onychomycosis(nail fungus) is a fungal infection of the nail plate and its surrounding structures: nail folds, matrix (growing part of the nail) and nail bed. It manifests itself as deformation and thickening of the nails, a change in 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%, exceeding the known indicators of the previous decade. It occurs 1. 5 times more often in men, but they go to the doctor 2 times less than women. Older people get sick more often, and children - very rarely.
The main problem in the treatment of the disease is that patients go 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, fungal infection occurs within the family, as the source is not identified in time and proper preventive measures are not taken.
Causes of the disease:most often direct contact with the patient or with the objects he uses (shoes, clothing, bath mats, wipes, manicure accessories). Infections usually appear when visiting gyms, baths, saunas and swimming pools.
The development of the disease is facilitated by microdamage: cracks in the interdigital folds that arise 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 concomitant diseases of the endocrine system (diabetes mellitus, obesity, hypothyroidism), vascular diseases of the extremities (venous insufficiency, lymphostasis), immunological disorders, as well as with the use of antibiotics, corticosteroids and cytostatic drugs . As a result of the above 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 pathogen, the penetration of the fungal infection and the clinical picture are different, so therapeutic approaches also differ.
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 frequently caused by non-dermatophytic molds (Aspergillus, Scopulariopsis, Fusarium).
If you notice similar symptoms, see your doctor. Do not self-medicate, it is dangerous for your health!
In addition to 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. Changes in the skin of the feet are characterized by peeling, which is accompanied by itching. In case of serious injuries, against a background of reddened and swollen skin, deep erosions and 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 emergence of modern antifungal drugs has improved the epidemiological situation, but foot mycosis remains one of the most important problems in dermatovenerology. The use of some drugs is limited in older people and patients with chronic diseases.
Infection routes
The risk of becoming infected with fungus is especially 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, thus causing an infection;
- domestic way. In this case, infection occurs when using the patient's personal items: shoes, personal hygiene items, etc.
Risk factor's
The incidence of onychomycosis increases at age 60. At this time, the probability of developing such an infection is 60%, which is explained by a slowdown in metabolism, especially in the distal (remote) parts of the body, which are the fingers and toes.
Other risk factors for developing nail fungus include:
- diabetes;
- varicose veins;
- injuries to nails and adjacent tissues;
- HIV and other immunodeficiency conditions;
- prolonged use of antibiotics;
- weakened immune system;
- vascular and skin diseases, dermatitis, diaper rash;
- disturbances in blood supply 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 nail color 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: decrease in the thickness of the plaque and its softening;
- koilonychia: the nail appears concave, teaspoon-shaped;
- pachyonychia - thickening of the nail plate, nail hypertrophy;
- onychogryphosis - thickening, discoloration of the nail plate, curved in the form of a beak;
- change in the thickness of the nail bed (hyperkeratosis - thickening of the nail bed);
- changes in the surface of the nail plate: pits, grooves, ridges;
- changes in the nail folds and surrounding skin (paronychia - inflammation of the proximal nail fold).
It is important to note that none of the symptoms are pathognomonic, that is, exclusively suitable for a specific pathogen, so it is impossible to determine it from the symptoms; additional tests are needed.
Pathogenesis of onychomycosis (nail fungus)
The pathogenesis of the disease depends on how the fungus reached the skin and nails.
Distal subungual type:If the fungus has penetrated the skin in the area of the nail folds or in the distal area, then the infection spreads through the free edge of the nail into the bed and beyond the matrix. At first, the nail plate may not change, but then, due to hyperkeratosis, it gradually moves away from the nail bed and becomes yellowish. The nail plate may gradually thicken.
White surface type:If whitish lesions form on the nail plate, over time the fungus takes over the entire nail plate. The nail thickens, crumbles and acquires a grayish-brown tint. 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 beyond the matrix, reaching the distal parts of the nail plate. Spots appear on the nail in the area of the hole and nail bed, and detachment of the nail plate occurs. There is no significant inflammation of the nail bed or matrix.
Total dystrophic type:The entire nail is affected. The proximal portions of the nail fold disappear or thicken so that the nail plate can no longer form and grow.
existsBiophysical concept of the pathogenesis of onychomycosis., which states that during the disease there is a confrontation between two forces: the colony of fungi that grows towards the matrix, and the natural growth of the nail from the matrix to the distal edge. Therefore, the speed of nail growth is crucial during the course of onychomycosis: the faster the nail grows, the sooner healing will occur. Perhaps this is what explains the low prevalence of the disease in children, since their nails grow faster than those of 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 dystrophic.
According to Arievich's classification (1970):
- normotrophic: in the thickness of the nail there are yellowish and whitish stripes, but the shape of the nail plate does not change, there is no subungual hyperkeratosis;
- hypertrophic:the nail plate turns yellow, thickens due to subungual hyperkeratosis, becomes brittle and with jagged edges;
- dystrophic:Thinning and detachment of the nail plate from the nail bed occurs with the formation of gaps.
Complications of onychomycosis (nail fungus)
Long-term onychomycosis increases the risk of developingdiabetic foot(formation of trophic ulcers on the legs) andgangreneif 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 skin rashes and even the development of bronchial asthma.
In an uncomplicated course, the disease causes traditional fungal symptoms and only causes serious discomfort in a person. But without treatment, onychomycosis can cause complications. Most often they manifest themselves together with a bacterial infection.
Sometimes onychomycosis is very acute with the appearance of blisters, ulcerations and weeping areas on the skin next to the nail. In severe cases, the disease takes on a generalized form. This means that nail fungus spreads to internal organs and systems, and then the patient will require emergency hospitalization.
Diagnosis of onychomycosis (nail fungus)
Before examining the methods of diagnosing onychomycosis, it is necessary to explain how to correctly collect material for research (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 the material varies depending on the form of onychomycosis:
- surface shape- make a scraping of the nail plate;
- distal form- it is necessary to scrape the nail bed and a piece of the nail plate;
- proximal subungual form- the material is collected with a drill, a biopsy of the nail is performed or the nail bed is scraped.
The quickest method to determine pathological nail fungus ismicroscopy. Technique: the material under study is treated with an alkaline solution to dissolve the keratin. To make the mushroom threads better visible, ink is added to the alkali. The resulting preparation is then studied under a microscope.
This research method is the fastest and most objective. The sensitivity is up to 80%. The 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 to diagnose onychomycosis. The material is seeded in a special medium and the result is interpreted under a microscope after 2-3 weeks. This method allows you to determine the type of pathogen; This helps determine treatment tactics and select medications 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 nail and nail bed are cut. The material is immersed in a formaldehyde solution and sent for histological examination to the laboratory. The advantages of this method are that it is very sensitive and allows the presence of a pathological fungus in the material to be determined.
Disadvantages: it is impossible to identify the pathogen, as well as establish the viability of microorganisms, the method is expensive and labor-intensive.
Genetic diagnosis: molecular biology research method (PCR). This is one of the new and highly 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 diagnosis in those medical institutions that have PCR laboratories, but at the moment it is only planned to introduce testing systems to identify dermatophytes and molds in laboratories. The method allows you to determine the type of pathogen and its sensitivity ranges from 80 to 90%. Disadvantages: high cost, inaccessibility, lack of technological standards and complexity of implementation.
Increasingly, doctors are introducing into practicedermoscopy. With this method, changes in the color and structure of the nail, as well as the condition of the surrounding structures, can be assessed. Dermoscopic examination allows a more accurate assessment of the depth of damage to the nail plate and a more correct calculation of the onychomycosis severity index (KIOTOS).
First of all, the patient is sent for microscopy, which makes it possible to identify the presence of the pathogen. In the future, it is necessary to determine your type in order to select the correct treatment for toenail fungus. At JSC "Medicine" (clinic of Academician Roitberg) in the center of Moscow, the most modern and widespread methods of diagnosing onychomycosis are practiced:
- cultural examination of a biological sample of affected tissue. To do this, it is placed in an artificial nutrient medium, where the pathogen is cultured to determine its type;
- Polymerase chain reaction (PCR) method to detect pathogenic DNA in an 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 when the first signs of the disease appear. A dermatologist treats nail onychomycosis in our clinic in the center of Moscow. The specialist will provide you with competent assistance and guide you until your complete recovery.
Preparing to visit the doctor
Before visiting a dermatologist, it is important not to treat the affected areas of the nails with anything, that is, do not use medications, including iodine and brilliant green. It is also necessary to avoid the use of anti-fungal creams and ointments. At your appointment, you must complete all previously performed tests, including those for other diseases. Affected nails should not be cut for 3-4 days before the consultation.
Treatment of onychomycosis (nail fungus)
There are several types of treatment for onychomycosis:
- Local therapy.
- Systemic therapy.
- Combination therapy.
- Corrective therapy.
Local therapyIt involves the application of medications 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 to the prescription of systemic drugs: hypersensitivity, liver disease, kidney dysfunction, pregnancy, lactation.
The advantages of this therapy are that high concentrations of the therapeutic agent are formed on the nail plate, which does not penetrate into the bloodstream. There are no side effects from the use of antifungal medications: 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 fungi are located in the nail bed or matrix. This, in turn, can lead to treatment failure. This type of treatment requires a lot of labor, since before applying the medicine it is necessary to remove the affected part of the nail.
Methods to remove affected nails:
- Mechanical removal using files, pliers or drill.
- Use keratolytic patches. Before applying a keratolytic dressing, the skin around the nail is sealed with a dressing, a plaster mass (urea with salicylic acid) is applied on top and sealed with an adhesive dressing. The plaster mass is changed every 2-3 days. After each extraction, the affected part of the nail is removed mechanically.
- Surgical. This operation is very painful and traumatic, since when the nail plate is removed, the growth area can be damaged, causing new growth of deformed nails.
Local antifungal agents are used after removal of the affected nail plate.Antifungalsdistinguished by place of application:
- applied to the nail: varnishes;
- applied to rollers: creams, ointments, solutions.
The most studied drug for topical use is1% naphthyfine solution, which has an evidence base of treatment effectiveness based on a Cochrane meta-analysis. This product is water-based, which facilitates better penetration of the antifungal substance into the affected area. Varnishes, the active ingredients of which are Ciclopirox and Amorolfine, have a dehydrated base, which reduces the penetration of the drug into deep layers. For this reason, dermatologists consider the use of varnishes unsatisfactory and increasingly prefer water-based products.
To obtain results from local therapy, it is necessary to follow the treatment regimen, it is important that the patient is responsible, constant and patient. The duration of therapy can be up to 12 months.
Systemic therapyIt allows the antifungal drug to penetrate the bloodstream to the site of injury, even if the nail bed and matrix are affected. A high concentration of the medication remains in the affected area for a long time after stopping use. The disadvantages of this type of treatment are associated with the risk of side effects and toxicities.
Indications for systemic therapy:
- Common forms of damage to the nail plate
- Lack of effect of local therapy (i. e. , after six months of treatment for onychomycosis on the hands and 9 to 12 months of treatment for onychomycosis on the feet, healthy nails did not grow back).
To determine treatment tactics, KIOTOS (Clinical Index for Assessing the Severity of Sergeev's Onychomycosis) is used, proposed by A. Yu. Sergeev in 1999. It is used as a therapeutic standard in several countries around the world.
Medicinesfor the treatment of onychomycosis can be classified as follows:
- antifungals - have an antifungal effect;
- antiseptics: they have antifungal and antibacterial effects. They are rarely used, only if there are no other antifungal agents;
- multicomponent: in addition to the antifungal agent, they also contain other medications, such as anti-inflammatories.
Prescription regimens:
- standard - taking medications daily 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 ingredient:
- triazoles;
- allylamines;
- others (third generation drugs).
It is currently used for systemic therapy.only third generation drugs.
With combined therapyLocal and systemic treatment is carried out simultaneously. Combination therapy is used when it is necessary to increase the effectiveness of systemic therapy and reduce treatment time.
Corrective therapy(treatment of concomitant diseases) - to select a treatment regimen, it is necessary to evaluate the general somatic state of the body. Diseases such as circulatory disorders in the extremities can reduce the access of the antifungal agent to the lesion. Therefore, drugs that improve tissue trophism are prescribed.
Due to the toxic effect of systemic antifungal drugs, it is necessary to exclude liver disease and, if necessary, prescribe hepatoprotectors.
Home remedies
Before using home remedies, you should consult your doctor. With their permission, you can use the following recipes:
- iodine. Before use, the feet should be steamed, washed with laundry soap, and then the affected areas of the nail plates should be removed. Next, treat the nails and skin between the fingers with iodine, soak them in a bath with a soda solution for 20-30 minutes and dry well;
- vinegar. For 3 liters of water, take 1 tablespoon. apple cider vinegar and add a little potassium permanganate. Soak your feet in the bath for 20 to 30 minutes and then dry them well;
- hydrogen peroxide. After thoroughly steaming your feet, remove the affected areas of the nail plates. Place cotton pads soaked in hydrogen peroxide on them, wrap them with a bandage and leave them for half an hour.
Dangerous myths and 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 have serious consequences, such as deformation and complete rejection of the nails from the nail bed.
In addition, an infected person poses a daily danger to their loved ones, since being close to them they also run the risk of getting sick. 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 fungal nail infection, the faster the disease can be cured and the nail plate restored. In long-term processes that affect the entire nail, the treatment of onychomycosis can be prolonged, but if all recommendations are followed, recovery often occurs. If there are contraindications to systemic therapy, long-term maintenance treatment with local medications is necessary.
For preventionIt is necessary to observe the rules of personal hygiene and reduce the possibility of reinfection:
- try to wear high-quality, comfortable shoes (to avoid excessive sweating of your feet);
- It is recommended to change socks and stockings daily;
- Use only single shoes. For those undergoing treatment for onychomycosis, shoes should be treated at the beginning of treatment, at least once a month throughout the treatment period and after its completion;
- if necessary, use foot antiperspirants;
- use an individual nail care kit (scissors, files);
- before and after visiting public places (swimming pool, bathhouse, gym), use external antifungal agents (sprays, creams and pencils);
- identify the source of fungal infection in the family and receive treatment at the same time.
It is recommended to periodically carry out an antifungal treatment of personal items, shoes, bathtubs, floors and carpets. For these purposes, you can use a 40% acetic acid solution, a 1% alcoholic solution of chlorhexidine (prescribed by a doctor) and disinfectant solutions. Bed linen can be boiled in a 1-2% soap and soda solution for 20-30 minutes and ironed at maximum temperature.