Onychomycosis – The fungal Toenail

The most commonly misdiagnosed condition we see by far are fungal nails. Thanks to aggressive marketing campaigns by pharmaceutical companies we have become hypersensitive to presence of and “harmful side effects” of fungal infections. In truth many of the diagnosed cases that get referred to us are not fungal in nature but due mechanical trauma. Of those that are fungal, the potential for systemic illness due to its presence are minimal. That said fungal infects of the nail are unsightly, do spread and can be the cause of discomfort when the nails become thickened.

Millions of Canadians are infected with dermatophytes, non-dermatophytes and candida species feeding on the nail keratin. These organisms propagate in a warm, dark and moist environment. There is no better place for nail fungus to reside and infect toes than in shoes. Infected nails have yellowing to brownish, or white spots on the nails. The large toenail is usually the first to be affected. As the infection develops, nails often become thicker, further discolour, fracture, and crumble. Progressive infection of other nails occurs often, secondary bacterial infections are not uncommon, and psychosocial issues.

As is seen with the common oral anti-fungals (Terbinafine, Itraconazole and Fluconazole) the re-occurrence rate can be extremely high. Topical anti-fungal liquids may help to alter this observation, most likely this is due to an underlying mechanical trauma damaging the nail and allowing subsequent injury and reinfection.

Do I need a podiatry visit?

Probably most people with fungal nail problems have tried topical and other home remedies at one time or another. Melaluca (tea tree oil) is a popular home remedy. It’s reported to work in a laboratory petri dish, but there is no evidence to substantiate its value. It’s does not seem to be of any value in the “real world”. It also stains the nail and surrounding skin. At this time there are only two Health Canada approved topical medications for onychomycosis. Penlac was the first topical approved, has very low efficacy. The newer topical medications are much more effective especially when combined with aggressive clinical reduction of the bulk of the infected nail. Overall efficacy is less than that of oral medications but without the associated systemic side effects.

Laser treatment for fungal nail infections is reportedly more effective than Penlac but less than Jublia. One must also be aware that there are many different types of lasers, each class developed and geared towards a specific application. For fungal nails a YAG laser at a wavelength of 1064 nm, seems to be ideal. The patient should ensure the equipment is Health Canada Approved for treatment of fungal nails.

More recent photo chemical treatments are now being offered but credible clinical trials have yet to be completed, we will await the results before further comment.