Fungal Nail Infection

Written By Ellie Woodcock, Verified By Magdalena Czerwiec-Pichlinska

Fungal nail infection (onychomycosis) occurs in, or on the toenails and fingernails. Different types of fungus or yeast can cause this infection, and it usually develops over time or as a result of contamination. This means that anyone can develop a fungal nail infection, however the populations most at risk are elderly or mature adults, immunosuppressed people (i.e. diagnosed with conditions such as diabetes or HIV), or anyone who has been exposed to fungal infections such as athlete’s foot or ringworm. Although this infection is not serious in its early stages, patients may experience pain and discomfort.

Fungal nail infections are commonly characterised by thickening of the nail, a change in the nail’s colour, and eventually cracks, or partial breakages in the nail. Initially, it may only affect part of the nail, however over time the whole nail can eventually change colour. If a nail changes colour due to a fungal infection, the discoloration tends to first appear as a creamy white colour, before progressing to a yellow-brown discoloration. Fungus is a living organism and can output gases during its reproductive growth cycles These gases cause fungal infections to produce an unpleasant odour as the fungus progresses over the whole nail. Other symptoms, if the nail is left untreated, include the nail lifting off from the nail bed and fungus spreading over the other nails, or nail inflammation (paronychia).This is when the nail becomes brittle and the shape begins to become distorted.

Whilst the symptoms above are the most common, fungal nail infections can present in a variety of ways. There are 4 other common types of nail fungus:

• Distal or lateral subungual onychomycosis: (most common) Fungus Dermatophyte (which feeds on Keratin) affecting the nail bed underneath the fingers and toes . Yellow in colour and usually appears from the edges of the nail. After some time, fungus spreads to the centre of the nail where it eventually becomes loose from the nail bed.
• White superficial onychomycosis: (less common) Affects mainly toe nails. Initially presents with white spots, which eventually cause the nail to deteriorate.
• Proximal subungual onychomycosis: (rare) Usually affects people with immunosuppression problems. First appears as a white spot in the centre of the nail bed. The fungus then spreads outwards as the nail grows.
• Candidal onychomycosis: (yeast caused infection) Usually happens after injury or infection. Nail appears to be more swollen and inflamed, and in time may entirely detach from the nail bed.

Fungi lives and grows in dark, damp and warm places, spreading through contact with individuals, or contaminated surfaces. It thrives in areas such as public showers, swimming pools, saunas and, if the tools used are not properly sanitised, nail salons.It is important to be mindful of sharing towels or old closed-toe shoes, as these can retain fungal bacteria that will spread predominantly across the feet.
Extra care should be taken, particularly after any injuries to a nail. If the nail is not protected, it could lead to a development of infection; individuals who suffer from a weakened immune system or poor blood circulation have a higher risk of infection.
It should also be noted that many causes of fungal nail infection often align with the causes of Athlete’s foot. This means that one ailment can cause the other and an individual can suffer from both simultaneously.

A diagnosis is made by having a thorough consultation with the patient, understanding the symptoms, any risk factors and possible sites of infection. A practitioner will discuss any pain or discomfort being experienced, especially when wearing footwear, and if there are potentially any close contacts with fungal nail infection.

Following this, there will be an examination of the area to assess the skin surrounding the infection and any other possible sites; if feasible the type of onychomycosis will be classified. For the clearest results, arrange with a medical professional for samples (clippings/ scraping) of your nails or skin to be taken for a fungal microscopic and culture evaluation.

Once signs of fungal infection begin to present, maintaining clean and short nails are vital to prevent the case from worsening. Over the counter topical antifungal treatments, such as amorolfine nail lacquer, work well in conjunction with nail cutting when the initial signs and symptoms of fungal nail infection appear.
If the nail becomes discoloured, thickens, has a distinct smell, or there is a noticeable increase in pain and discomfort, it is recommended to speak to your doctor.
As with many infections, the most effective treatment options are derived from a clear diagnosis. Therefore, based on clinical findings, your doctor will prescribe an antifungal medication such as :

• Terbinafine
• Itraconazole
• Fluconazole
• Griseofulvin

The nail should be assessed 3-6 months after the start of the antifungal medication treatment.

The duration of the infection varies for each individual and is very much dependent on the initial treatment management and its effectiveness. With the use of antifungal medications symptoms can begin to lessen after 2 months. Other factors determining the length of infection may be dependent on the accuracy of the initial diagnosis and medication prescription.

Complications may arise in circumstances such as for those who are immunosuppressed and if medication or preventative measures are not being adhered to. It is strongly advised to have the fungal infection professionally assessed 3-6 months after the beginning of treatment.

There are a number of day-to-day practices that can be adopted to help prevent the risk of developing a fungal nail infection:

• Maintaining a high standard of hygiene by: washing hands regularly; drying your feet thoroughly after shower; keeping your floors clean, etc.
• Avoiding being barefoot in public showers, swimming pools.
• Taking care of any injuries, such as cuts and bruises around the toenail, by using disinfectants and clean bandages.
• Reducing any regular use of artificial nails.
• Being mindful of immune deficiencies.

You should see the GP if the symptoms are not improving after the first steps of treatment, or if:

• Initial home remedies are not helpful in preventing the fungus spreading on the nail,or to the surrounding nails.
• You notice further discoloration on your nails.
• The nails continue to become thicker or more brittle.