TOE FOES

Fungal toenail infections may be the last thing a nail tech wants to be faced with, but it’s important to be able to identify and understand them. Podiatrist Andy Blecher explains how

Fungal nail infections affect approximately 50% of the population, while fungal skin infections, otherwise known as tinea pedis (or more commonly, athlete’s foot), affect around 30%.

Tinea pedis and onychomycosis form a vicious cycle, where an infection on the nail constantly affects skin and viceversa. Being able to recognise the different kinds of tinea pedis is valuable because this is as contagious as fungal nail infections.

Spotting onychomycosis

Onychomycosis is a fungal infection of the nail plate and or matrix (nail root) by a fungal pathogen (i.e. dermatophyte, mould or yeast), which produces an enzyme that digests nail keratin. Anyone can contract this infection but there are factors that contribute to the likelihood:

• Wearing tight, closed shoes especially with no socks

• Walking barefoot in public areas, especially bathrooms and showers

• History of nail trauma

• Constantly wearing nail polish and using false nails

• Warm water foot soaks – this creates an environment for any fungal infection present, whether on the skin or the nails to spread more widely and easily

• Diabetes

• Neglect and ignorance

• Medical conditions, e.g. exposure to certain medications and immunocompromised conditions.

Signs of a fungal nail infection

• Subungual hyperkeratosis (debris under the nail)

• Nail plate thickening

• Brittleness

• Changes in the shape of the nail

• Crumbling of the nail

• Discolouration (yellow, white, black, green, purple, brown)

• Onycholysis (detachment of the nail plate)

In clinical practice, samples of the nail are often sent to the laboratory to identify the exact causative pathogen.

It’s important to note that there are many other nail conditions that can look like a fungal infection but are not. These include psoriasis, lichen planus, onychogryphosis and nail trauma.

Treating fungal infections

There are two main treatments for fungal nail infections: 1. Oral tablets, which can only be prescribed by a doctor. Treatment takes three to six months. Such tablets have side effects and these must be discussed in detail between the practitioner and the patient.

2. Laser treatment, which is an effective option and bypasses the systemic system, as treatment is directed to the site of infection. It has very limited side effects, if any at all.

The efficacy rate of both laser treatment and oral tablets is the same. However, remember that laser treatment has no side effects whereas oral tablets carry the risk of many side effects. Neither treatment can give the patient a guaranteed outcome. Many factors will determine this and should be discussed with the patient.

A prescribed topical treatment is mandatory. This is applied to all the nails, even those not infected from the time of diagnosis until at least two years after there are no signs of fungal infection at all. Fungal nail infections have a very high recurrence rate. When discussing treatment, we must discuss prevention from all possible sources of further contamination and spread of infection.

Diagnosis and referral

Nails and skin fall under the care of a dermatologist. However, specific to the feet they would fall under the care, diagnosis and treatment of a podiatrist.

Only once a diagnosis has been made can an appropriate course of treatment be determined. The choice of treatment depends on many factors. To mention a few: underlying medical conditions; medication the patient is on; history; how many nails are involved; and what percentage of nail plate is infected.

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Clients should be referred to a podiatrist as soon as the nail technician or therapist notices that the nail, or any part of the nail, does not look like a normal nail should.

This is to safeguard both therapist and client as the therapist is exposed to contracting the fungal infection themselves, especially if they are doing a pedicure without gloves. This would also apply to infected fingernails.

Equipment used by therapists (e.g., nail nippers, files, orange sticks etc.) will all be contaminated after being used on a client’s infected nails and skin. It is therefore vitally important that at this stage we talk about sterilisation and disinfection. These are both decontamination processes.

While disinfection is the process of eliminating or reducing harmful microorganisms from inanimate objects and surfaces, sterilisation is the process of killing all microorganisms. Fungal infections are very difficult infections to eliminate and can only be prevented from spreading with the use of registered sterilisation techniques.

Fungal infections are not to be ignored and can cause other complications. They are contagious, so the sooner the correct diagnosis is made and treatment started, the better the prognosis.

Andy Blecher is a member of PASA (Podiatry Association of South Africa) and has a special interest in the diabetic foot, paediatrics, the treatment of ingrowing toenails and verrucae, and specialised laser treatment for onychomycosis.