An estimated 10 million Americans suffer from onychomycosis, or nail fungus infection. Affected fingernails or toenails are typically discolored a dirty yellow and appear thickened, distorted or crumbly. In time large amounts of debris may accumulate underneath the nail plate leading to onycholysis, or separation of the nail from the bed below.
Nail fungus infections can be caused by a variety of microscopic plant life. Dermatophytes, the same fungal organisms responsible for common superficial skin infections like “ringworm,” “athlete’s foot,” and “crotch rot,” are responsible for the majority of nail fungus infections. The remainder are caused by certain yeasts and molds. All three types of germs, however, share the ability to flourish in moist, warm and dark environments like the shoes.
Onychomycosis accounts for over 50 percent of all toenail problems in any age group. Individuals at higher risk for developing onychomycosis are those who work with their hands or are on their feet a lot, or those chronically exposed to moisture or perspiration, such as athletes, military people and blue-collar workers. The majority of sufferers are between the ages of 40 and 60.
Since onychomycosis in otherwise healthy individuals is not a life-threatening condition, it is unfortunately often trivialized by physicians as “only” a cosmetic problem. However, in a country where more than $5 billion dollars are spent annually on nail cosmetics, such an approach is clearly misguided. Up until relatively recently, therapy for nail fungus infections tended to be expensive, very long term, and often unrewarding, which may have accounted in part for physician lack of enthusiasm in dealing with the condition, and for the fact that a surprising only 10 percent of those with the infection sought treatment.
But recent studies indicate that onychomycosis may be a significant source of physical distress (eg. discomfort walking, loss of dexterity, inability to obtain comfortable footwear) and psychosocial compromise to those afflicted with it. Findings indicate that there is a decrease in self-esteem and an increase in feeings of depression, inadequacy, and social isolation. Moreover, concern over contagiousness to others and conversely fear by others of catching the disease serve only to heighten these feelings. What all this indicates is that physicians must give serious attention to treating onychomycosis and not merely dismiss it as a cosmetic nuisance.
In 1958, the first oral antifungal agent, griseofulvin (Grifulvin), had to be taken for a year or sometimes two or more, was effective in only at most a third of cases, and was plagued by high recurrence rates and many side effects. Almost a quarter-century later ketoconazole (Nizoral) appeared. It was more potent and tackled more kinds of fungi, but it, too, had to be taken for long periods of time and had high relapse rates. Even more importantly, it posed a significant potential risk for the development of chemical hepatitis, a serious liver problem.
Happily, the past few years has seen the introduction of three oral antifungal agents with greater efficacy, much shorter treatment times and better side effect profiles. All three agents are fairly easily absorbed from the gastrointestinal system and have a reservoir effect, meaning that they are stored in the nail plate and nail bed for many months until the nail grows out. Itraconazole (Sporonox) may be given on a once-daily basis for about six weeks for fingernail fungus and three months for toenail disease. More commonly, however, it is prescribed for what is known as “pulse dosing.” A typical pulse dosing schedule consists of taking two capsules twice daily for only one week per month for two months for fingernails and three or four months for toenails.
Although not yet approved for treating nail fungus, another agent, fluconazole (Diflucan), a chemical relative of itraconazole, has also been found effective when used on a one dose per week pulsing schedule for nine months.
Both itraconazole and fluconazole are fungistatic drugs, meaning that they work by arresting the growth and reproduction of the fungi, rather than outright killing them. And unfortunately, the particular chemistry of these two agents allows them to interact adversely with a wide variety of other common medications, a fact that can often makes their use a bit tricky particularly in older individuals who are on lots of different medications for various medical problems.
A third agent, terbinafine (Lamisil), is chemically unrelated to the latter two drugs and is a fungicidal drug, which means it kills the germs rather than simply interferes with their proliferation. The usual dosage is one pill daily for six weeks for fingernails and twelve weeks for toenails. The once-daily, vitamin pill-like routine has the advantage of being the least complicated of all the regimens and thus the easiest to comply with.
Ciclopirox 8 percent (Penlac), is the first topical therapy to be approved for nail fungus. While cure rates with this agent are nowhere near the 65 percent to 85percent cure rates reported for oral therapies, the approval of a topical agent is welcome, especially for those for whom oral therapy would not be advised. Doctors are able to prescribe compounded preparations, however, that have greater penetration into the thickened nails. Many physicians currently combine oral and topical therapies in hopes of increasing cure rates.
Of course, despite these newer therapies, an old standby, surgical removal of thick, infected nails (nail avulsion), remains a useful adjunctive measure for improving the chances for a cure. Alternatively, to avoid the resultant discomfort and disability associated with surgery, many physicians prefer to apply a chemical, applied under an occlusive dressing, to slowly dissolve the nail away. Prescription-strength urea 40 percent has been used successfully for years for this purpose, either as solo therapy for nail fungus or combined with oral therapy. In a nutshell: having nail fungus no longer means that you have to suffer in silence.
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