Posts Tagged ‘onychomycosis’
Proximal Subungual Onychomycosis (Nail Fungus)
Least common in people with healthy immune systems but found frequently in people who have compromised immune systems, proximal subungual onychomycosis stands out because the progression of the disease starts at the cuticle and grows out with the nail.
Proximal subungual onychomycosis usually causes the nail to become disfigured, as in other nail fungus infections, but as it starts at the cuticle and works its way up, it is more likely to infect the nail bed early on, causing the nail bed to develop bumps and irregularities. This then may cause the nail plate to become dislodged and fall off, exposing the nail bed to possible further infection.
Similar to distal subungual onychomycosis, the majority of cases of proximal subungual onychomycosis are caused by the same dermatophyte, Trichophyton ruburm. However this particular nail fungus infection can also be caused by a different dermatophyte, Trichophyton mentagrophytes. Proximal subungual onychomycosis can also be caused by molds. Another defined symptom of proximal subungual onychomycosis is the skin around the nail may become swollen, red and inflamed and may start to ooze pus. This is more commonly seen when the nail fungus infection is caused by molds than by dermatophytes.
Unfortunately, these distinguishing symptoms are what cause proximal subungual onychomycosis to be misdiagnosed as a bacterial infection instead of a fungal infection by some physicians. As antibiotics do not kill fungi, this course of treatment does nothing to stop the infection. An antifungal is required to eradicate molds, yeasts and dermatophytes.
Proximal subungual onychomycosis occurs more often in people who have depressed or deficient immune systems. It is rarely seen in people with good immunity. Immunodepression can be caused by procedures like chemotherapy or in people who are recovering from an autoimmune disease or an organ transplant and have had their immune system deliberately suppressed.
Proximal subungual onychomycosis occurs frequently in people with unhealthy immune systems and even more commonly in people with human immunodeficiency virus or HIV. This is such a common occurrence that if a patient contracts this form of nail fungus infection and no other cause can be found, the doctor will likely suggest an HIV test. Be prepared if you have a fungal nail infection and it is discovered to be proximal subungual onychomycosis, to have your doctor suggest an HIV test. This is a test that requires your consent to perform. And just because you may receive a diagnosis of proximal subungual onychomycosis doesn’t necessarily mean that you have contracted HIV.
The only way to cure proximal subungual onychomycosis is to take an oral antifungal medication. If the nail fungus is caused by dermatophytes Trichophyton rubrum or Trichophyton mentagrophytes then it is likely that your doctor will prescribe terbinafine, also known as Lamisil. The dose is usually one 250 mg pill once a day for six weeks for a fingernail infection and twelve weeks for a toenail infection. A nice thing about Lamisil is that it is usually less expensive than the other current generation antifungals.
Itroconazole, or Sporanox, is used for treatment when the cause of the proximal subungual onychomycosis is unknown because it is effective against both dermatophytes and Candida infections. This tends to be a more expensive treatment method than some of the others.
Fluconazole commercially known as Diflucan, is able to treat proximal subungual onychomycosis but is not used as often as the other available medications. This medication stops the fungal growth and therefore the spread of the disease but does not kill the fungus itself. The difference between these two processes is referred to as fungistatic (stopping growth) and fungicidal (killing growth).
This particular drug tends to slow down the growth so that the immune system can take care of it on its own. As many of the cases of proximal subungual onychomycosis happen in people with previously depressed immune systems, this is not necessarily the best drug choice. Fluconazole (Diflucan) is taken until the symptoms resolve and the infection is gone.
What are the symptoms of a Nail fungus and
how can I tell if I have a Nail Fungus Infection?
You’d think these would be fairly straightforward questions that ought to illicit simple answers. Unfortunately not only is this not true, but it is confusing enough that sometimes doctors misdiagnose nail fungus (or onychomycosis). Knowing the symptoms will assist you in helping your doctor to order the appropriate diagnostic tests so that you end up with the correct solution to your problem.
There are two basic causes of nail infections. Bacterial and fungal. Onychomiycosis, or fungal nail infection, is usually caused by a dermatophyte called Trichophyton rubrum. If not, it is caused by Candida albicans, a yeast growth (also a fungus). As nail infections differ in variety and in cause, the correct cure must be applied. A fungal infection should be treated with an anti-fungal whereas a bacterial infection should be treated with an antibiotic.
Onychomycosis affects the nail bed (skin underneath the nail) nail plate (the hard surface that we refer to as the nail) or the skin around the nail. About one third of skin infections and half of nail infections are caused by Onychomycosis. The visual signs are the abnormalities caused by the nail fungus. A white or yellowish crust appears on top of or embedded in the nail. This is the actual fungus growth. Sometimes it appears as streaks that follow the line of the nail against the infected digit (finger or toe) and sometimes it appears at the cuticle (soft area at the base of the nail). As the fungus spreads, it covers the entire surface of the nail, turning it to a milky white or yellow. Frequently it causes the nail to become ridged and deformed. This is a result of the dermaptophytes emitting destructive waste product as a result of consuming keratin. If the fungus gets underneath the nail plate, it can cause the nail bed to become irregular. This causes the nail plate to release from the bumpy nail bed and the nail becomes loose and can fall off.
If the nail fungus infection becomes severe, or if it contains Candida, the area around the nail can become swollen and sensitive to the touch. The skin may express (think ooze) pus and be very uncomfortable, even painful. These are common signs of infection. The pus is a result of white blood cells rushing to the area to fight off the infection. This is your body trying to do its job and tell you and your doctor that something is wrong.
It is most common for pus to be present in the case of bacterial infections. Thus your doctor should check for this before looking for fungal infections. To add to the confusion, there are diseases that mimic a nail fungus, including hallopeau acrodermatitis, lichen planus, nail bed psoriasis (which can occur in conjunction with fungal infection of the nail), nail bed melanoma, Reiter syndrome, yellow nail syndrome, onycholysis, and paronychia. Because of this factor, more than one test may be necessary to determine the correct course of treatment.
Different forms of onychomycosis will require different samples from the affected area. In some cases the nail can be sampled from the end or the top can be scraped for a sample, in others, the nail will need to be removed entirely. Whereas this can be a bit scary, it is also to your advantage as it then exposes the nail bed so that it can be treated.
The most typical tests performed on a nail culture to look for onychomycosis are a potassium hydroxide wash, which allows for the sample to be put under a microscope and searched for evidence of fungal growth, or a fungal culture, where the sample piece of nail is put in an environment (usually a petri dish) where it has the necessary components to thrive and create new growth, thus showing what kind of fungal infection it is. In the unlikely event that neither of these tests show positive for onychomycosis, the remaining nail sample can be pulverized and sent to a pathology lab for analysis or submitted for a bacterial culture if it is determined that the infection is bacterial instead of fungal.
Determining what kind of infection you have and what to do about it are very important when dealing with a nail infection of any kind. Having the infected area looked at by a physician, preferably a dermatologist, is the best way to deal with these diseases as they can help to rule out and diagnose serious problems as well as knowing what to do about the infection in the first place.
Removing All of or a Portion of Your Nail
to Treat Nail Fungus – Is it Effective?
No one really knows. Little to no research has been done on removing all or part of the nail to treat a nail fungus infection. That’s because it’s sort of a last resort treatment for dealing with onychomycosis. However if you are unable to take any of the oral medications suggested for treating onychomycosis and if none of the topical solutions are effective, or if you have tried treating your nail fungus in several ways and none of them have been effective, then surgery may be an option.
Another thing to consider is if you continue to experience recurring nail fungus infections, you might need to make some dietary changes and/or do a medical cleanse to get the possible sources of infection out of your system.
How does it work?
Your options for having your nail removed are as follows:
- Complete removal – known as avulsion
- Partial removal – known as debridement
There are also two options for having these procedures done:
- Surgery – Your doctor will numb the skin around and under your nail with a local anesthetic, either topical or a shot. Then a tool will be used to separate your nail from the surrounding skin and nail bed. (Your nail bed is the skin underneath your nail. This is most commonly where a nail fungus hides and breeds.) Once the nail has been removed your nail bed and surrounding skin should heal in 2-3 weeks.
- Ointment – Your doctor will cover the skin around your infected nail to protect it (similar to taping a window or door while painting.) Then an ointment will be put on the infected nail. The infected nail is covered with a plastic dressing, which will need to be kept dry. After a week to a week and a half, your nail should be soft enough to be removed by your doctor. The exposed nail bed and surrounding skin should heal in 2-3 weeks.
After you have undergone either of these procedures, your doctor will probably recommend taking an oral antifungal medication, or putting a topical ointment on the exposed nail bed to deliver the medicine directly to the affected area.
A fingernail, once the infected portion is removed should grow back healthy within about 6 months. A toenail may take up to 18 months to grow back.
If infection continues after this procedure, your doctor may recommend completely removing the nail again and putting a chemical on the cuticle (the soft layer of skin at the base of your nail) to prevent your nail from growing back.
Does it help?
Again, no one really knows as no one has put the time and research into the effects of removing part or all of the nail to cure onychomycosis.
So far, there is one reliable study that compared taking oral antifungal medication against other types of treatment, including removing part of the nail and putting a topical antifungal medication directly on the nail bed. The results were that people who chose the oral antifungal medication were happier with their treatment outcome than people who had part of their nail removed or who used any sort of topical remedy.
Possible Side Effects?
Once your nail has been removed from the nail bed, you will need to keep it clean and dry to prevent possible further infection of the area. Your doctor may also recommend using an antibiotic cream to ensure that everything heals well and stays healthy.
Another possible problem is that the side or corner of your nail could re-grow into the skin surrounding your toe. This is referred to as an ingrown toe nail. Mild symptoms of an ingrown toenail can be treated by soaking your foot in warm salt water and then propping the ingrown porting of your toenail to encourage it to grow above the skin. A more severe ingrown toenail will require you to return to your doctor for treatment.
Onychomycosis is a broad term for many different kinds of fungal infection. Our nails are necessary parts of our body and protect the sensitive tissue beneath them from harm. Onychomycosis makes our nails look bad and become brittle with development of the disease. Treatment can be long and difficult but ultimately effective.
- The nail begins to discolor, usually to opaque white or yellow
- This usually begins at the tip of the nail and works its way down
- The nail begins to thicken and become unattractive
- As the nail thickens, it can develop darker yellow and brown spots
- The nail becomes brittle and begins to crumble or flake off
- Ultimately the nail may pull away from the nail bed and partially or entirely fall off.
- These symptoms cause people embarrassment in public because of the appearance of their nails
- Their ability to walk or feel things may be hampered by pain or discomfort because of the disease
Causes and potential hazards
Onychomycosis is an infection that anyone and everyone can contract. It is seen most commonly as people age and it affects far more of the elderly population than the younger population, beginning around 40. Seeing it in kids is fairly rare, while people who are towards the end of life seem to suffer from it frequently. These people also tend to suffer from diseases that assist the fungus growth, like diabetes and poor circulation.
The easiest way to reduce the possibility of contracting a nail fungus infection is to take good care of your nails. The healthier they are, the easier it is for them to resist infection.
Treating and Healing From this Disease
The hardest part for most people about this disease is that it takes so long to cure it. Many people get frustrated and quit, determined to endure it, before they can eradicate the fungus causing the infection.
The best way to treat a nail fungus infection is to apply an antifungal to the infected areal. There are many available treatments, topical and oral, standard medicine and alternative medicine, to choose from. The sooner this infection is caught, the easier it is to cure as once the fungus has embedded itself underneath the nail it becomes much harder to get at.
If the infection has become severe, oral antifungal medication may become a necessity, or even surgical removal of the nail.
The best solution to the whole problem is to keep your nails clean and healthy to prevent infection and if you are already infected, work to cure the infection as well.
A Doctor’s Detailed Description of Onychomycosis
Onychomycosis is the medical term for a fungal infection of the fingernails or toenails. Onycho refers to the nail, mycosis refers to fungal infection. This condition represents about 33% of all fungal skin infections. Approximately half of all diagnosed diseases of the fingernails or toenails are onychomycosis.
Onychomycosis usually occurs in older people, most commonly 40 and above. The likelihood of the disease occurring in adults rather than children is about 30%. Onychomycosis is a regularly occurring disease and the chances of contracting it increase as people age. Approximately 20% of all people between the ages of 40 and 60 have onychomycosis. It is thought that upwards of 90% of elderly patients have it.
Onychomycosis occurs more regularly in men than in women, however women are more likely to contract a specific type of the fungus called Candida. The disease seems to have no preference in race. There has been an increase in the number of cases of onychomycosis in recent years. Doctors believe this has to do with people living longer, thus facing the greater probability of diseases that are common causes of onychomycosis. For instance, the level of diabetes has increased in the population as well. The same corollary can be drawn between the aging population and the number of people with diabetes. Interestingly enough, having diabetes makes it more likely that a patient will contract onychomycosis as diabetics have a harder time fighting off infection and healing from wounds. Poor circulation is another commonly related disease as people who suffer from this have a less healthy immune system.
The most common symptom and complaint of sufferers of onychomycosis is the disfiguration of the nail. One of the greatest difficulties in catching a fungal nail infection early on is that it doesn’t present serious symptoms, especially in the beginning, when it is easiest to cure.
The fact that onychomycosis disfigures the nail is not to be disregarded. It causes people to avoid certain social interactions because of the embarrassment they feel having a nail fungus will bring. They become concerned that a fungal infection is infectious or that they will be seen as “unclean” or “unhealthy”. It is of serious concern to doctors, the psychological and emotional effect that onychomycosis can have on people.
Although this disease starts as a series of cosmetic symptoms, if left unchecked it can develop into a far more serious set of problems. Pain in the affected finger or toe can occur. Because the nail thickens, it deadens the sensitivity in the affected digits. This can lead to loss of sensation and therefore ability in the hands and feet. Tasks like writing and other daily activities are affected by fingernail fungus, being able to sense the floor, causing difficulty with walking and even causing serious falls, are an advanced symptom of toenail fungus. For patients who are already affected by diseases that cause problems with the nerves in the legs, this can make things even worse.
There are four main types of onychomycosis:
- Distal subungual onychomycosis – This is the most common form of onychomycosis and is caused by a dermatophyte called Trichophyton rubrum. What happens is the dermatophyte penetrates the nail plate and buries itself in the nail bed. The term ‘subungual’ refers to underneath the nail. The infection manifests as a whitish-yellow growth under and on the nail towards the tip (the part you trim) This then works its way down toward the cuticule and underneath to the nail bed. The nail becomes thick, pitted, ridged and can start to crumble.
- Proximal subungual onychomycosis – starts at the cuticle end of the nail instead of at the tip. It then works its way up the nail and under the nail as the nail grows out. This form of nail fungus infection occurs more regularly in people who have issues with immune deficiency. Proximal subungual onychomycosis is caused by Trichophyton ruburm, just as distal subungual onychomycosis is, but it is also caused by other fungi and molds.
- White superficial onychomycosis – This is probably the least commonly occurring form of onychomycosis, happening in only 1 of 10 cases on average. This fungus develops on the top of the nail or in its topmost layers. As the name ‘white superficial’ would imply, this is a lesion that forms at the top of the nail and is white in color. Gradually, the fungus will take over the entire nail if left unchecked. Unlike most other forms of onychomycosis, white superficial onychomycosis is caused by Trichophyton mentagrophytes, a different dermatophyte.
- Candida onychomycosis – This final form of onychomycosis starts out its life as chronic mucocutaneous candidas, or reoccurring mucous level or low level yeast infection. This tends to affect the skin surrounding the nail, specifically in the proximal and lateral nail folds. Usually multiple nails are affected by Candida onychomycosis and the nails can be fully destroyed by this more serious form of fungal infection.
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