A fungal nail infection (a.k.a. onychomycosis) is an infection of the nail plate caused by either a fungus, bacteria, mould or yeast. Without definitive microscopy (a laboratory test) to determine what type of infection is at play, treatment is typically on a ‘trial and error’ basis, although it's worth mentioning that up to 90% of all fungal toenails are caused by a single organism - trichophyton rubrum (a dermatophyte; type of fungus).
Fungal nail infections have a certain look about them. Typically, the nail is thickened, which may affect either the entire nail plate or just a portion of it. The nail may break easily and appear crumbly. It it discoloured; from white-ish, to shades of yellow and gold to green and even black. There is typically a degree of malodour if you are willing to sniff that crumbly bit of nail or are the sort of person who likes to clear the crudge out from beneath the free edge of the nail and give that a whiff. It is not uncommon to see a thick yellow, orange or white band (a dermatophytoma) with a chronic infection.
Fungal nail infections are hugely misdiagnosed. It is estimated that 50% of diagnoses are incorrect and that, actually, your thickened, discoloured crumbly nail has come about due to trauma rather than a fungal infection.
This is definitely a fungal infection!
Do your big toes stick up as you walk? That thickened strip of white nail along the nail plate is much likely to be due to trauma rather than a fungal infection. HOWEVER, it is important to note that when the nail is traumatized, particularly if there is a split in it, this is a convenient portal of infection for fungi etc. Fungus, like bacteria and yeasts, are everywhere; just waiting to find a willing host – and so what may have originated as just a damaged nail can become a fungal nail very easily.
Fungal Infections - it's in the family. There is a strong genetic tendency towards fungal infections of the skin and nails.
So – do you have a fungal nail infection?
This is not a yes or no answer unfortunately – you should either consult a podiatrist who will be able to diagnose a fungal infection on clinical grounds or your GP who can arrange to send a sample for microscopy and culture BUT they must ensure they take a decent sample in order for the test to be worthwhile. Sample testing can also be arranged privately via your podiatrist.
RECOMMENDATIONS
The first line of defense is always a topical treatment, and you needn’t spend a fortune. Previously, my advice was to either use Clotrimazole 1% cream applied daily or tea tree oil* applied on alternate days HOWEVER I now advocate simple white vinegar as a first line treatment for early fungal nails. The vinegar changes the pH of the nail environment so that the fungus cannot thrive. You can add a couple of drops of lavender or tea tree oil to improve the aroma (otherwise you may end up smelling like a bag of chips!). Either apply the vinegar with some cotton wool after bathing and drying properly, or pop some in an atomiser and spritz onto your nail/s daily. Take a 'before' photo so that you can accurately judge any improvement. Do this for up to 12 weeks in order to assess new nail growth and determine whether the treatment is working. Please bear in mind toenails grow at a rate of 1mm per month, so it can take a long time to notice a difference!
You’ll also need to boil wash your socks (that's a minimum of 60 degrees, ideally 90 degrees) or pop them in the freezer for 24 hours (as temperatures below 7 degrees also kill fungal spores), and spritz your shoes with an antifungal spray (such as Daktarin or Scholl) as otherwise the spores will continue to reinfect your nails (and likely your skin also).
If your nail is particularly thick, it will need to be reduced before commencement of a topical agent. Additionally, it is helpful to manually remove (trim away) as much infected nail as possible. A podiatrist is the most qualified person to safely achieve this for you. Thicker, more chronically infected toenails may also benefit from a topical antifungal agent rather than white vinegar. Although, proceed with caution and do not use a topical antifungal indiscriminately - there is a growing body of evidence to indicate we are becoming resistant to common antifungal treatments.
Depending on your general health, your GP can prescribe an oral antifungal (Terbinafine or Itraconazole; a tablet taken by mouth). This is the only treatment with a decent amount of research behind it. However, I wouldn’t knock anecdotal evidence in podiatric practice – just because a treatment hasn’t got a large scale randomized controlled trial behind it doesn’t mean it’s a load of old tosh; there is a lot to be said for clinical experience.
WHAT ABOUT THESE FANCY HOT AND COLD LASERS?
Personally, I’m not sold on these at all. The evidence indicates that lasers are typically only effective when used alongside a topical antifungal agent. I certainly would not fork out for any expensive treatment without sending a sample of your nail for microscopy and culture as you could be completely wasting your time and money.
There is now a chairside budget-friendly test to check whether you have a dermatophyte (the usual suspect) infection of the nail. A sample of your nail is popped in a test tube with a chemical, shaken up and checked for dermatophytes using a reagent stick. The whole test is completed within a few minutes. Speak to your podiatrist if you are interested in arranging this simple test.
LIKE THIS BUT HUNGRY FOR MORE?
If you’d like more information or would like to book an appointment, please get in touch.
*If either of these products cause redness/swelling/discomfort etc please discontinue use.
For more helpful information on foot health, please see The Royal College of Podiatry's website.
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