Onychomycosis is very difficult and
sometimes impossible to treat, and therapy is often long-term.
Therapy consists of topical treatments that are applied directly to
the nails, as well as two systemic drugs, griseofulvin and
ketoconazole. Topical therapy is reserved for only the mildest
cases. The use of griseofulvin and ketoconazole is problematic, and
there are typically high relapse rates of 50-85%. In addition,
treatment must be continued for a long duration (10-18 months for
toenails), with monthly laboratory monitoring for several side
effects, including liver toxicity. Individuals taking these
medications must also abstain from alcohol consumption.
In the last five years, newer oral
antifungal agents have been developed, and include itraconazole
(Sporanox), terbinafine (Lamisil), and fluconazole (Diflucan). These
agents, when taken orally for as little as 12 weeks, bring about
better cure rates and fewer side effects than either griseofulvin or
ketoconazole. The most common side effect is stomach upset.
Patients taking oral antifungal therapy must have a complete blood
count and liver enzyme workup every four to six weeks. Terbinafine
in particular has markedly less toxicity to the liver, one of the
more severe side effects of the older agents, griseofulvin and
ketoconazole.
Treatment should be continued until
microscopic exam or culture shows no more fungal infection. Nails
may, however, continue to look damaged even after a clinical cure is
achieved. Nails may take up to a full year to return to normal. If
the nail growth slows or stops, additional doses of antifungal
therapy should be taken.
Nail debridement is another treatment
option, but it is considered by many to be primitive compared with
topical or systemic treatment. Clinicians perform nail debridement
in their offices. The nail is cut and then thinned using surgical
tools or chemicals, and then the loose debris under the nail is
removed. The procedure is painless, and often improves the
appearance of the nails immediately. In addition, it helps whatever
medication being used to penetrate the newly thinned nail. Patients
with very thickened nails will sometimes undergo chemical removal of
a nail. A combination of oral, topical, and surgical removal can
increase the chances of curing the infection.
In general, nutrition may also play a
role in promoting good nail health and thus preventing nail disease.
Adequate protein and minerals, in the form of nuts, seeds, whole
grains, legumes, fresh vegetables, and fish, should be consumed.
Sugars, alcohol, and caffeine should be avoided.
Onychomycosis is typically quite
difficult to cure completely. Even if a clinical cure is achieved
after long therapy with either topical or oral drugs, normal regrowth
takes four to six months in the fingernails, and eight to 12 months
in the toenails, which grow more slowly. Relapse is common, and
often, the nail or nail bed is permanently damaged.
Keeping the feet clean and dry, and
washing with soap and water and drying thoroughly are important
preventive steps to take to prevent onychomycosis. Other preventive
measures include keeping the nails cut short and wearing shower shoes
whenever walking or showering in public places. Daily changes of
shoes, socks, or hosiery are also helpful.
Excessively tight hose or shoes promote
moisture, which in turn, provides a wonderful environment for
onychomycotic infections. To prevent this, individuals should wear
only socks made of synthetic fibers, which can absorb moisture more
quickly than those made of cotton or wools. Manicure and pedicure
tools should be disinfected after each use. Finally, nail polish
should not be applied to nails that are infected, as this causes the
water or moisture that collects under the surface of the nail to not
evaporate and be trapped.
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