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Toenail Fungus (Onychomycosis)

Nail Fungus Infections - An Underreported Health Problem

Fungal infection of toenails is a common foot health problem. A majority of victims don't seek treatment, maybe don't even recognize the existence of a problem. Studies estimate that it afflicts three to five percent of the population; however, doctors of podiatric medicine think that because so many cases go unreported, the incidence is much higher than that (they treat perhaps 2.5 million people annually, but that's less than a quarter of the cases estimated by the studies).

Probably one reason that so many people ignore the infection is that it can be present for years without ever causing pain. Its prevalence rises sharply among older adults (20 to 30 percent, the studies say, though podiatric physicians think it's much higher). Because the older adults may be experiencing much more serious medical problems, it is understandable that fungal nails can be passed over as very minor, though it is anything but that.

Whatever the case, the disease, characterized by a change in a toenail's color, is often considered nothing more than a mere blemish -- ugly and embarrassing. It is apparently assumed that since white markings or a darkening of the nail are minor occurrences, the change represents something minor as well, even when the blemish spreads. It may be that cosmetologists see this condition as often as doctors. Nail polish is an easy solution for many women, rendering the problem "out of sight, out of mind."

In many cases, however, that change in color is the start of an aggravating disease that ultimately could take months to control. Fungal infection of the nails is known to podiatrists and other physicians as onychomycosis. It is an infection underneath the surface of the nail, which can also penetrate the nail. If it is ignored, its spread could impair one's ability to work or even walk. That happens because it is frequently accompanied by thickening of the nails, which then cannot easily be trimmed and may cause pain while wearing shoes. This disease can frequently be accompanied by a secondary bacterial and/or yeast infection in or about the nail plate.

What is a Fungal Nail?

Onychomycosis is an infection of the bed and plate underlying the surface of the nail, and is caused by various types of fungi, which are commonly found throughout the environment. Fungi are simple parasitic plant organisms, such as molds and mildew, that lack chlorophyll and therefore do not require sunlight for growth. A group of fungi called dermophytes easily attack the nail, thriving off keratin, the nail's protein substance.

When the tiny organisms take hold, the nail may become thicker, yellowish-brown or darker in color, and foul smelling. Debris may collect beneath the nail plate, white marks frequently appear on the nail plate, and the infection is capable of spreading to other toenails, the skin, or even the fingernails.

Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are especially vulnerable around damp areas where people are likely to be walking barefoot -- swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more susceptible to all types of infection, including fungal infection. Those who suffer chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails. Other contributory factors may be a history of athlete's foot and excessive perspiration.


Because fungi are everywhere, including the skin, they can be present months before they find opportunities to strike, and before signs of infection appear. By following precautions, including proper hygiene and regular inspection of the feet and toes, chances of the problem occurring can be sharply reduced, or even put to a halt.

Clean, dry feet resist disease; a strict regimen of washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection. Shower shoes should be worn when possible, in public areas. Shoes, socks, or hosiery should be changed daily. Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe. Use a quality foot powder -- talcum, not cornstarch -- in conjunction with shoes that fit well and are made of materials that breathe.

Avoid wearing excessively tight hosiery, which promotes moisture. Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks, especially for those with more active life styles.

Artificial Nails and Polish

Moisture collecting underneath the surface of the toenail would ordinarily evaporate, passing through the porous structure of the nail. The presence of an artificial nail or a polish impedes that, and the water trapped below can become stagnant and unhealthy, ideal for fungi and similar organisms to thrive.

Always use preventive measures when applying polishes. Disinfect home pedicure tools and don't apply polish to nails suspected of infection ń those on toes that are red, discolored, or swollen, for example.


Depending on the nature of the infection and the severity of each case, treatment may vary. A daily routine of cleansing, over a period of many months, may temporarily suppress mild infections. White markings that appear on the surface of the nail can be filed off, followed by the application of an over-the-counter liquid antifungal agent.

However, even the best-over-the-counter treatments, such as Tineacide or Nailstat antifungal cream, may not prevent a fungal infection from coming back. A fungus may work its way through the entire nail, penetrating both the nail plate and the nail bed. If an infection is not overcome, or continues to reappear, further medical attention is strongly recommended.

Podiatric Medical Care

A podiatric physician can detect a fungal infection early, culture the nail, determine the cause, and form a suitable treatment plan, which may include prescribing topical or oral medication, and debridement (removal of diseased nail matter and debris) of an infected nail. Debridement is a common foot care procedure performed by DPMs.

Newer oral antifungals approved by the Food and Drug Administration may be the most effective treatment. They offer a shorter treatment outlook (three to four months) and improved effectiveness, though DPMs advise that lengthier treatments, up to 12 months, may still be required for some infections. Current studies show that, for a small percentage of the population, there are some unwanted side effects with any oral antifungal.

In some cases, surgical treatment may be required. Temporary removal of the infected nail can be performed to permit direct application of a topical antifungal. Permanent removal of a chronically painful nail, which has not responded to any other treatment, permits the fungal infection to be cured, and prevents the return of a deformed nail.

Trying to solve the infection without the qualified help of a podiatric physician can lead to more problems. With new technological advances in combination with simple preventive measures, the treatment of this lightly regarded health problem can often be successful.

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Fungal Toenail and Foot Health Tips From The APMA

Foot Health Tips:
bulletWash your feet regularly with soap and water.
bulletRemember to dry your feet thoroughly after washing.
bulletProperly fitted shoes are essential; an astonishing number of people wear shoes that don't fit right, and cause serious foot problems. A shoe with a firm sole and soft upper is best for daily activities.
bulletShower shoes should be worn when possible, in public areas.
bulletShoes, socks, or hosiery should be changed daily.
bulletToenails should be clipped straight across so that the nail does not extend beyond the tip of the toe.
bulletUse a quality foot powder -- talcum, not cornstarch -- in conjunction with shoes that fit well and are made of materials that breathe.
bulletAvoid wearing excessively tight hosiery, which promotes moisture.
bulletWear socks made of synthetic fiber which tend to "wick" away moisture faster than cotton or wool socks, especially for sports activity.

Reprinted and edited with permission from the American Podiatric Medical Association.

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The Food and Drug Administration (FDA) is issuing a public health advisory concerning Sporanox® (itraconazole) Capsules and Lamisil® (terbinafine hydrochloride) Tablets for the treatment of onychomycosis. It is important for physicians to be aware of the association of congestive heart failure and hepatic adverse events with the administration of these therapies. Prior to prescribing systemic antifungal drug therapy for the treatment of onychomycosis, healthcare professionals should consider this new safety information.

Sporanox® Capsules and Lamisil® Tablets, synthetic antifungal agents, are approved in the United States for the treatment of onychomycosis [Sporanox® Capsules, Oral Solution, and Injection are also approved for the treatment of serious systemic fungal infections (e.g., esophageal candidiasis, aspergillosis, blastomycosis, and histoplasmosis).]


FDA believes that there is a small but real risk of developing congestive heart failure associated with Sporanox® therapy. Recent studies conducted in dogs and healthy human volunteers revealed negative inotropic effects with intravenous (IV) itraconazole. In these studies, once the drug was stopped the negative inotropic effects resolved. The mechanism for these cardiac effects has not been determined.

Since becoming aware of these findings, FDA reviewed spontaneous post-marketing reports received between September 1992 and April 2001 for congestive heart failure (CHF) in association with itraconazole use. During this period, FDA received 94 U.S. and international spontaneous reports of CHF in which itraconazole was listed as a suspect drug. In 58 of the 94 cases, FDA believes itraconazole contributed to or may have been the cause of CHF. In 26 of the 58 cases, itraconazole was being administered for the treatment of onychomycosis. Of these 58 cases, 28 were hospitalized. Death was reported in 13 cases. However, the causal relationship between the 13 deaths and itraconazole is unclear because of confounding factors, including 10 of the 13 patients who had serious underlying conditions.

Because of the low but possible risk of cardiac toxicity, Sporanox® should NOT be administered for the treatment of onychomycosis in patients with ventricular dysfunction such as CHF or a history of CHF. If signs or symptoms of CHF occur during treatment for onychomycosis, Sporanox® should be discontinued.

If signs or symptoms of CHF occur during treatment for more serious systemic fungal infections, continued Sporanox® use should be reassessed as to the appropriate risk benefit analysis in relationship to any other therapeutic options.


Both Sporanox® and Lamisil® have been associated with serious hepatic toxicity, including liver failure and death, including some cases involving patients who had neither pre-existing liver disease nor a serious underlying medical condition.

As of April 2001, the FDA is aware of 16 cases of liver failure in association with Lamisil® Tablet use (including 11 deaths and two liver transplantations). These patients received Lamisil® Tablets for the treatment of various dermatologic conditions, including onychomycosis.

FDA's concerns about hepatic risks associated with the use of Lamisil® do not apply to topically applied formulations of terbinafine, such as Lamisil® Solution and Lamisil® AT Cream.

As of March 2001, the FDA is aware of 24 cases of liver failure associated with Sporanox® use (including 11 deaths). These patients received Sporanox® for the treatment of either onychomycosis or systemic fungal infections.

Given the possible risks associated with both drugs, FDA wants healthcare providers to be aware of this new safety information for the two most commonly prescribed systemic onychomycosis drug therapies. Because of these risks, the new labeling for both Sporanox® and Lamisil® recommends that healthcare providers obtain nail specimens for laboratory testing prior to prescribing the medications for onychomycosis to confirm the diagnosis. However, there is insufficient data to allow FDA to make any kind of statement about the comparative safety of Sporanox® and Lamisil®.


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