Onychomycosis(onychomycosis) fungal infection of the nail plate and surrounding structures: nail folds, matrix (the growth part of the nail) and the nail bed. This manifests itself in the deformation and thickening of the nails, a change in their color - the nails become white or yellow.
This disease is quite common. According to some data, the prevalence of onychomycosis among Europeans reaches 10-12%, which exceeds the known indicators of the previous decade. It occurs 1. 5 times more often in men, but they consult a doctor 2 times less often than women. The elderly are sick more often, children very rarely.
The main problem in the treatment of the disease is that patients visit a 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 spread by a sick person. Very often, a fungal infection occurs within the family, because the source is not identified in time and adequate preventive measures are not taken.
Causes of the disease:most often, direct contact with the patient or the objects used by the patient (shoes, clothes, bath mats, towels, manicure accessories). Infections often occur when visiting gyms, spas, saunas and swimming pools.
The development of the disease is facilitated by microdamages - cracks in the interdigital folds, which are caused by wear, excessive sweating, dry skin, poor drying after water procedures and flat feet.
Nail fungus can occur with simultaneous diseases of the endocrine system (diabetes, obesity, hypothyroidism), vascular diseases of the limbs (venous insufficiency, lymphostasis), immune system disorders, and antibiotics, corticosteroids, orcytostatic drugs. As a result of the above diseases, the microcirculation of the blood in the nail area is interrupted and the natural immunity decreases, 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;
- molds.
Depending on the type of pathogen, the penetration of the fungal infection and the clinical picture are different, so the approaches to therapy are also different.
Toenails are affected by the fungus 10 times more often than fingernails. In most cases, the fungus is caused by dermatophytes (such as Trichophyton rubrum). The remaining cases are most often caused by non-dermatophyte molds (Aspergillus, Scopulariopsis, Fusarium).
If you experience similar symptoms, contact your doctor. Do not self-medicate - it is dangerous for your health!
In addition to nail fungus, athlete's foot 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. Skin lesions on the feet are characterized by peeling accompanied by itching. In case of severe changes, erosions and deep cracks appear on the sole and in the space between the toes against the background of reddened and swollen skin, which are accompanied by pain and make it difficult to walk.
The advent of modern antifungal agents has improved the epidemiological situation, but foot mycosis remains one of the most significant problems in dermatovenerology. The use of some drugs is limited in the elderly and patients with chronic diseases.
Routes of infection
The risk of fungal infection is particularly high in public places with high humidity. These are saunas, swimming pools, gyms, public baths, etc. The most common ways of infection:
- direct contact with an infected person. Here, the fungus moves from its habitat to healthy areas, thereby causing infection;
- in a household way. In this case, the infection occurs when using the patient's personal items: shoes, personal hygiene items, etc.
Risk factors
The incidence of onychomycosis increases up to the age of 60. At this time, the probability of developing such an infection is 60%, which can be explained by a slowdown in metabolism, especially in the distant (remote) parts of the body, which are the fingers and toes.
Additional risk factors for the development of nail fungus are as follows:
- diabetes;
- varicose veins;
- injuries to nails and adjacent tissues;
- HIV and other immunodeficiency conditions;
- long-term use of antibiotics;
- weakened immune system;
- vascular and skin diseases, dermatitis, diaper rash;
- disorders of the blood supply to the limbs;
- insufficient hygiene.
Symptoms of onychomycosis (nail fungus).
The longer the disease lasts, the more pronounced its symptoms are. The main symptoms of onychomycosis are:
- dyschromia - a change in the color of the nail 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 - a decrease in the thickness and softening of the disc;
- koilonychia - the nail looks concave, in the form of a teaspoon;
- 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 on the surface of the nail plate: pits, grooves, ridges;
- changes in the nail folds and the surrounding skin (paronychia - inflammation of the proximal nail fold).
It is important to note that none of the symptoms are pathognomonic, i. e. suitable for a unique pathogen, therefore it cannot be determined based on symptoms - further tests are required.
Pathogenesis of onychomycosis (nail fungus).
The pathogenesis of the disease depends on how the fungus got on the skin and nails.
Distal subungual type:if the fungus has penetrated the skin in the nail folds or in the distal area, the infection spreads through the free edge of the nail into the matrix. At first, the nail plate cannot change, but later, due to hyperkeratosis, it gradually moves away from the nail bed and turns yellow. The nail plate may gradually thicken.
Type of white surface:If whitish lesions form on the surface of the nail, the fungus will eventually take over the entire nail plate. The nail thickens, crumbles and takes on a gray-brown hue. In this case, the matrix and epithelium of the nail bed are not affected. There is no inflammation on the surrounding skin.
Proximal subungual type:the fungus can spread from the skin and the folds around the nail to the nail plate and then further to the matrix, reaching the distal parts of the nail plate. Spots appear on the nail in the area of the hole and the nail bed, and the nail plate detaches. There is no significant inflammation on the nail bed or matrix.
Full dystrophic type:My whole nail is affected. The proximal parts of the nail fold disappear or thicken, so that the nail plate can no longer form or grow.
Existsbiophysical concept of the pathogenesis of onychomycosis, which states that two forces collide during the course of the disease: the fungal colony growing toward 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 onychomycosis - the faster the nail grows, the sooner healing occurs. Perhaps this explains the low prevalence of the disease among children, since their nails grow faster than those of adults and the elderly.
Classification and developmental stages of onychomycosis (nail fungus).
The following classification of onchomycosis exists:
- distal subungual;
- superficial white;
- proximal subungual;
- completely dystrophic.
According to Arievich's (1970) classification:
- normotrophic: there are yellowish and whitish stripes in the thickness of the nail, 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, with jagged edges;
- dystrophic:thinning and separation of the nail plate from the nail bed occurs with the formation of cavities.
Complications of onychomycosis (nail fungus).
Long-term onychomycosis increases the risk of its developmentdiabetic foot(formation of trophic ulcers on the legs) andgangreneif the patient has diabetes or vascular disease of the lower extremities.
In immunosuppressive states (primary and secondary immunodeficiency states), fungi can spread to the skin and internal organs and cause allergies in the body. This can manifest itself as a skin rash and even in the development of bronchial asthma.
The disease causes uncomplicated symptoms typical of the fungus, only causing severe discomfort in humans. But without treatment, onychomycosis can cause complications. Most often, they manifest as a bacterial infection.
Sometimes onychomycosis is very acute, with the appearance of blisters, ulcers and weeping areas on the skin next to the nail. In severe cases, the disease takes a generalized form. This means that the nail fungus spreads to internal organs and systems, and then the patient requires emergency hospitalization.
Diagnosis of onychomycosis (nail fungus).
Before examining the methods of diagnosing onychomycosis, it is necessary to explain how to correctly collect the material necessary for research (the patient does this independently or the nails are prepared before the diagnosis). Before collecting material for research, the nail plate should be treated with 70% alcohol to avoid contamination with other bacteria.
The method of material collection varies depending on the form of onychomycosis:
- surface form- make a scraping from the nail plate;
- distal form- it must be scraped from both the nail bed and a piece of the nail plate;
- proximal subungual form- the material is collected with a drill, or a nail biopsy or scraping from the nail bed is performed.
The fastest way to determine the pathological fungi in the nail ismicroscopy. Technique: the examined material is treated with an alkaline solution to dissolve the keratin. To make the mushroom threads more visible, ink is added to the lye. The resulting preparation is then studied under a microscope.
This research method is the fastest and most objective. The sensitivity is up to 80%. Among the disadvantages of the method is the fact that it is impossible to determine the type of pathogen during its application.
Bacteriological culture: an additional method for the diagnosis of onychomycosis. The material is sown on a special culture medium, and the result is interpreted under a microscope after 2-3 weeks. This method makes it possible to determine the type of pathogen - this helps to determine treatment tactics and select drugs based on sensitivity. But the disadvantage of the test is that it takes a lot of time, and its sensitivity is only 30-50%.
Biopsy: With the help of a scalpel and anesthesia, we cut the nail and the nail bed. The material is immersed in a formaldehyde solution and sent to the laboratory for histological examination. The advantage of this method is that it is extremely sensitive and allows determining the presence of pathological fungi in the material.
Disadvantages: it is impossible to identify the pathogen and determine the viability of microorganisms, the method is expensive and labor-intensive.
Genetic diagnosis: molecular biological research method (PCR). This is one of the new and extremely 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 diagnostics in those healthcare institutions where a PCR laboratory is operating, but currently, the introduction of test systems for the identification of dermatophytes and molds is only planned for the laboratories. The method makes it possible to determine the type of pathogen, and its sensitivity ranges from 80-90%. Disadvantages: high costs, inaccessibility, lack of technological standards and complexity of implementation.
Doctors are increasingly introducing the practicedermatoscopy. With this method, you can evaluate changes in the color and structure of the nail, as well as the condition of the surrounding structures. The dermatoscopic examination enables a more accurate assessment of the depth of damage to the nail plate and a more accurate calculation of the onychomycosis severity index (KIOTOS).
First of all, the patient is sent for a microscopic examination, which allows to identify the presence of the pathogen. In the future, it is necessary to determine its type in order to choose the right treatment for nail fungus. In the center of JSC "Medicine" (Academic Roitberg Clinic) in Moscow, the most modern and widespread methods are used to diagnose onychomycosis:
- cultural examination of a biological sample of the affected tissue. To do this, it is placed in an artificial medium where the pathogen is grown to determine its type;
- polymerase chain reaction (PCR) method for the detection of pathogenic DNA in a sample of the affected tissue.
When to see a doctor
Many people who have encountered onychomycosis know that the disease develops slowly and is incredibly difficult to treat. Therefore, it is very important to see a doctor at the first signs of the disease. At our clinic in the center of Moscow, a dermatologist treats nail onychomycosis. The specialist will provide competent help and guide you through to complete recovery.
Preparing for the doctor's visit
Before visiting the dermatologist, it is important not to treat the affected areas of the nail with anything, e. g. do not use drugs, including iodine and brilliant green. The use of antifungal creams and ointments should also be avoided. At the time of your appointment, you must complete all previous tests, including tests for other diseases. The affected nails should not be cut 3-4 days before the consultation.
Treatment of nail fungus (onychomycosis).
There are several treatments for onychomycosis:
- Local therapy.
- Systemic therapy.
- Combined therapy.
- Corrective therapy.
Local therapyinvolves the application of drugs 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 for the prescription of systemic drugs: hypersensitivity, liver disease, kidney dysfunction, pregnancy, breastfeeding.
The advantage of this therapy is that the therapeutic agent is formed in a high concentration on the surface of the nail, which does not penetrate into the bloodstream. The use of antifungal agents has no side effects - 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 is very labor-intensive, as the affected part of the nail must be removed before applying the medicine.
Ways to remove affected nails:
- Mechanical removal with a file, pliers or drill.
- Use of keratolytic patches. Before applying the keratolytic plaster, the skin around the nail must be sealed with plaster, plaster mass (carbide with salicylic acid) is applied on top and sealed with an adhesive plaster. The plaster mass is changed every 2-3 days. After each removal, the affected part of the nail is removed mechanically.
- Surgical. This operation is very painful and traumatic, as the growth zone may be damaged when the nail plate is removed, which leads to the regrowth of deformed nails.
After removing the affected nail plate, topical antifungal agents are applied.Antimycoticsdifferentiated according to the place of application:
- applied to the nail: lacquers;
- applied to cylinders: creams, ointments, solutions.
The most frequently studied drug intended for local use is1% Naftifin solution, which has evidence based on a Cochrane meta-analysis of treatment effectiveness. This product is water-based, which facilitates better penetration of the antifungal agent 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 the deep layers. Therefore, dermatologists find the use of lacquers unsatisfactory and increasingly prefer water-based products.
To achieve the results of local therapy, it is necessary to follow the treatment regimen, it is important for the patient to be responsible, consistent and patient. The duration of the therapy can be up to 12 months.
Systemic therapyallowing the antifungal drug to enter the bloodstream to the lesion site, even if the nail bed and matrix are involved. A high concentration of the drug remains in the affected area for a long time after use. The disadvantages of this type of treatment are the risk of side effects and toxic effects.
Indications for systemic therapy:
- Common forms of damage to the nail plate.
- Lack of effect of local therapy (ie, after six months of treatment for onychomycosis on the hands and after 9-12 months of treatment for onychomycosis of the feet, healthy nails did not grow back).
KIOTOS (Clinical Index for Assessing the Severity of Onychomycosis by Sergeev) proposed by A. Yu. Sergeev in 1999 is used to determine treatment tactics. It is used as a therapeutic standard in different countries of the world.
MedicinesThe treatment of onychomycosis can be classified as follows:
- antifungal agents - they have an antifungal effect;
- antiseptics - they have both antifungal and antibacterial effects. They are rarely used, only when there is no other antifungal agent;
- multi-component - in addition to the antifungal agent, they also contain other drugs, for example, anti-inflammatory drugs.
Prescription dosage regimens:
- standard - taking daily medications during the prescribed treatment period;
- shortened - the treatment period is shortened, in regular doses or can be increased;
- intermittent - the treatment is prescribed in several short courses, the intervals between the courses are equal to the duration of the courses;
- pulse therapy - the treatment is prescribed in several short courses, the intervals between the courses are longer than the duration of the courses.
Antifungal drugs are divided according to the active ingredient:
- triazoles;
- allyl amines;
- others (third generation drugs).
It is currently used for systemic therapyonly the third generation drugs.
With combined therapylocal and systemic treatment are performed simultaneously. Combined therapy is used when it is necessary to increase the effectiveness of systemic therapy and reduce the treatment time.
Corrective therapy(treatment of accompanying diseases): the selection of the treatment regimen requires an assessment of the body's general somatic condition. Diseases such as circulatory disorders of the extremities can reduce the access of the antifungal agent to the lesion. Therefore, drugs are prescribed that improve tissue trophism.
Due to the toxic effect of systemic antifungal agents, liver disease should be ruled out and hepatoprotectors should be prescribed if necessary.
Home Remedies
Consult your doctor before using home remedies. With his 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. Then treat the nails and the skin between the fingers with iodine, soak for 20-30 minutes in a bath with soda solution and dry thoroughly;
- vinegar. 1 tablespoon for 3 liters of water. apple cider vinegar and add a little potassium permanganate. Soak your feet in the bath for 20-30 minutes, then dry them thoroughly;
- hydrogen peroxide. After thoroughly steaming the foot, remove the affected areas of the nail plates. Place cotton pads soaked in hydrogen peroxide on them, wrap them with a bandage and let them stand for half an hour.
Myths and dangerous misconceptions in the treatment of nail fungus
One of the most important and dangerous myths is that nail fungus is not a serious disease. In fact, onychomycosis, as it progresses, can lead to serious consequences, including deformation and complete rejection of the nails from the nail bed.
In addition, the infected person poses a daily danger to his loved ones, since they can also get sick if they are near him. Therefore, it is important to know how to cure nail fungus in time.
Forecast. Prevention
The sooner the patient consults a doctor with signs of fungal nail infection, the faster the disease can be cured and the faster the nail plate can be restored. In the case of long-term processes affecting the entire nail, the treatment of onychomycosis can be lengthy, but if all recommendations are followed, recovery often occurs. If there are contraindications to systemic therapy, long-term maintenance treatment with local drugs is required.
For prevention purposesPersonal hygiene rules must be followed and the possibility of re-infection must be reduced:
- try to wear comfortable and high-quality shoes (to prevent excessive sweating of the feet);
- It is recommended to change socks and stockings daily;
- use only individual shoes. For those receiving treatment for onychomycosis, shoes should be treated at the beginning of treatment, at least once a month throughout the duration of treatment and after treatment is completed;
- if necessary, use antiperspirants on the feet;
- use a personal nail care kit (scissors, file);
- before and after visiting public places (swimming pool, spa, gym) use antifungal external agents (spray, cream and pencil);
- identify the source of the fungal infection in the family and treat it at the same time.
We recommend periodic antifungal treatment of personal items, shoes, bathtubs, floors and carpets. For this purpose, you can use 40% acetic acid solution, 1% alcohol chlorhexidine solution (prescribed by a doctor) and disinfectant solutions. Linen can be boiled in a 1-2% soap-soda solution for 20-30 minutes and ironed at maximum temperature.