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Onychomycosis

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Onychomycosis is a medical term for a fungal infection of the nails.

Toefungus
Toefungus

This condition affects about 10 percent of the adult population. It is much more common in toenails than in fingernails. The infection changes the physical structure and appearance of the nail. Nails may become thick, brittle, or discolored with white, yellow, black, or green patches. In advanced cases, the nail can separate from the nail bed.

Advanced onychomycosis
Advanced onychomycosis

This can cause the nail to break off completely. While often painless, severe cases can cause inflammation and pain in the surrounding skin.

The infection is caused by various pathogens within the fungus kingdom. Dermatophytes are the most common cause in temperate western countries. One specific fungus, Trichophyton rubrum, is the most frequent dermatophyte involved. In tropical or subtropical regions with high humidity, Candida yeasts and nondermatophytic molds are more common. For example, Candida species often affect fingernails in people who frequently submerge their hands in water. Molds, such as those in the genus Neoscytalidium or Aspergillus, are more frequent in people over age 60. This is often due to a slight weakening in the nail's ability to defend itself.

Doctors classify onychomycosis into five distinct types based on how the fungus invades. Distal subungual onychomycosis is the most common form. In this type, the fungus invades the nail bed and the underside of the nail plate. White superficial onychomycosis (WSO) occurs when fungus invades the superficial layers of the nail plate. This creates "white islands" and accounts for about 10 percent of cases. Proximal subungual onychomycosis involves the fungus penetrating the nail through the proximal nail fold. This is rare in healthy people but common in those who are immunocompromised. Finally, endonyx onychomycosis and Candidal onychomycosis represent other specific patterns of invasion.

Understanding the history of this condition helps us see how medical science has progressed. In 1853, Georg Meissner first determined that these nail changes were the result of a fungal infection. Since then, scientists have identified many specific species. They have also updated the names used in medical laboratories to ensure accuracy. For instance, the name Scytalidium was recently changed to Neoscytalidium. Some older names, like Trichophyton mentagrophytes, are now restricted to different types of infections. These scientific advancements allow doctors to identify exactly which fungus is causing the problem.

Many factors increase the risk of developing this infection. Advancing age, particularly over 60, is a major risk factor. This is due to diminished blood circulation, slower nail growth, and reduced immune function. Men are affected more often than women. Other risks include having athlete's foot, diabetes, or poor circulation. People who frequent damp public places like gyms or swimming pools are also at higher risk. Wearing shoes that do not allow for ventilation can increase moisture and encourage fungal growth.

Advanced onychomycosis
Advanced onychomycosis

Diagnosis is usually suspected by looking at the nail but must be confirmed with laboratory tests. Doctors often use nail scrapings or clippings for these tests. Common methods include a potassium hydroxide (KOH) smear, a culture, or a histology examination. A polymerase chain reaction (PCR) test can also be used. A nail plate biopsy with a periodic acid-Schiff (PAS) stain is considered very useful for confirmation. It is important to distinguish onychomycosis from other conditions like nail psoriasis or melanoma. This ensures that the patient receives the correct treatment for their specific issue.

Treatment options vary depending on the severity and type of infection. Oral terbinafine is one of the most effective medications, with a 76 percent effectiveness rate. However, it can be associated with liver problems, so doctors must monitor patients. Topical treatments include nail polishes like efinaconazole or ciclopirox. Efinaconazole has shown cure rates significantly higher than ciclopirox in clinical trials. Some newer topical medications, such as Terclara, were launched in Sweden in 2024 to provide effective treatment with fewer side effects.

A patient's left foot - after ten weeks of Terbinafine oral treatment
A patient's left foot - after ten weeks of Terbinafine oral treatment

Even with treatment, the infection can return in up to half of all cases. To reduce the risk of recurrence, patients should avoid using old shoes after they have finished treatment.

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File:A patient's left foot - after ten weeks of Terbinafine oral treatment.png
A patient's left foot - after ten weeks...
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