Should Old Nail Be Removed During Nail Fungus Treatment
Fungal boom infection (onychomycosis [OM]) is a mycotic infection caused by fungal invasion of the nail structure[1]
and is one of the most common smash disorders, representing one-half of smash abnormalities in adults[ii]
. Its prevalence in Europe is around iv.three% over all age groups[3]
and fifteen.5% of all boom dystrophies in children[four]
. OM is more commonly diagnosed in men and older people, affecting 20–50% of people anile over 60 years[5]
. An increased incidence among older people may be attributed to multiple factors, including reduced peripheral circulation, diabetes, inactivity, relative immunosuppression, and reduced smash growth and quality[half-dozen]
. Toenails are affected more normally than fingernails.
This article will cover the causes, types and treatment of OM, practical information to help guide patient consultations and when to refer to podiatry.
Nail anatomy and onychomycosis infection
Effigy 1 shows the limerick of the smash, including the boom plate (the visible part of the smash), blast bed (the skin under the nail) and nail matrix.
Figure ane: Nail anatomy and physiology
The boom plate and boom bed are joined by layers of hard, translucent, keratinised cells. The nail bed and nail matrix are vascular components of the nail, with nail cells located inside the smash matrix where the boom plate is formed. The thickness of the boom plate determines the length of the matrix
[7], [8]
.
Damage to the nail structure can touch on nail growth, shape, size and, consequently, predispose the nail to infection. OM can invade any office of the nail but typically enters the nail's free edge, sulci or damaged cuticles (come across Figure 2).
Figure 2: Anatomy of a healthy toenail
Source: LeBlond RF, Brown DD, Suneja G & Szot JF. DeGowin'south Diagnostic Exam, 10th ed. McGraw-Hill
Onychomycosis can invade any part of the nail but typically enters the nail'southward complimentary edge, sulci or damaged cuticles.
Where OM infects the area underneath the nail plate, the infection produces a thick hyperkeratotic nodule that contains clusters of branching filaments (hyphae) called dermatophytoma (see Photoguide: A)[9]
. Consequently, the blast becomes severely deformed and can cause blast lifting, brittleness and discoloration, which may issue in acute pain[x]
. The abnormal thickness of the nail may atomic number 82 to soft tissue breakdown and/or infection resulting in inflamed subcutaneous tissue (cellulitis), ulceration in the blast bed (subungual ulceration) and/or bone infection (osteomyelitis)[10]
.
Causes
Dermatophytes
Effectually 85–90% of OM cases are caused by dermatophytes (fungal organisms that require keratin for growth), such every bit Trichophyton rubrum and Trichophyton
mentagrophtyes
[five], [11]
. Dermatophytes are highly resistant and can survive for long periods of fourth dimension, especially in moist and dark environments[12], [13]
, which may explicate why toenails are more susceptible to OM than fingernails.
Non-dermatophyte moulds
Effectually 2–5% of cases of OM are acquired by non-dermatophyte moulds, such asScopulariopsis,Scytalidium,Aspergillus,Fusarium andAcremonium species that typically impact toenails. Fingernails are rarely afflicted[5], [xi]
.
Yeasts
Candida spp. is responsible for five–10% of OM infections, affecting fingernails more oft than toenails[xiv]
.
Photoguide: Types of onychomycosis
Source: Shutterstock.com / Courtesy of Marion Yau
Types of onychomycosis
Distal lateral subungual onychomycosis
The nearly common blazon of OM is distal lateral subungual onychomycosis (DLSO) (see Photoguide: B). Information technology is characterised by build-up of soft yellowish keratin between the smash plate and nail bed (subungual hyperkeratosis), disengagement of the blast from the blast bed (onychosis) and skin infection around the smash (paronychia). DLSO spreads proximally to the blast matrix[15]
.
White superficial onychomycosis
Cases of white superficial onychomycosis (meet Photoguide: C) are characterised by distinct white 'islands' on the nail surface, which gradually spread to the entire blast, causing it to go soft and crumbly[xv]
.
Endonyx onychomycosis
White milky patches without subungual hyperkeratosis (build of keratin underneath the boom) indicate endonyx onychomycosis (EO) (see Photoguide: D). Pitting is involved with splitting of the nails. EO usually affects fingernails[15]
.
Proximal subungual onychomycosis
Affecting fingernails and toenails, proximal subungual onychomycosis (PSO) (meet Photoguide: E) is oftentimes institute in, simply not unique to, patients with HIV. The fungal infection begins at the cuticle and the boom fold earlier penetrating the nail plate. PSO is characterised past white discoloration that usually includes paronychia with some discharge[15]
.
Full dystrophic onychomycosis
The most advanced type of OM is full dystrophic onychomycosis (see Photoguide: F), which invades the nail plate, smash bed and nail matrix causing astringent nail dystrophy. There can be chronic swelling at the distal phalanx with the affected nail appearing thickened, yellow-dark-brown in colour and severely deformed[15]
.
Diagnosis
Despite OM having singled-out clinical features, around half of nail dystrophy cases are caused past fungal infection and, therefore, clinical examination alone is rarely sufficient to diagnose OM[1]
.
Characteristics are shared with other nail diseases, such equally psoriasis, lichen planus or bacterial infections (see Table i). In addition to examining the nail(due south) afflicted, pharmacists should ask the patient the post-obit questions to assist institute a diagnosis[16]
:
- How long have you had this condition?
- Practice you take whatsoever skin disorders such as psoriasis, lichen planus, athlete's pes?
- Have yous had the smash tested for fungus or any nail diseases?
- Accept you suffered any trauma?
- Practise you take any family history of fungal smash infection?
- What is your occupation? (Jobs that involve the private coming into contact with water may increment risk of OM)
- Practice your nails/toenails injure?
- Does the consequence affect daily activities such every bit walking or continuing?
Ideally, OM should be confirmed by directly microscopy and cultures to eliminate non-infective differential diagnosis, to identify mixed infections and to detect resistant OM[v], [17]
. Around 30% of culture examinations are reported as false negative[18]
and where OM is strongly suspected in the presence of a negative culture, the test should be repeated.
The British Association of Dermatologists (BAD) supports laboratory investigation prior to commencing oral treatment, which is in support of guidance from Public Health England (PHE)[5],[sixteen]
. Nonetheless, this guidance suggests that oral treatment can be offered despite negative findings if in that location is a strong clinical suspicion[five],[ten],[15]
. Guidance for use of topical medications for DLSO is less clear and although investigations would present skilful exercise, these treatments take minimal associated risks compared with oral treatment. Even so, incomplete sample collection could take a major impact on faux negatives. Time constraints and continuity in working patterns should exist considered as culture and microscopy results may take two–6 weeks to come back.
| Clinical indicators | Description |
|---|---|
| Punctate leukonychia | White spots on the nails; leukonychia is total whitening of the smash plate |
| Trauma or injury | Very similar appearance of onychomycosis, causing the smash to lift from the nail bed (onycholysis), thicken (onychauxis) or develop white marker |
| Psoriasis | Pitting of the nails; yellow-red boom discolouration under the nail plate that resembles a drop of claret or oil |
| Lichen planus | Ridged nails, melanonychia, thinning of the nail plate and boom dystrophy |
| Xanthous nail syndrome | Loss of cuticle, yellowish-greenish discolouration of the nails with thickening and curvature |
| Anaemia | Abnormal shape of the fingernail (koilonychia) with thinning, raised ridges and an inward bend |
| Chronic eczema | Pitting of the nail with ridging, adjacent skin involvement with vesicles, scaling and erythema |
| Chronic renal failure | Proximal blast bed whiteness and distal nail bed red/pink/brownish discolouration (called half and one-half nails); absent-minded lunula and tiny blood clots under the blast (splinter haemorrhages) |
| Source: Neale's Disorders of the Foot[nineteen] , Onychomycosis (Tinea unguium, Blast fungal infection)[xx] | |
On exam, pharmacists should consider the post-obit factors and patient groups and it may be necessary to refer the patient to a podiatrist or their GP:
- The infection affects more two nails or more than half of the nail;
- In that location is nail dystrophy or destruction;
- The blast condition appears to exist other than DSLO (differential diagnosis by pharmacists is essential to ensure the patient received the right treatment — if there is whatever doubt of the diagnosis, the patient should be referred to a podiatrist or their GP);
- Patients with weather condition that predispose them to fungal infections (due east.g. immunosuppression, diabetes, peripheral circulatory disorders);
- Pregnant or breastfeeding women;
- Patients aged under xviii years;
- If there is no improvement subsequently three months of handling.
Treatment
The management of OM depends on the type, extent and severity of nail involvement, symptoms and pre-existing conditions. The aim of treatment is to eradicate the pathogen, restore the nail and prevent re-infection. OM is challenging to treat and affected nails may never return to normal equally the infection may take caused permanent damage.
As OM has a loftier relapse rate of 40–70%[v]
, advice on preventative and appropriate self-care strategies to avert re-infection should be offered to patients.
Topical treatments
The meaty and difficult nature of the blast beefcake means topical drug penetration can be poor, with the concentration reducing by 1,000 times from the outer to inner areas[5]
.
The BAD advises the use of monotherapy topical antifungal agents to be restricted to:
- Superficial white onychomycosis (except for transverse or striate infections);
- Early on DLSO (except where longitudinal streaks exist) without lunula involvement and where less than 80% of the boom plate is affected;
- When systemic antifungals are contraindicated.
Amorolfine
The only topical nail lacquer bachelor in the UK for over-the-counter (OTC) buy is amorolfine. It is licensed for mild (not more two nails affected) DLSO and patients aged 18 years or over. Amorolfine is a broad-spectrum synthetic fungicidal with high action against dermatophytes, as well every bit other fungi, yeasts and moulds. It is bachelor every bit a 5% lacquer that should be applied once or twice per calendar week[sixteen], [21]
. PHE recommend a treatment elapsing of six months for fingernails and 12 months for toenails, and so adherence is essential[16]
.
Earlier application, patients should be advised to file down the affected boom surfaces using a single-use boom file, clean the nail surface with the supplied swab and dry the nail surface[xvi]
. Patients should be reminded that this procedure should exist repeated for sequential treatments; a step that is commonly missed out. Sterile cotton buds should be used to apply the lacquer to avoid contamination.
Amorolfine maintains clinical efficacy in the smash for xiv days after treatment; however, twice-weekly application results in better outcomes compared with once-weekly application (71% versus 76% mycological cure)[22], [23]
. Compliance is essential; pharmacists should encourage patients to continue the handling, given the prolonged treatment duration of 6–12 months. Side effects are rare and express to smash disorders (e.g. discolouration, and cleaved and brittle nails), which may be related to OM itself.
Tioconazole
The BAD recommends tioconazole, a prescription-merely medicine (POM), for superficial and distal OM[v]
. Tioconazole is an imidazole derivative with a broad spectrum of action against dermatophyte and yeast-similar fungal species. It is available as a 283mg/mL medicated blast lacquer and is practical to afflicted nails twice a 24-hour interval. Treatment duration ranges from vi–12 months depending on the pathogen, the severity and the location of the infection. Mutual side effects include mild and transient local irritation that usually presents during the get-go week of handling[24]
.
Systemic therapy
For adults with confirmed OM, systemic therapy is advised when self-care strategies with or without topical therapy are unsuccessful or inappropriate. A contempo Cochrane systematic review of oral antifungal treatments for toenail OM in more 10,000 patients institute loftier-quality testify indicating that terbinafine and azoles were effective treatments for mycological and clinical cure compared with placebo[eleven]
.
Terbinafine and itraconazole are considered the mainstay of oral therapy for OM, although terbinafine is generally preferred over itraconazole owing to better cure rates compared with azole in toenail OM[11],[sixteen]
. Other systemic therapies are available (see Table 2).
| Handling | Contraindication and cautions | Dosing | Monitoring | Common adverse reactions |
|---|---|---|---|---|
| Terbinafine (first or second line) | Adventure of developing lupus erythematosus-like effect; worsens symptoms of psoriasis | 250mg/mean solar day for vi weeks (fingernails) or three–12 months (toenails) | Liver part: 4–6 weeks | Intestinal discomfort, anorexia, arthralgia, diarrhoea, dyspepsia, headache, myalgia, nausea, rash, urticaria[25] |
| Itraconazole (beginning or 2d line) | Run a risk of centre failure; avoid giving to patients with ventricular dysfunction or center failure | 200mg once daily for iii months, so 200mg twice daily for 7 days, repeated at 21 days. Fingers require two courses, toes require three courses and persistent infections crave an additional form of treatment | Liver office: 4–6 weeks | Abdominal hurting, diarrhoea, dyspnoea, headache, hepatitis, hypokalaemia, nausea, rash, gustatory modality disturbances, vomiting[26], [27] |
| Fluconazole (3rd line) | Currently non licensed for use in onychomycosis | Fingernails: 150–450mg once per week for 3 months; toenails: 150–450mg once per calendar week for half-dozen months | — | Abdominal discomfort, diarrhoea, flatulence, headache, nausea, rash[28] |
| Griseofulvin (fourth line) | — | Fingernails: 500–1,000mg daily for vi-nine months; toenails: 500–1,000mg daily for 12–18 months | — | Intestinal pain, agitation, defoliation, depression, diarrhoea, dizziness, dyspepsia, fatigue, glossitis, hepatotoxicity, impaired hearing, kidney failure, leucopenia, menstrual disturbances, nausea, peripheral neuropathy, photosensitivity, rash, sleep disturbances, systemic lupus erythematosus, gustation disturbances, vomiting[29] |
| Ameen Chiliad, Lear JT, Madan Fiveet al. British Association of Dermatologists' guidelines for the direction of onychomycosis 2014.Br J Dermatol 2014;171(five):937–958[5] | ||||
Combination therapy
Topical and systematic combination therapy may provide synergistic antimicrobial activity. The BAD recommends this for patients who have responded poorly to topical treatment solitary[5]
. Amorolfine 5% blast lacquer with systemic antifungals has been supported by a meta-assay and systematic review to provide a college percentage of total OM clearance compared with monotherapy of systemic terbinafine, without an increase in adverse effects[30]
.
Photodynamic therapy
Photodynamic therapy combines light irradiation and a photosensitising drug to cause destruction of selected cells. Laser therapies, such as neodymiumyttrium-aluminum-garnet and low-level laser, are aimed to selectively inhibit fungal growth[31]
. These alternative therapies may be appropriate because they are selective to local infection and avoid systemic side effects; however, robust data are scarce[v]
and they are not offered on the NHS.
Lifestyle communication
According to the National Institute for Health and Care Excellence (Overnice), patients require advice effectually foot intendance in order to avert and minimise exposure to situations that predispose individuals to OM (e.yard. prolonged exposure to damp conditions, occlusive footwear, prevention of damaged nails and to ensure meticulous hygiene of the affected human foot)[14]
.
Treatment must include a combination of proper hygiene and foot care as the adventure of reinfection is high. Self-intendance to forbid infection should be stringently practiced until the mucus is eradicated, which may take up to xviii months[14]
.
Pharmacists should advise patients on smash care, washing and drying feet daily, using the right footwear and encouraging the use of antifungal powder to assistance go along shoes pathogen free. Run across Box for important self-care letters.
Box: Lifestyle communication for human foot care and hygiene
Do:
- Maintain good foot hygiene by washing anxiety daily, drying properly (especially in between the toes);
- Minimise exposure to environments that aggregate onychomycosis (e.g. warm, damp conditions);
- Wearable well-fitted shoes that are not-occlusive to prevent trauma and limit perspiration;
- Supersede all old shoes and old socks to foreclose re-infection[32]
; - Habiliment breathable or antimicrobial socks (eastward.grand. cotton, bamboo or sliver fibre);
- Treat all family members to prevent cross infection;
- Avoid nail trauma.
Practice not:
- Use cosmetic smash varnishes or bogus nails;
- Share nail clippers with others;
- Walk without footwear in public areas (due east.g. gym, hotel rooms, saunas);
- Cut nails as well short.
When to refer to podiatry
Earlier initiating topical or oral therapy, patients should ideally be referred to a podiatrist for nail trimming and debridement. This assists with removing as much mucus as possible and improves topical drug penetration. Debridement lone cannot exist recommended for the handling of OM; patients using a combination of debridement and topical nail lacquer accept shown a significant improvement in mycological cure compared with debridement only[23]
. Patients with nail trauma attributable to footwear, dystrophic toenails affecting other toes or who depict discomfort when walking owing to thickened toenails should too be referred.
When there is handling failure with topical, oral and combination therapies, a podiatrist may exist able to behave out a chemical or surgical nail avulsion (total nail removal or fractional avulsion).
If in that location is incertitude over the original diagnosis, or where no comeback has been seen with treatment, pharmacists should refer patients to a podiatrist or their GP.
Supported past RB
RB provided fiscal support in the production of this content.
The authors were paid by The Pharmaceutical Journal to write this article and full editorial control was maintained by the journal at all times.
References
[1] Elewski BE. Onychomycosis: pathogenesis, diagnosis, and management. Clin Microbiol Rev 1998;11(3):415–429. PMID: PMC88888
[2] Gupta AK, Versteeg SG & Shear NH. Onychomycosis in the 21st century: an update on diagnosis, epidemiology, and treatment. J Cutan Med Surg 2017;21(half-dozen):525–539. doi: 10.1177/1203475417716362
[three] Sigurgeirsson B & Baran R. The prevalence of onychomycosis in the global population: a literature study. J Eur Acad Dermatol Venereol 2014;28(11):1480–1491. doi: 10.1111/jdv.12323
[4] Eichenfield LF & Friedlander SF. Pediatric onychomycosis: the emerging role of topical therapy. J Drugs Dermatol 2017;16(two):105–109. PMID: 28300851
[five] Ameen Chiliad, Lear JT, Madan 5 et al. British Clan of Dermatologists' guidelines for the direction of onychomycosis 2014. Br J Dermatol 2014;171(v):937–958. doi: 10.1111/bjd.13358
[6] Frowen P, O'Donnell M & Burrow JG. In: Lorimer D (ed). Podiatric direction of the elderly. Neale's Disorders of the Human foot. 8th ed. Churchill Livingstone; 2010.
[7] Ross MH & Pawlina West. Histology: A text and atlas. fourth edition. Lippincott Williams & Wilkins; 2006. p447.
[eight] Haneke E. Anatomy of the nail unit and the smash biopsy. Semin Cutan Med Surg 2015;34(2):95–100. doi: x.12788/j.sder.2015.0143
[9] Campos Southward & Lencastre A. Dermatoscopic correlates of nail apparatus disease. In: Imaging in dermatology. Elsevier. 2016;43–58.
[ten] Rubin AI, Jellinek NJ, Daniel RC, Scher RK (eds). Scher and Daniel'southward nails: Diagnosis, surgery, therapy. 4th ed. Springer; 2018.
[eleven] Kreijkamp-Kaspers S, Hawke Grand, Guo L et al. Oral antifungal medication for toenail onychomycosis. Cochrane Database Syst Rev 2017;(7):CD010031. doi: 10.1002/14651858.CD010031.pub2
[12] Abd Elmegeed ASM, Ouf SA, Moussa TAA & Eltahlawi SMR. Dermatophytes and other associated fungi in patients attending to some hospitals in Egypt. Braz J Microbiol 2015;46(iii):799–805. doi: 10.1590/S1517-838246320140615
[13] White TC, Findley K, Dawson TL Jr et al. Fungi on the skin: dermatophytes and Malassezia. Cold Spring Harb Perspect Med 2014;four(viii): a019802. doi: x.1101/cshperspect.a019802
[fourteen] National Found for Wellness and Care Excellence. Fungal nail infection; 2014. Available at: https://cks.nice.org.united kingdom of great britain and northern ireland/fungal-boom-infection#!diagnosissub:1 (accessed November 2018).
[15] Singal A & Khanna D. Onychomycosis: Diagnosis and management. Indian J Dermatol Venereol Leprol 2013;77(half-dozen):659–672. doi: 10.4103/0378-6323.86475
[16] Public Health England. Fungal skin and smash infections: Diagnosis and laboratory investigation. Public Health England: Protecting and improving the nation's health 2017. Available at: https://avails.publishing.service.gov.great britain/government/uploads/system/uploads/attachment_data/file/619770/Fungal_skin_and_nail_infections_guidance.pdf (accessed November 2018)
[17] Fletcher CL, Hay RJ & Smeeton NC. Onychomycosis: the development of a clinical diagnostic assist for toenail affliction. Office I. Establishing discriminating historical and clinical features. Br J Dermatol 2004;150(4):701–705. doi: 10.1111/j.0007-0963.2004.05871.ten
[eighteen] Eisman Due south & Sinclair R. Clinical Review. Fungal nail infection: diagnosis and management. BMJ 2014;(348):g1800. doi: x.1136/bmj.g1800
[19] Frowen P, O'Donnell M & Burrow JG. In: Lorimer D (ed). The skin and nails in podiatry. Neale's Disorders of the Foot. 8th ed. Churchill Livingstone; 2010.
[20] Lipner, SR, Scher, RK & Ashourian, North. Onychomycosis (Tinea unguium, Nail fungal infection); 2017. Bachelor at: https://www.dermatologyadvisor.com/dermatology/onychomycosis-tinea-unguium-smash-fungal-infection/commodity/691367/ (accessed November 2018)
[21] Electronic Medicines Compendium: Aspire Pharma Ltd. Amorolfine 5% w/five Medicated Nail Lacquer; 2018. Bachelor at: https://www.medicines.org.britain/emc/product/7414/smpc (accessed November 2018)
[22] Reinel D. Topical treatment of onychomycosis with amorolfine 5% nail lacquer: comparative efficacy and tolerability of in one case and twice weekly utilize. Dermatology 1992;184(one):21–24. doi: 10.1159/000247612
[23] Malay DS, Yi S, Borowsky P et al. Efficacy of debridement alone versus debridement combined with topical antifungal blast lacquer for the treatment of pedal onychomycosis: a randomized, controlled trial. J Foot Ankle Surg 2009;48(3):294–308. doi: ten.1053/j.jfas.2008.12.012
[24] Electronic Medicines Compendium: Creo Pharma Limited. Tioconazole 283 mg/ml medicated nail laquer; 2017. Available at: https://www.medicines.org.uk/emc/product/8643/smpc (accessed November 2018)
[25] British National Formulary. Terbinafine; 2018. Available at: https://www.medicinescomplete.com/#/content/bnf/_203423860 (accessed November 2018)
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[27] British National Formulary. Itraconazole; 2018. https://world wide web.medicinescomplete.com/#/content/bnf/_398441057 (accessed November 2018)
[28] British National Formulary. Fluconazole; 2018. https://www.medicinescomplete.com/#/content/bnf/_870309169?hspl=Fluconazole (accessed November 2018)
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[thirty] Feng X, Xiong Ten & Ran Y. Efficacy and tolerability of amorolfine v% nail lacquer in combination with systemic antifungal agents for onychomycosis: A meta-analysis and systematic review. Dermatologic Therapy 2017;thirty(3). doi: x.1111/dth.12457
[31] Kolodchenko VY & Baetul VI. A novel method for the treatment of fungal boom illness with 1064 nm Nd:YAG. J Laser Health Acad; 2013. Available at: https://world wide web.laserandhealthacademy.com/media/objave/university/priponke/42_47___kolodchenko___onychomycosis___jlaha_2013_1.pdf (accessed November 2018)
[32] Broughton RH. Reinfection from socks and shoes in tinae pedis. Br J Dermatol 1955;67(7):249–254. PMID:13239972
Final updated
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