Onychomycosis(nail fungus) is a fungal infection of the nail plate and its surrounding structures: nail folds, matrix (part of nail growth) and nail bed. It is manifested by deformation and thickening of the nails, changing their color - the nails become white or yellow.
This disease is quite common. The prevalence of onychomycosis in Europeans, according to some data, reaches 10-12%, which is higher than the known indicators from the previous decade. It occurs 1. 5 times more often in men, but they go to the doctor 2 times less often than in women. Older people get sick more often, children very rarely.
The main problem in the treatment of the disease is that patients come to the dermatologist long after the first symptoms appear. Because of this, the pathological fungus covers a large area and treatment is delayed.
Pathogenic fungi can only be transmitted by a sick person. Very often, a fungal infection occurs within the family, because the source is not detected in time and adequate preventive measures are not taken.
Causes of the disease:most often direct contact with the patient or with the objects he uses (shoes, clothes, bath mats, washcloths, manicure accessories). Infections often occur when visiting gyms, baths, saunas and swimming pools.
Microdamages contribute to the development of the disease - cracks in the interdigital folds that occur as a result of abrasion, excessive sweating, dry skin, poor drying after water procedures and flat feet.
Nail mycoses can also occur in the presence of accompanying diseases of the endocrine system (diabetes mellitus, obesity, hypothyroidism), vascular diseases of the extremities (venous insufficiency, lymphostasis), immune disorders, as well as with the use of antibiotics, corticosteroids and cytostatics. As a result of the above-mentioned diseases, blood microcirculation in the nail area is disturbed and natural immunity is reduced, which contributes to the development of secondary infection.
Onychomycosis is caused by the following types of fungi:
- dermatophyte;
- yeast-like fungi of the genus Candida;
- mold fungi.
Depending on the type of causative agent, the penetration of the fungal infection and the clinical picture are different, so the approaches to therapy are also different.
Toenails are affected by fungus 10 times more often than fingernails. In most cases, the fungus is caused by dermatophytes (for example, 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 for your health!
Along with nail fungus, foot fungus 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, which is accompanied by itching. In the case of severe lesions, on the 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 antifungal drugs has improved the epidemiological situation, but foot mycoses still remain one of the most significant problems in dermatovenerology. The use of some drugs is limited in the elderly and patients with chronic diseases.
Routes of infection
The risk of fungal infection is particularly high in public places with high humidity. These are saunas, swimming pools, gyms, public baths, etc. The most common routes of infection:
- direct contact with an infected person. Here, the fungus moves from its habitat to healthy areas, causing infection;
- home way. In this case, infection occurs when using the patient's personal belongings: shoes, personal hygiene items, etc.
Risk factors
The incidence of onychomycosis increases until the age of 60. At this moment, the probability of developing such an infection is 60%, which is explained by the slowing down of metabolism, especially in the distal (remote) parts of the body, namely the fingers and toes.
Other risk factors for the development of nail fungus are:
- diabetes;
- varicose veins;
- injuries to nails and adjacent tissues;
- HIV and other immunodeficiency conditions;
- long-term use of antibiotics;
- weakened immune system;
- vascular and skin diseases, dermatitis, diaper rash;
- disorders in blood flow to the extremities;
- insufficient 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 the color of the nail 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 bed;
- change in the thickness of the nail plate;
- hapalonychia - reduction in the thickness of the plate and its softening;
- koilonychia - the nail looks concave, in the shape of a spoon;
- pachyonychia - thickening of the nail plate, nail hypertrophy;
- onychogryphosis - thickening, discoloration of the nail plate, curved in the shape of a beak;
- change in the thickness of the nail bed (hyperkeratosis - thickening of the nail bed);
- changes on the surface of the nail plate: pits, grooves, ridges;
- changes in the nail folds 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, uniquely suitable for a particular pathogen, so it is impossible to determine it by symptoms - additional tests are required.
Pathogenesis of onychomycosis (nail fungus)
The pathogenesis of the disease depends on how the fungus got to the skin and nails.
Distal subungual type:if the fungus has penetrated the skin in the area of the nail fold or the distal area, then the infection spreads through the free edge of 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 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 takes over the entire nail plate. The nail thickens, crumbles and takes on a gray-brown shade. 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. Stains appear on the nail in the area of the hole and the nail bed, and the nail plate separates. There is no significant inflammation of the nail bed or 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.
There isbiophysical concept of onychomycosis pathogenesis, who states that during the disease there is a conflict between two forces: the fungal colony growing towards the matrix and the natural growth of the nail from the matrix to the distal edge. This is why the speed of nail growth is crucial during onychomycosis – the faster the nail grows, the faster it will heal. Perhaps this is what explains the low prevalence of the disease in children, because their nails grow faster than in adults and the elderly.
Classification and stages of development of onychomycosis (nail fungus)
There is the following classification of onchomycosis:
- distal subungual;
- surface white;
- proximal subungual;
- total dystrophy.
According to the classification of Arievich (1970):
- normotrophic: there are yellowish and whitish stripes in the thickness of the nail, but the shape of the nail plate does not change, there is no subungual hyperkeratosis;
- hypertrophic:the nail plate becomes yellow, thickened due to subungual hyperkeratosis, becomes brittle, with jagged edges;
- dystrophic:there is thinning and separation of the nail plate from the nail bed with the creation of gaps.
Complications of onychomycosis (nail fungus)
Long-term onychomycosis increases the risk of developmentdiabetic foot(formation of trophic ulcers on the legs) igangreneif the patient has diabetes mellitus or vascular diseases of the lower extremities.
In immunosuppressive conditions (primary and secondary immunodeficiencies), fungi can spread to the skin, internal organs and cause allergies in the body. This can manifest itself as a rash on the skin, and even the development of bronchial asthma.
In an uncomplicated course, the disease causes symptoms traditional for a fungus, causing only severe discomfort to a person. But without treatment, onychomycosis can cause complications. They are most often manifested by the addition of a bacterial infection.
Sometimes onychomycosis is very acute with the appearance of blisters, ulcerations and weeping areas on the skin near 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 will need urgent hospitalization.
Diagnosis of onychomycosis (nail fungus)
Before examining methods for diagnosing onychomycosis, it is necessary to explain how to properly collect research material (the patient does it independently, or prepares the nails before diagnosis). Before collecting material for research, it is necessary to treat the nail plate with 70% alcohol to avoid contamination with other bacteria.
The method of collecting material varies depending on the form of onychomycosis:
- surface form- make a scraping from the nail plate;
- distal form- a scraping from the nail bed and a piece of the nail plate are also needed;
- proximal subungual form- the material is taken with a drill, or a biopsy of the nail is performed, or a scraping from the nail bed.
The fastest method for determining pathological nail fungus ismicroscopy. Technique: the material under study is treated with an alkaline solution to dissolve the keratin. To make the mushrooms more visible, ink is added to the lye. Then the obtained preparation is studied under a microscope.
This research method is the fastest and most objective. The sensitivity is up to 80%. Disadvantages of the method include the fact that when using it, it is impossible 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 interpreted under a microscope after 2-3 weeks. This method allows you to determine the type of pathogen - it helps to determine treatment tactics and select drugs based on sensitivity. But the disadvantage of the study is that it takes a long time, and its sensitivity is only 30-50%.
Biopsy: Using a scalpel and applying anesthesia, the fingernail and toenail are cut off. The material is immersed in a formaldehyde solution and sent to the laboratory for histological examination. The advantages of this method are that it is very sensitive and allows you to determine the presence of a pathological fungus in the material.
Disadvantages: it is impossible to identify the pathogen, as well as to determine the viability of microorganisms, the method is expensive and labor-intensive.
Genetic diagnostics: molecular biological research method (PCR). This is one of the new and very 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 those health institutions that have PCR laboratories, but it is currently planned to introduce a test system for the identification of dermatophytes and molds in laboratories. The method allows you to determine the type of pathogen, and its sensitivity ranges from 80-90%. Disadvantages: high price, inaccessibility, lack of technological standards and complexity of implementation.
Doctors are introducing more and more into practicedermatoscopy. Using this method, you can assess changes in the color and structure of the nail, as well as the condition of the surrounding structures. Dermatoscopic examination enables a more precise assessment of the depth of damage to the nail plate and a more accurate calculation of the onychomycosis severity index (KIOTOS).
First of all, the patient is sent for microscopy, which allows identification of the presence of pathogens. In the future, it is necessary to determine its type in order to choose the right treatment for toenail fungus. At 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 the biological sample of the affected tissue. To achieve this, it is placed in an artificial nutrient medium, where the pathogen is grown to determine its type;
- Polymerase chain reaction (PCR) method for detection of pathogen DNA in affected tissue sample.
When to see a doctor
Many who have encountered onychomycosis know that the disease develops slowly and is incredibly difficult to treat. That is why it is very important to consult a doctor at the first signs of illness. A dermatologist treats nail onychomycosis in our clinic in the center of Moscow. The specialist will provide you with competent help and guide you to complete recovery.
Preparing for a visit to the doctor
Before visiting the dermatologist, it is important not to treat the affected nail areas with anything, i. e. do not use drugs, including iodine and brilliant green. The use of anti-fungal creams and ointments should also be avoided. When making an appointment, you need to do all previously taken tests, including those for other diseases. Damaged nails should not be cut 3-4 days before the consultation.
Treatment of onychomycosis (nail fungus)
There are several types of treatment for onychomycosis:
- Local therapy.
- Systemic therapy.
- Combined therapy.
- Corrective therapy.
Local therapyinvolves applying medication 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 for prescribing systemic drugs: hypersensitivity, liver disease, renal dysfunction, pregnancy, breastfeeding.
The advantages of this therapy are that high concentrations of the therapeutic agent are formed on the surface of the nail, which does not penetrate into the bloodstream. There are no side effects of using antifungal drugs - nausea, loss of appetite, abdominal pain. The disadvantage of the method is that the medicinal substance does not always reach the habitat of the pathogen, especially if the fungus is located in the nail bed or 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 applying the medicine.
Methods for removing infected nails:
- Mechanical removal using files, pliers or a drill.
- Using keratolytic patches. Before applying the keratolytic patch, the skin around the nail is glued with a patch, plaster mass (urea with salicylic acid) is applied on top and stuck with an adhesive patch. 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 agents are used.Antimycoticsvaries by application site:
- applied to the nail: varnishes;
- applied to rollers: creams, ointments, solutions.
The most studied drug for local application is1% Naftifin solution, which has an evidence base for treatment efficacy based on a Cochrane meta-analysis. This product is water-based, which facilitates penetration of the antifungal substance into the affected area. Lacquers, whose active ingredients are ciclopirox and amorolfine, have a dehydrated base, which reduces the penetration of the drug into deep layers. Therefore, dermatologists consider the use of varnishes unsatisfactory and increasingly prefer water-based products.
To achieve the results of local therapy, it is necessary to adhere to the treatment regimen, it is important for the patient to be responsible, consistent and patient. The duration of therapy can be up to 12 months.
Systemic therapyallows the antifungal drug to penetrate the bloodstream to the site of the lesion, even if the nail and matrix are involved. A high concentration of the drug remains in the affected area for a long time after the end of use. 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 damage to the nail plate.
- Lack of effect of local therapy (that is, after six months of treatment of onychomycosis on the hands and 9-12 months of treatment of onychomycosis of the feet, healthy nails did not grow).
To determine treatment tactics, KIOTOS (Clinical index for assessing the severity of onychomycosis by Sergeev) is used, proposed by A. Yu. Sergeev in 1999. It is used as a therapeutic standard in various countries around the world.
Medicinesfor the treatment of onychomycosis can be classified as follows:
- antimycotics - have an antifungal effect;
- antiseptics - have both antifungal and antibacterial effects. They are used rarely, only if there are no other antifungal agents;
- multi-component - in addition to an antifungal agent, they also contain other drugs, such as anti-inflammatory drugs.
Prescription regimes:
- standard - daily medication intake during the prescribed treatment period;
- shortened - the treatment period is shortened, it can be carried out in regular doses or increased;
- intermittent - treatment is prescribed in several short courses, the intervals between courses are equal 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 according to the active substance:
- triazoles;
- allylamines;
- others (third-generation drugs).
It is currently used for systemic therapyonly third generation drugs.
With combined therapylocal and systemic treatment are carried out simultaneously. Combined therapy is used when it is necessary to increase the effectiveness of systemic therapy and reduce treatment time.
Corrective therapy(treatment of accompanying diseases): to select a treatment regimen, it is necessary to assess the general somatic condition of the organism. Diseases such as circulatory disorders in the extremities can reduce the access of the antifungal agent to the lesion. Therefore, drugs are prescribed that improve tissue trophism.
Due to the toxic effect of systemic antifungal drugs, it is necessary to rule out 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 must be removed. Then treat the nails and the skin between the fingers with iodine, soak them in a bath with soda solution for 20-30 minutes and dry well;
- vinegar. For 3 liters of water, take 1 tbsp. apple cider vinegar and add a little potassium permanganate. Soak your feet in the bath for 20-30 minutes, then dry them well;
- hydrogen peroxide. After thoroughly steaming your feet, remove the affected areas of the nail plates. Put cotton pads soaked in hydrogen peroxide on them, wrap them with a bandage and leave for half an hour.
Myths and dangerous misconceptions in the treatment of nail fungus
One of the most important and dangerous myths is that nail fungus is not considered a serious disease. In fact, onychomycosis, as it progresses, can lead to serious consequences, including deformation and complete rejection of the nail.
In addition, an infected person poses a daily danger to those close to him, since they risk getting sick in his vicinity. That is why it is important to know how to cure nail fungus in time.
Forecast. Prevention
The sooner a patient consults a doctor with signs of a fungal nail infection, the faster the disease can be cured and the nail plate restored. With long-term processes that affect the entire nail, the treatment of onychomycosis can be long-term, but if all recommendations are followed, recovery often occurs. If there are contraindications for systemic therapy, long-term maintenance treatment with local drugs is required.
For preventionIt is necessary to follow 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;
- use single shoes only. For those treated for onychomycosis, shoes must be treated at the beginning of treatment, at least once a month throughout the treatment period and after its completion;
- if necessary, use antiperspirants for the feet;
- use an individual nail care kit (scissors, files);
- before and after visiting public places (swimming pool, bathroom, gym) use external means against fungi (sprays, creams and pens);
- identify the source of the fungal infection in the family and treat at the same time.
It is recommended to periodically carry out antifungal treatment of personal belongings, shoes, bathtubs, floors and rugs. For these purposes, you can use a 40% solution of acetic acid, a 1% alcoholic solution of chlorhexidine (prescribed by a doctor) and disinfectant solutions. Bed linen can be boiled in a 1-2% solution of soap soda for 20-30 minutes, ironed at maximum temperature.