Onychomycosis - symptoms and treatment

Onychomycosis(Nail fungus) is a fungal infection of the nail plate and its surrounding structures: the nail fold, matrix (the growing part of the nail), and nail bed. It manifests itself as deformation and thickening of the nails, color changes - whitening or yellowing of the nails.This disease is very common. According to some data, the prevalence of onychomycosis in Europeans reaches 10-12%, exceeding known indicators in the previous decade. Men are 1. 5 times more likely to develop the disease than women, but seek medical attention twice as often as women. Older people get sick more often, children less often.The main problem with treating this disease is that patients wait long after the first symptoms appear to see a dermatologist. Because of this, pathological fungi cover a large area and delay treatment.Pathogenic fungi can only be spread by sick people. Many times, fungal infections occur within the home because the source of infection is not identified in time and adequate preventive measures are not taken.Causes:The most common is direct contact with the patient or objects he uses (shoes, clothes, bath mats, towels, manicure accessories). Infections often occur when visiting gyms, bathrooms, saunas and swimming pools.Microtrauma promotes the development of this disease - cracks in the interdigital folds due to wear and tear, excessive sweating, dry skin, poor drying after water treatments, and flat feet.Onychomycosis may also occur in the setting of diseases of the endocrine system (diabetes, obesity, hypothyroidism), vascular diseases of the extremities (venous insufficiency, lymphatic stasis), immune disorders and the use of antibiotics, corticosteroids and drugs. Cytostatic drugs. Due to the above diseases, the blood microcirculation in the nail area is disrupted and the natural immunity is reduced, leading to the occurrence of secondary infections.Onychomycosis is caused by the following types of fungi:

• dermatophytes;
• Yeast-like fungi of the genus Candida;
• Mold.

Depending on the type of pathogen, fungal infections vary in their degree of penetration and clinical manifestations, and therefore in their treatment.Toenails are 10 times more likely to be infected by fungus than fingernails. In most cases, the fungus is caused by dermatophytes such as Trichophyton rubrum. The remaining cases are most commonly caused by nondermatophyte molds (Aspergillus, Scopus, Fusarium).If you notice similar symptoms, talk to your doctor. Don’t self-medicate – it’s harmful to your health!In addition to onychomycosis, foot fungus can also occur. Podiatry (dermatophytosis, tinea pedis) is a skin disease of the feet caused by pathogenic or opportunistic fungi. Skin changes on the feet are characterized by peeling, accompanied by itching. When the disease is severe, the skin will be red and swollen, and erosion and deep cracks will appear on the soles of the feet and between the toes, accompanied by pain and difficulty walking. The advent of modern antifungal drugs has improved the epidemiological situation, but foot mycosis remains one of the most important problems in dermatology and venereology. The use of certain medications is limited in older adults and people with chronic illnesses.

route of infection

The risk of fungal infection is especially high in public places with high humidity. These are saunas, swimming pools, gyms, public baths, etc. The most common routes of infection:

• Direct contact with an infected person. Here, the fungus moves from its habitat into healthy areas, causing infection;
• Family way. In this case, the infection occurs while using the patient's personal belongings: shoes, personal hygiene products, etc.

risk factors

At age 60, the incidence of onychomycosis increases. At this point, the probability of developing such an infection is 60%, due to a slowdown in metabolism, especially in the distal (distal) parts of the body, namely the fingers and toes.Other risk factors for developing onychomycosis include:

• diabetes;
• Varicose veins;
• Injury to nails and adjacent tissues;
• HIV and other immunodeficiency diseases;
• long-term antibiotic use;
• weakened immune system;
• Vascular and skin disorders, dermatitis, diaper rash;
• Disturbances in the blood supply to the limbs;
• Not enough hygiene.

Symptoms of onychomycosis (onychomycosis)

The longer the disease lasts, the more pronounced its symptoms become. The main symptoms of onychomycosis include:

• Pigmentation abnormalities - nail color changes 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 nail bed;
• changes in nail plate thickness;
• hapalonychia - reduction in the thickness of the plates and their softening;
• Onychomycosis - Nails that appear concave and teaspoon-shaped;
• Hyperonychia - thickening of the nail plate and hypertrophy of the nails;
• Onychomycosis - The nail plate is thickened, discolored, and curved like a beak;
• Changes in nail bed thickness (hyperkeratosis - nail bed thickening);
• Changes in the surface of the nail plate: pits, grooves, ridges;
• Changes in the nail fold and surrounding skin (paronychia - inflammation of the proximal nail fold).

It is important to note that no symptom is specific, i. e. only suitable for a specific pathogen, so it is not possible to identify it from symptoms - additional tests are required.

The pathogenesis of onychomycosis (onychomycosis)

The pathogenesis of the disease depends on how the fungus attaches to the skin and nails.Distal subungual type:If the fungus has penetrated the skin in the nail fold area or distal areas, the infection can spread through the free edge of the nail bed and further into the matrix. At first, the nail plate may not change, but later, due to hyperkeratosis, it gradually moves away from the nail bed and turns yellow. The deck may gradually become thicker.Confession type:If white lesions form on the nail surface, over time the fungus can take over the entire nail plate. Nails become thickened, crumbled, and appear grey-brown. In this case, the matrix and epithelium of the nail bed are unaffected. There is no inflammation in the surrounding skin.Proximal subungual type:Fungi can spread from the skin and periungual folds into the nail plate and further into the matrix, reaching distal portions of the nail plate. Spots appear on the holes in the nails and the nail bed area, and the nail plate peels off. There is no significant inflammation of the nail bed or nail matrix.Complete malnutrition:The entire nail can be affected. The proximal portion of the nail fold disappears or thickens so that the nail plate no longer forms or grows.existBiophysical concepts in the pathogenesis of onychomycosis, which states that during the disease process there is an antagonism between two forces: the growth of the fungal colony towards the matrix, and the natural growth of the nail from the matrix to the distal edge. Therefore, the rate of nail growth is crucial in the course of onychomycosis—the faster the nail grows, the faster it will heal. Perhaps this is why the disease is less common in children, as their nails grow faster than those of adults and older adults.

Classification and stages of onychomycosis (onychomycosis)

Onychomycosis is classified into the following categories:

• distal subungual;
• Surface white;
• proximal subungual;
• Total malnutrition.

According to Arievich (1970) classification:

• Nutritionally normal: There are light yellow and light white stripes in the nail thickness, but the shape of the nail plate does not change, and there is no subungual hyperkeratosis;
• Hypertrophic type:The nail plate turns yellow, becomes thickened and brittle due to subungual hyperkeratosis, and has jagged edges;
• Malnutrition:As voids form, the nail plate thins and detaches from the nail bed.

Complications of Onychomycosis (Onychomycosis)

Long-term onychomycosis increases the risk of onychomycosisdiabetic foot(formation of trophic ulcers on the legs) andgangreneIf the patient has diabetes or vascular disease of the lower extremities.In immunosuppressed conditions (primary and secondary immune deficiencies), the fungus can spread to the skin, internal organs and cause allergies in the body. This can manifest as a rash or even develop into bronchial asthma.In an uncomplicated process, the disease causes the traditional symptoms of a fungus and causes nothing but severe discomfort in the person. But if left untreated, onychomycosis can cause complications. Most commonly, they manifest as bacterial infections.Sometimes onychomycosis is so severe that blisters, sores, and areas of oozing appear on the skin near the nail. In severe cases, the disease takes on a generalized form. This means that onychomycosis can spread to the internal organs and system, and the patient then needs emergency hospitalization.

Diagnosis of Onychomycosis (Onychomycosis)

Before studying the diagnostic methods of onychomycosis, it is necessary to explain how to correctly collect research materials (either independently by the patient, or by preparing the nails before diagnosis). Before collecting research materials, the nail plates need to be treated with 70% alcohol to avoid contamination with other bacteria.The method of collecting material varies depending on the form of onychomycosis:

• surface morphology- Scrape off the nail plate;
• remote mode- Need to scrape the nail bed and a deck;
• proximal subungual morphology- Use a drill to collect material, or perform a nail biopsy, or scrape it from the nail bed.

The fastest way to identify nail pathological fungi ismicroscopy. Technique: The material under study is treated with an alkaline solution to dissolve keratin. To make the mushroom filaments more clearly visible, ink is added to the base. Next, the resulting preparation was studied under a microscope.This research method is the fastest and most objective. The sensitivity is as high as 80%. Disadvantages of this method include the inability to determine the type of pathogen when using this method.Bacterial culture: is another way to diagnose onychomycosis. The material is sown on special media and the results are interpreted under a microscope after 2-3 weeks. This method allows you to determine the type of pathogen - this helps determine treatment strategies and select drugs based on susceptibility. But the disadvantage of this study is that it takes a lot of time and its sensitivity is only 30-50%. Biopsy: Using a scalpel and applying anesthesia, the nail and nail bed are removed. The material is immersed in a formaldehyde solution and sent to a laboratory for histological examination. The advantage of this method is that it is highly sensitive and can determine whether pathological fungi are present in the material.Disadvantages: Pathogens cannot be identified and the viability of microorganisms cannot be determined. This method is expensive and labor-intensive.genetic diagnosis: Molecular Biology Research Methods (PCR). This is one of the new, highly sensitive methods for diagnosing onychomycosis - it helps detect the DNA of the disease causative agent. In our country, it is recommended to introduce such diagnostics in medical institutions with PCR laboratories, but currently only test systems for identifying dermatophytes and molds are planned to be introduced into laboratories. The method can determine the type of pathogen with a sensitivity ranging from 80-90%. Disadvantages: high cost, difficult to obtain, lack of technical standards, complex implementation.More and more doctors are introducing it into practiceDermoscopy. Using this method, you can evaluate changes in nail color and structure as well as the condition of surrounding structures. Dermoscopy allows for a more accurate assessment of the depth of nail plate damage and a more accurate calculation of the Onychomycosis Severity Index (KIOTOS).First, the patient is sent for microscopic examination to identify the presence of the pathogen. In the future it will be necessary to determine its type in order to choose the correct onychomycosis treatment. At the JSC "Medicine" (Roitberg Academician Clinic) in the center of Moscow, the most modern and extensive diagnostic methods for onychomycosis are used:

• A biological sample of the affected tissue is cultured. To do this, it is placed in an artificial nutrient medium, in which the pathogen is cultured to determine its type;
• The polymerase chain reaction (PCR) method detects pathogen DNA in samples of affected tissue.

When to see a doctor

Many people who have suffered from onychomycosis know that the disease develops slowly and can be very difficult to treat. That's why it's important to consult a doctor when the first signs of the disease appear. Dermatologists treat onychomycosis at our clinic in the center of Moscow. Experts will provide effective help and guide you until full recovery.

getting ready to see a doctor

Before visiting a dermatologist, it is important not to treat the affected area of the nail with anything, that is: do not use medications, including iodine and bright green. Creams and ointments targeting fungi must also be avoided. At the time of your appointment, you should have all previous tests, including tests for other medical conditions. The affected nail should not be cut for 3-4 days before your appointment.

Treat onychomycosis (onychomycosis)

There are several treatments for onychomycosis:

1. Topical treatment.
2. Systemic treatment.
3. Combination therapy.
4. Corrective treatment.

topical treatmentInvolves applying medication to the nail plate and nail fold. Indications for topical treatment:

1. There are limited forms of damage to the nail plate (according to KIOTOS).
2. There are contraindications for systemic use: allergies, liver disease, renal insufficiency, pregnancy, lactation.

The advantage of this treatment is the formation of a high concentration of therapeutic agent on the nail surface that does not penetrate into the bloodstream. There are no side effects of using antifungal drugs - nausea, loss of appetite, abdominal pain. The disadvantage of this method is that the medicinal substances do not always reach the habitat of the pathogen, especially when the fungus is located in the nail bed or matrix. This in turn can lead to treatment failure. This type of treatment is very laborious because the affected part of the nail must be removed before the medication can be applied.Methods to remove affected nails:

1. Use a file, pliers or drill for mechanical removal.
2. Use cuticle patches. Before applying a keratolysis plaster, seal the skin around the nail with a plaster, apply a patch of plaster (urea with salicylic acid) on top and seal with tape. Plaster blocks are replaced every 2-3 days. After each removal, the affected portion of the nail is mechanically removed.
3. surgical. The procedure is very painful and traumatic because when the nail plate is removed, the growth zone may be damaged, causing the deformed nail to regrow.

After removing the affected nail plate, apply a topical antifungal medication.antifungal drugsDistinguished by application locations:

• Apply to nails: varnish;
• Suitable for rollers: creams, ointments, solutions.

The most studied topical drugs are1% naftifine solution, which has an evidence base for treatment effectiveness based on Cochrane meta-analyses. The product is water-based, which facilitates better penetration of antifungal substances into the affected area. The active ingredients of varnish are ciclopirox and amorolfine and have a dehydrating matrix that reduces the penetration of the drug into deeper layers. Therefore, dermatologists consider the use of varnishes unsatisfactory and increasingly prefer water-based products.In order to obtain the results of topical treatments, the treatment protocol must be followed; patient responsibility, persistence, and patience are also important. The duration of treatment can be up to 12 months.systemic treatmentEven if the nail bed and matrix are affected, antifungal drugs can penetrate into the bloodstream and reach the lesion. After use, high concentrations of the drug will remain in the affected area for a long time. Disadvantages of this treatment are related to the risk of side effects and toxic effects.Indications for systemic therapy:

1. Common forms of deck damage.
2. Topical treatments lack effectiveness (i. e. , healthy nails do not grow back after 6 months of treatment for onychomycosis on hands and 9-12 months of treatment for onychomycosis on feet).

To determine the treatment strategy, KIOTOS (Sergeev's Clinical Index for the Assessment of the Severity of Onychomycosis) proposed by A. Yu. Sergeev in 1999 was used. It is used as a standard of care in countries around the world.drugTreatment of onychomycosis can be divided into the following categories:

• Antifungals - have antifungal effects;
• Antiseptic - has antifungal and antibacterial properties. They are rarely used only when other antifungals are not available;
• Multi-Ingredient – In addition to antifungals, they also contain other medications such as anti-inflammatory drugs.

Prescription plan:

• Standard—take medication every day for the prescribed treatment period;
• Shortening - the treatment period is shortened and can be carried out at the regular dose or at an increased dose;
• Intermittent - treatment is divided into several short sessions with intervals equal to the duration of the sessions;
• Pulse therapy - treatment is divided into several short sessions, with intervals between sessions that are longer than the duration of the session.

Antifungal drugs are divided according to active substances:

• Triazoles;
• Allylamine;
• Others (third generation drugs).

Currently used for systemic treatmentOnly third generation drugs.combination therapyLocal and systemic treatments are performed simultaneously. Combination therapy is used when there is a need to increase the effectiveness of systemic therapy and shorten treatment time.Orthodontic treatment(Treatment of Concomitant Diseases): When selecting a treatment option, it is necessary to assess the general physical condition of the body. Conditions such as circulatory disorders in the extremities may reduce the chance of antifungal drugs reaching the affected area. Therefore, drugs that improve tissue nutrition are prescribed.Due to the toxic effects of systemic antifungals, liver disease needs to be ruled out and hepatoprotective drugs prescribed if necessary.

home remedies

You should consult your doctor before using home remedies. With his permission you can use the following recipes:

• iodine. Before use, feet must be steamed dry, washed with laundry soap, and the affected nail plate area removed. Next, treat the nails and the skin between the fingers with iodine, soak them in the soda solution for 20-30 minutes 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 bathtub for 20-30 minutes, then dry them thoroughly;
• hydrogen peroxide. After thoroughly steaming your feet, remove the affected nail plate area. Place a cotton pad soaked in hydrogen peroxide over it, wrap it with a bandage, and leave it for half an hour.

Myths and Dangerous Misconceptions about Treating Onychomycosis

One of the most important and dangerous misconceptions is that nail fungus is not considered a serious disease. In fact, as the condition progresses, onychomycosis can lead to serious consequences, including nail deformation and complete rejection of the nail bed.In addition, an infected person poses a daily risk to loved ones, who are also at risk of getting sick by being near him. That’s why it’s important to know how to treat onychomycosis promptly.

forecast. prevention

The sooner a patient with signs of a fungal nail infection sees a doctor, the faster the disease will heal and the deck will recover. Treatment for onychomycosis can be lengthy due to the long-term process involving the entire nail, but recovery is usually possible if all recommendations are followed. If contraindications to systemic therapy exist, long-term maintenance therapy with topical agents is required.for preventionIt is necessary to observe personal hygiene rules to reduce the possibility of reinfection:

• Try to wear comfortable, high-quality shoes (to prevent your feet from sweating excessively);
• It is recommended to change socks and tights every day;
• Only use separate shoes. For patients being treated for onychomycosis, shoes must be disposed of at the beginning of treatment, throughout treatment, and at least monthly after treatment is completed;
• Use foot antiperspirant if necessary;
• Use personal nail care kit (scissors, files);
• Use antifungal topical preparations (sprays, creams and pencils) before and after going to public places (pools, bathrooms, gyms);
• Identify the source of fungal infections in the home and treat them at the same time.

Regular antifungal treatments are recommended for personal belongings, shoes, bathtubs, floors and carpets. For this, you can use a 40% acetic acid solution, a 1% chlorhexidine alcohol solution (prescribed by a doctor) and a disinfectant solution. Linen can be boiled in a 1-2% soap soda solution for 20-30 minutes and ironed at the highest temperature.