Nailed by Fungus

Onychomycosis--a fungal infection of the nail plate. The scourge of athletes and even many couch potatoes, nail fungus is one of the most common and stubborn infections around, especially in patients with biomechanical problems with their feet, and even more commonly in diabetics.

There's still no quick-hit, 100-percent-effective treatment, even though the condition is common. Nail fungus is uncommon before puberty, but with increased age the risk increases.

Fungus rears its ugly head: The first indication is generally discoloration, usually whitish or yellowish. An infected nail can also become brittle, soggy or thickened. Then comes a creeping, slowly growing area of whiteness. When the infection really gets a grip, there may be pain and an offensive odor. Depending on severity, the appearance of the nail can range from mildly gross to flat-out disgusting.

Toenails are more susceptible than fingernails. When (only) fingernails are involved, it's an alarm that something else is going on in the system. The cause could be psoriasis, eczema of the hands or too much exposure to moisture, leading to breakdown of the natural defenses of the cuticle. Fingernail fungus can accompany changes in immune status too, perhaps resulting from corticosteroid drugs, chemotherapy or HIV infection.

The long road to recovery: The sooner you treat it, the better your chances of getting rid of the fungus. If a younger person notices it and gets treated, he has by far the best change of cure. The infection is more difficult to cure in later stages and in older people. Traditionally, treatment has been frustrating and disappointing, sometimes requiring a year or more, plus return visits to the doctor. The mainstays have been two oral medicines, griseofulvin and ketoconazole.

Treatment is lengthy, partly because nails grow slowly. This traditional approach results in a cure rate of up to 80 percent for fingernail disease after six months, but only about 25 percent for toenail disease after 12 to 18 months. One should check liver function studies every 3 months while on them.

Some experts are placing their bets on two new drugs, itraconazole and terbinafine. Itraconazole was approved by the Food and Drug Administration late in 1992 for fungal infections that strike the lungs and other parts of the body. In a Belgian study of 39 patients with nail infection, researchers found that itraconazole has a 100 percent cure rate for fingernails. Results for toenails were good too; about three-quarters of the patients responded well.

Terbinafine is not yet approved, but some published studies suggest its effectiveness. A researcher from the Leeds General Infirmary in England concluded that terbinafine is effective when given for three months. Goodfield treated 85 patients for three months, giving some of them 250 milligrams a day and the others a placebo. The rate of toenail cure was 82 percent; for fingernails, 71 percent. Of the group taking terbinafine, 33 percent reported side effedts, mostly gastrointestinal disturbances.

Griseofulvin is certainly the safest medication, and you can take it for long periods. But it's no cure-all.

To aid recovery, some recommend that you use a topical antifungal spray or cream i.e. Spectazole, once daily, after soaks in addition to the oral medication, scrubbing the nailbed every day so the spray penetrates better. When all else fails, the nail may be removed altogether. Because different forms of fungus respond differently to treatment, some experts recommend that you take a culture before committing to either drugs or surgery.

Once you've had the fungus, recurrence is hard to prevent. But if you have it under control, your best bet is to apply a topical, prescription antifungal cream for at least a year. And if you've been lucky so far, you might be able to remain fungus-free by paying attention to hygiene. Keep your feet and hands as clean and dry as possible. After a shower, dry your feet and toes thoroughly. Consider using talcum powder on your feet, and change your socks often.

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