematic review of 1914 articles, the prevalence of onychomycosis is as follows:

• the general population - 3.22%.
• children - 0.14%.
• elderly people - 10.28%.
• patients with diabetes mellitus - 8.75%.
• patients with psoriasis - 10.22%.
• HIV-positive patients - 10.40%.
• dialysis patients - 11.93%.
• after kidney transplantation - 5.17%.

Onychomycosis accounts for about half of all nail pathologies and is the most common adult nail disease. As for the affected areas, according to statistics, the legs are affected much more often than the hands. The main forms of onychomycosis are Distal lateral subungual onychomycosis Proximal subungual onychomycosis White superficial onychomycosis Endonyx-onychomycosis Candidal onychomycosis Often, patients have a combination of these subtypes, or total dystrophic onychomycosis - a lesion of the entire nail complex.

The main forms of onychomycosis are:

• Distal lateral subungual onychomycosis
• Proximal subungual onychomycosis
• White superficial onychomycosis
• Endonyx-onychomycosis
• Candidal onychomycosis

Often, patients have a combination of these subtypes, or total dystrophic onychomycosis a lesion of the entire nail complex.

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Classification of Onychomycosis

Distinguish between normotrophic, hypertrophic, and onycholysis (atrophic) onychomycosis.

In the normotrophic form, the affected nail retains its thickness and shine but changes color.

In the hypertrophic form, in addition to the color change, an increasing subungual hyperkeratosis is observed. The nail loses its shine, becomes dull, thickens, and deforms up to the formation of onychogryphosis (thickening and curvature of the nail like the claw of the mythical bird of the griffin), partially collapses, especially from the sides, patients often experience pain when walking.

The onycholysis form is characterized by a dull brownish-gray color of the affected part of the nail, its atrophy, and rejection from the bed - the exposed area is covered with loose hyperkeratotic layers; at the same time, the proximal part of the nail remains unchanged for a long time.

In addition, classification is used based on the localization of the nail lesion: distal onychomycosis (with damage to the nail at the free edge), lateral (with damage to the lateral sides), proximal (with damage to the posterior ridge), and total (with damage to the entire nail) are distinguished.

Onychomycosis causes

What is the cause of onychomycosis?

Onychomycosis is caused by three main classes of fungi: dermatophytes, yeasts, and non-dermatophytic molds.

There are various types of fungi that can cause onychomycosis. First of all, these are dermatophytes. In second place are the yeast fungi of the genus Candida, which are always present in small quantities on human skin (they often affect the nails of the hands). Infection with molds is also possible (usually they are accompanied by other pathogens. Isolated infection with molds is characteristic not for ours, but for a tropical climate).

The risk of fungal infection increases with age. In children, nail fungus is very rare, and, conversely, in older people, it is detected relatively often. Moreover, men suffer from onychomycosis more often than women.

The age specificity of the fungus is explained by the fact that our local immunity decreases over the years, while the natural defense of a young organism, as a rule, well suppresses the activity of fungi, preventing them from colonizing the nail plate. There is dependence not only on local immunity but also on general immunity. The weakening of general immunity is a favorable background for the development of any fungal infection.

For fungi of the genus Candida, it is enough that there are problems with the immune system: they simply begin to actively multiply. Fungi of other species still need to somehow get into our bodies from the external environment. Some types of fungi can be carried by animals. Molds are found everywhere; they are able to reproduce without a host. However, in most cases, the fungal infection spreads from person to person.

Mushrooms love moist environments. Therefore, fungal infection often occurs in places where the humidity is high. These are swimming pools, saunas, changing rooms, gyms. Wearing socks and shoes on wet feet can also be a provoking factor.

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If there are wounds and cracks, they allow infection to penetrate directly into the tissues, avoiding the need to storm the protective barrier that forms the surface of our skin.

The spread of fungi is facilitated by negligence in relation to personal hygiene: you cannot use other people's slippers, soap, and a towel. Precisely because not every family follows this rule, nail fungus often becomes a family disease.

Nail involvement usually begins at the edge. Dermatophytes penetrate under the free edge of the nail plate (in the subungual notch). In this case, the

pathological process develops mainly in the nail bed. The second way of penetration of fungi is from the nail fold. The Candida fungus usually affects the posterior nail fold first (paronychia occurs), and only then the nail itself suffers. One type of dermatophyte (T. mentagrophytes) can penetrate directly through the nail plate.

Distal subungual onychomycosis: In distal lateral subungual onychomycosis, Trichophyton rubrum is usually detected. In immunocompromised patients, proximal subungual onychomycosis with T. rubrum is typical. The same type of onychomycosis, but with periungual inflammation, is caused by non-dermatophytic molds. White superficial onychomycosis of the nails provokes Trichophyton mentagrophytes, and its deeper forms - non-dermatophytic molds. Candidal nail infection is common in premature babies, immunocompromised patients, and those with chronic mucosal candidiasis.

Risk factors for the development of onychomycosis:

• family history.
• elderly age.
• warm and humid climate.
• weakened body.
• trauma to the nails.
• regular fitness classes.
• immunosuppression (drug, HIV, etc.).
• visiting public pools, baths, and saunas.
• tight shoes.

Repeated microtraumas of nails in tight and uncomfortable shoes provoke onycholysis (detachment of the nail from the soft tissues of the toe) and other dystrophic conditions that contribute to the penetration of fungi into the nails.

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Onychomycosis symptoms

What are the Symptoms of onychomycosis?

At first, onychomycosis is asymptomatic - patients can consult a doctor due to visible cosmetic defects of the nail plate but without any discomfort. As the disease progresses, paresthesias, pain, and discomfort occur in the affected area. This makes it difficult to walk, interferes with sports and in everyday life.

The clinical manifestations of onychomycosis depend on its type:

Distal subungual onychomycosis there is subungual hyperkeratosis and onycholysis, the plate becomes yellow-white. In its central part, yellow stripes and/or yellowish onycholysis areas are visible.

Proximal subungual onychomycosis is represented by leukonychia (white spots and stripes) in the proximal parts of the nail plate, which move distally (to the edge) as the nail grows. If there are molds among the pathogens, periungual inflammation occurs.

White superficial onychomycosis: small white speckles form on the toenails, the nail plate becomes rough and crumbles easily. Variations with a deeper spread of the pathological process into the nail are possible, depending on the causative agent of the disease.

Endonyx-onychomycosis: the color of the nail plate becomes milky white. Unlike distal onychomycosis, there are no signs of subungual hyperkeratosis or onycholysis.

Candidal onychomycosis of the nails is associated with chronic mucocutaneous candidiasis or immunosuppression, while several or all of the nails are affected at once with the presence of periungual inflammation. The fingers of these patients often take on the shape of onion or drumstick.

To assess the severity of the disease developed a Severity Index onychomycosis (Onychomycosis Severity Index, OSI). The result is obtained by multiplying the scores of the area of the lesion by the scores of the proximity of the lesion to the zone of nail growth. Mild degree - 1–5 points, medium - 6–15, severe - 16–35. Dermatophytoma (spots or longitudinal stripes) more than 2 mm with subungual hyperkeratosis is estimated at 10 points.

In its manifestations, onychomycosis is similar to many other nail pathologies. For example, leukonychia (stripes) resemble an injury to the nail plate. To confirm the diagnosis, it is necessary to perform a laboratory mycological study. Interestingly, a negative result does not exclude onychomycosis, since microscopy can be falsely negative in 10% of cases and field culture in 30% of cases. A more reliable, albeit more expensive, the method is the PCR study (polymerase chain reaction).Lunula nails: What does it mean when you have no Lunula

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Onychomycosis Diagnosis

How is onychomycosis diagnosed?

The diagnosis of onychomycosis can only be made by a doctor, the reason to turn to which will be a change in the shape or color of the nails. If the nails have lost their transparency, changed color, spots or areas of cloudiness have appeared on them, if the thickness of the nail plate has changed, the nails have become fragile, you should immediately consult a doctor. The earlier the diagnosis is made and the treatment of onychomycosis is started, the higher the probability of a complete cure.

Unfortunately, many do not pay attention to the change in the state of their nails for a long time, and, even suspecting they have onychomycosis, do not seek medical help, preferring to be treated on their own by "handy", often the most unexpected means (kerosene, iodine, chlorine-containing household chemicals), or, simply ignore their condition, explaining the changes in the nails by trauma, pollution. It is important to understand: the treatment is most effective precisely at the initial stage of the disease when the changes in the nail are still minimal. With deep lesions of mycosis, long-term therapy (9-12 months) is required for a full cure, using not only local but also tablet forms of drugs.

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Onychomycosis treatment

How is onychomycosis treated?

How do you get rid of onychomycosis, Can onychomycosis go away on its own?

Topical antifungal agents are ineffective in case of damage to nail plates. Treatment with antifungal ointments, creams, solutions, varnishes must necessarily be preceded by the removal of the affected area of the nail mechanically or with the help of keratolytic patches.

Mechanical removal is cutting or cutting fragments of damaged nail plates.

The use of keratolytic patches in the treatment of onychomycosis allows the nails to be softened so that they can be easily and painlessly removed from the surface of the cuticle using a blunt scalpel or scissors.

The keratolytic used is a ready-to-use Set of Mikospore, consisting of an ointment containing 1% bifonazole and 40% urea. The ointment is applied to the surface of the nail and covered with a fixed patch and bandage. After one day of onychomycosis, the affected areas are cleaned. The procedures are performed daily until the affected nails are completely removed. In the future, as the affected nail is removed with keratolytic, local antimycotics are used: antifungal varnishes.

In the first month of treatment, grizeofulvin is prescribed. 6-8 tablets per day (750-1000 mg), the second time with the same dose every other day and then 2 times a week until whole nail plates grow. It is taken in 3 doses with a teaspoon of vegetable oil. the duration of treatment of hand mycosis is 4-6 months, leg mycosis - 9-12, and even 18 months.

Treatment with griseofulvin alone provides a cure in only 40% of patients. Combination with nail removal increases the cure rate. However, its use is limited by many side effects, as well as a high incidence of relapses.

Ketoconazole is used in a daily dose of 200 mg (1 tablet) with meals. The duration of treatment of chewing nails of hand nail plates is 4-6 months, for onychomycosis of the feet - 8-12 months. Treatment with ketoconazole alone leads to the cure of approximately 40% of patients with onychomycosis of the feet. Surgical nail removal can increase the cure rate.

Itraconazole is used in two regimens. According to the first, the drug is taken 200 mg (2 capsules) per day for 3 months. The second regimen used in recent years is the use of itraconazole in the pulsating form: 7 days at 400 mg per day (200 mg in the morning and evening), then followed by a break of 3 weeks and a new one week course of treatment With mycosis of the hands, 2 courses of pulse therapy are prescribed, with mycosis of the feet - 3-4 courses. The cure is observed in 80-85% of patients even without nail removal.

We use terbinafine daily in a daily dose of 250mg (1 tablet). For hand onychomycosis, the duration of treatment is 1.5 months, for foot onychomycosis - 3 months. Lamisil alone has an efficiency of 88-94%. It should be noted that the proportion of treated patients increases after the end of treatment and reaches a maximum after 48 weeks.

For 6 months Fluconazole is prescribed in a dose of 150mg once a week for mycosis of the hands and from 8 to 12 months for mycosis of the feet. recently the medicament is used for mycotic nail infection treatment relatively. According to researchers, cure occurs in 83-92% of patients. For the successful and safe treatment of onychomycosis with systemic antifungal agents, it is recommended to follow certain rules.

First of all, the diagnosis must be reliable. The medicament shouldn't be prescribed without laboratory confirmation.

It's necessary to collect an allergic history, after establishing the diagnosis. If concomitantly, medications or foods that cause allergic reactions or other intolerances are detected, their use should be discontinued.

It is recommended to limit the use of non-essential medicinal products during treatment with systemic antimicrobials. To avoid malfunction of the gastrointestinal tract, it is recommended to exclude from the diet foods that cause bloating: black bread, legumes, milk, cabbage. No less important is the choice of comfortable shoes both during and after treatment.

The improvement in the condition of the affected nails is often associated with the wearing of shoes, which is highly incompetent since the compression of tissues caused by shoes can be the cause of exacerbation or recurrence of distal subungual onychomycosis.

Before starting treatment, it is recommended to conduct a study of the general and biochemical parameters of blood tests.

For the first time, control tests should be carried out after 2 weeks, then once a month. Examination of microscopy - 6 months after the end of treatment. The detection of pathogenic fungal mycelium is a sign that repeated treatment is required, having previously carried out surgical removal of the damaged nails.

The same symptoms can be signs of different diseases, and the disease may not proceed. Do not try to heal yourself - consult your doctor.

Onychomycosis antibiotic

A common and unpleasant infection found on internal organs, this type of lesion comes from candida - the yeast-like fungus Candida. Diseases belong to systemic (visceral, generalized) candidiasis, fungi spread in the gastrointestinal tract, on the respiratory organs, in the urinary system. Less commonly - in the nervous and cardiovascular system, in the brain tissue. Various types of antimycotic drugs are active even in chronic, granulomatous forms of visceral candidiasis.

Antibiotic and antifungal therapy is always supported by other means: antiseptics, vitamins, pills to stimulate immunity, antibacterial, etc. Often, systemic candidiasis is accompanied by manifestations on the nail folds, plates. In this case, therapy is supplemented with drugs for external use (formulations of Terbinafine, Cyclopirox, Amorolfine, see the previous paragraph). Skin lesions in candidiasis are rare.

The appointment of this or that remedy is done according to the indications: depending on which organ is affected by candidal infection, how pronounced it is, how fast it spreads.

Onychomycosis and diabetes

Fungal infection, Onychomycosis in diabetes is very dangerous, it cannot be ignored, since its further development can negatively affect a person's ability to work, cause pain when walking even in his usual comfortable shoes. Swelling and thickening of the nails can cause cracks in the skin, which get infected.

If the focus of the fungal infection is not treated and it continues to spread, the condition can be further exacerbated by the development of a bone infection or gangrene. In such cases, in order not to lose the entire leg, the infected part of the limb is amputated. Therefore, diabetics need to immediately treat onychomycosis: this will save you from more severe complications in the future.

Prevention

Shoes must be in size. Tight shoes disrupt the blood supply to the feet, provoke excessive friction of the toes, and promote ingrowth of nails. Injured skin and nails are easily infected with fungus.

• Preferred shoes made from natural materials. Synthetic materials create a "greenhouse effect" by maintaining excess moisture inside the shoe, which is a favorable environment for the development of an athlete's foot.
• Trying on shoes in shoe stores should not be done on bare feet, use an individual pair of socks for this purpose.
• At a party, refuse the offered slippers, they may be unsafe, bring a "change" with you.
• Dry your outdoor shoes when you return home.
• In the pool, sauna, bath, wear replaceable rubber slippers, which must be thoroughly washed and dried after each use.
• After any contact with water (visiting the pool, sauna, taking a bath or shower), thoroughly dry your feet with a towel. Excessive moisture, especially in the interdigital spaces, contributes to the development of the fungus.
• It is advisable to do pedicures and manicures in specialized salons equipped with equipment for sterilizing instruments. The best option would be to purchase a personal toolbox.

Secondary prevention is relevant for those who have already undergone a course of antifungal treatment, the purpose of such prevention is to avoid a relapse of the disease.

• Dispose of all shoes that you used before and during treatment.
• Use of local antifungal drugs for 6 months after the completion of the main treatment.
• Increasing the body's resistance by healthy lifestyle methods (hardening, regular physical activity, balanced nutrition).

For a long time, onychomycosis can only represent a cosmetic problem, the affected nails do not cause any painful sensations. But, even at the initial stage of the development of the disease, an infected person poses a danger to others, first of all, to children and the elderly. Ignoring your illness, postponing a visit to the doctor, neglecting the necessary treatment is unacceptable. For any changes in the appearance of the nail plates, you should consult a specialist.

Despite the fact that in the pharmacy network, a variety of drugs with antimycotic activity, deceivingly promising a quick effect, are publicly available, you should not self-medicate. Therapy of onychomycosis should be carried out only under medical supervision. It is important to understand that the treatment of fungal nail infections is always long-term, from 9 months to several years, which is associated with a slow growth rate of the nail plates and the risk of re-infection.

Remember, careful care of the feet and adherence to the rules for the prevention of onychomycosis will help to avoid contracting this unpleasant disease.

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