CLINICAL FUNGAL INFECTION CPD SUPERFICIAL FUNGAL INFECTIONS OF THE NAILS Superficial fungal infections tend to infect the stratum corneum layer of the skin, the hair or the nails, causing various types of clinical symptoms, which can be very distressful to the patient.
AETIOLOGY AND Onychomycosis is much more common mellitus or peripheral PREVALENCE in adults and can affect up to 80% of circulatory disorders. There are many diseases that can the geriatric population. Onychomycosis afflict the nails causing them to become can persist for years and rarely ever Figure 2: unsightly. Of those diseases, around gets cured without treatment. The Examples of 50% are due to fungal infections. On cure rate is only 48%-75% with the onychomycosis average, around 8% of the population fingernails having the best prognosis. will be affected by a fungal infection of However, most people will have TOENAILS VS the nails, called onychomycosis. some residual nail changes such as FINGERNAILS Onychomycosis refers to a fungal permanent discoloration of the nail Nail fungus occurs more infection that affects the nails. These plate. One should also be aware often in toenails than in fungi, known as dermatophytes, infect that the reinfection rate is as high as fingernails, partly because: the superficial layers of the skin and its 50%, therefore regular check-up is • Toenails often are appendages. These dermatophytes are mandatory. confined in a dark, warm, divided into three genera; trichophyton, moist environment - inside microsporum and the epidermophyton. SYMPTOMOLOGY shoes - where fungi The most common infective agents Nail fungus is a common condition that can thrive are the Trichophyton rubrum and T. begins as a white or yellow spot under • Toes usually have less mentagrophytes. There are instances the tip of the fingernail or toenail. Later blood flow than do fingers, where moulds and yeasts can cause on, there is subungual hyperkeratosis making it harder for the infection of the nails, but this occurs which becomes more prominent and body's immune system to less likely and with a slightly spreads until the entire nail becomes detect and stop infection. different picture. affected. Toe nails are more frequently As the fungal infection continuous DIAGNOSIS involved and can lead to pain, deeper into the nail, the fungus may The diagnosis is made discomfort, paraesthesia and loss of trigger the nail to discolour, thicken clinically, however, if unsure, dexterity. The fungus gains access to and become brittle and eventually there are various methods the nail bed via the hyponychium [this is separated from its bed (referred to as to detect the presence of the organism. makes a person more prone to the area between the nail plate and the onycholysis) as a result of piling-up of These methods include fungus developing such infections. Factors distal part of the finger (see Figure 1)]. subungual keratin. At this stage, the detection by sending nail clippings that can increase risk of developing nail At times, the infection can also begin patient might experience pain in the to the laboratory, polymerase chain fungus include: from the nail folds. The organism then toes or fingertips and a slightly foul reaction (not widely available) and the • Age, owing to reduced blood flow, multiplies and causes damage to the odour may occur. The infection can use of dermoscopy by dermatologists. more years of exposure to fungi and nail plate. At a later stage, total damage affect several nails but usually not all Clinical diagnosis is most commonly slower growing nails. to the nail plate ensues. of the nails at once. With progression used, bearing in mind that conditions • Heavy perspiration. the infection can spread to the other like malignant melanoma, lichen • Male gender, especially if you have a Figure 1. toes and fingernails if left untreated, planus, psoriasis, eczema and trauma family history of nail fungal infections. affecting all the nails in the end, also commonly cause changes of the • Working in a humid or moist resulting in discomfort and loss of nail plates. One should not rely fully environment or in a job where confidence to the patient. on the final results due to the fact the hands are often wet, such as This complaint is not purely a that there is a very high rate of false bartending or housekeeping cosmetic problem, but is also a sign negative results. If unsure, a biopsy • Wearing socks and shoes that of local weakness in the defensive can be performed to differentiate from hinder ventilation and don't absorb functions in the area affected. psoriasis of the nails, eczema or even perspiration Onychomicosis is a potential health melanoma. • Use of communal baths Nail plate hazard for persons suffering from RISK FACTORS • Living with someone infected with a hyponychium metabolic disorders such as diabetes There are many risk factors that nail fungus
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• Walking barefoot in damp communal damage to the nails. It may also PREVENTION patient has sweaty feet. areas, such as swimming pools, gyms lead to other serious infections that Are there any ways to prevent the • Choose shoes that reduce and shower rooms spread beyond the feet if you have a infection? It is almost impossible to humidity. It also helps to • Athlete’s foot suppressed immune system due to prevent onychomycosis, but one can occasionally take off shoes or wear • Minor skin or nail injuries or a skin medication, diabetes or other medical decrease the chance of getting it. open-toe footwear. condition, such as psoriasis underlying conditions. Furthermore, due to the high relapse • Discard old shoes. If possible, avoid • Diabetes, circulation problems, a Diabetic patients may have reduced rate it is very important to be aware wearing old shoes, which can harbour weakened immune system or, in blood circulation and nerve supply in of and implement the below habits, to fungi and cause a reinfection. Or treat children with Down syndrome. the feet. They are also at greater risk of prevent reinfection of the nails: them with disinfectants or antifungal cellulitis, therefore any relatively minor • Keep hands clean, nails short powders. COMPLICATIONS injury to the feet - including a nail fungal and dry. • Use an antifungal spray or A severe case of nail fungus can be infection - can lead to a more serious • Wear socks that absorb sweat. powder. Spray or sprinkle your feet painful and may cause permanent complication. Change socks often, especially if the and the insides of your shoes. • Wear rubber gloves. This protects your hands from overexposure to water. Between uses, turn the gloves inside out to dry. • Don't trim or pick at the skin around nails. This may give germs access to skin and nails. • Don't go barefoot in public places. Wear sandals or shoes around pools, showers, and locker rooms. • Choose a reputable nail salon. Make sure that manicurists sterilise their instruments. Better yet, bring your own and disinfect them after use. • Give up nail polish and artificial nails. Although it may be tempting to hide nail fungal infections under a coat of polish, this can trap unwanted moisture and worsen the infection. • Wash your hands after touching an infected nail. Nail fungus can spread from nail to nail.
TREATMENT Treating onychomycosis can be challenging as the nails grow slowly, receive very poor blood supply along with the high recurrence rate, which results in the need for a prolonged treatment regime until the regrowth of a healthy nail. The regrowth of a healthy finger nail can take anything from 6-9 months, whereas toenails can take up to 18 months. Most cases are treated with oral antifungals and at times combining oral treatment with topical treatment may increase the chances of cure. Terbinafine can be taken orally as it distributes into the nail plate within a few weeks and the treatment should be continued for at least three to four months. As for itraconacozole, it may be taken in a pulse regimen of 400 mg twice daily for a week once a month. Fingernail treatment should be continued for at least 4-6 months and toe nails may need much longer time period. Published results of clinical studies with oral administration of antimycotic preparations (terbinafin / itraconazol) show that the rates of healing in the case of oral therapy were far short of 100%. After 72 weeks, the success rate with terbinafin was 75% (12-week therapy) and 80% (16- week therapy) respectively. X With itraconazol, after three pulse-
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therapy cycles only 38%, and after topically reach the problem site which active substances (i.e. clotrimazole, All study participants assessed four pulse-therapy cycles only 49% is located underneath the nail, in the amorolfine, terbinafine) as well as a the application of the respective test of patients were classified as nail bed. Furthermore, some topical product containing plant oils as the substances, using the applicator being healed. solution available on the market are active ingredients were tested on 50 system, as being easy and reliable. Furthermore, available preparations still regarded as expensive and not very patients with onychomycosis, using a All participants rated local tolerance which have to be applied systemically convenient to apply, requiring frequently newly-developed carrier system (ethyl as good. No local side effects were are relatively expensive, with some of filing or buffing of the nail(s) which lactate) as the medium. observed. In view of the test results, then having considerable side effects. could become very uncomfortable or A customary antimycotic nail primary therapy in the case of Thick nails can be chemically sore if done continuously. Other topical varnish (amorolfine) was selected as chemically/microscopically diagnosed removed using urea or surgically treatments result in much wastage a comparison preparation. The result onychomycosis using topical application avulsed. Laser beams can also of the product, due to poor product of the comparative study shows that of one of the test substances examined, penetrate the nail plate and kill the applicators available which results the active substances dissolved in the dissolved in the Clearnail BioEqual fungus. The Nd:YAG or photodynamic in inconvenient usage and poor newly-developed carrier system (ethyl carrier system, is an efficient and safe therapy can be used, but more than patient compliance. lactate) are therapeutically clearly therapy option. No local side effects one treatment is required and these Up to now, the majority of the superior compared to the nail varnish. were found in any of the cases, and treatment options are costly. topical application systems available Overall, among the 50 study rationally, no systemic side effects are The therapy associated with in the market have all been limited participants, 176 toenails with to be expected. onychomycosis has been an unresolved by their greatly inadequate efficacy. onychomycotic changes were treated. Therefore, due to the known side problem. Due to the side effect and/ The following paragraphs discuss the The topically applied antimycotic effects associated with systemic or cost implications of systemic clinical efficacy of an effective topical preparations clotrimazole, amorolfine, antimycotic therapy, and other and chemical/ laser therapy topical treatment solution available. terbinafine and the Phyto-Combination therapeutic options being significantly treatment options are often considered in the BioEqual carrier system returned more expensive, preference should for the treatment of fungal nail CLINICAL EVIDENCE successful results of between 90%- be given to topical therapy using infections. However, the effectiveness FOR A TOPICAL SOLUTION 100%. With the use of the comparison standardised applicator systems of topical solutions is unsure, mainly AVAILABLE substance amorolfine varnish, after 12 (BioEqual carrier systems). due to the uncertainty as to how the In a study conducted by Miller in 2001, weeks only 24 out of 34 toenails, i.e. active ingredients that are applied three known allopathic, antimycotic 70%, were free of mycotic infection. References available on request. SUPERFICIAL FUNGAL INFECTIONS
OF THE NAILS 3 CPD POINTS SURNAME INITIALS YOUR HPCSA REGISTRATION NO. MP Address:
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The three essentional oils in Clearnail (Bio-Equal) are…… Can Clearnail be used by the elderly and athletes? A 1 A. Tea tree, Eucalyptus, Blue Cypress 6 A. No A B B. Tea tree, Lavender, Blue Cypress B. Usually B C C. Lavender, Eucalyptus, Tea tree C. Yes C D D. None of the above D. Sometimes D
Which one of the following facilitates the absorption of Clearnail (Bio-Equal)? On average what is the % rate of people that can be affected by 2 A. Ethyl Lactate A 7 fungal infections? B. Amorolfine B C A. 10% A C. Terbinafine B D. All of the above D B. 14% C. 8% C D Who was the author of the study entitled Onychomycosis? D. 6% 3 A. Dr W Smith A B. Dr S Gunther B What are the risk factors that can lead to nail fungus infection? C. Dr W Miller C 8 A. Being older, owing to reduce blood flow, and slower growing D. None of the above D of the nails. A B. Perspiring heavily B Which nails (hands or feet) are predominantly affected by fungal infestation? 4 C. All of the above C And % occurrence. D. None of the above D A. Hands 10%/Feet 90% A B. Hands 60%/Feet 40% B True or false: A severe case of infection can be painful and cause C. Hands 20%/Feet 80% C permanent damage to a nail D. Hands 40%/Feet 60% D 9 A. False A B What is the dosage/directions for use of Clearnail? B. True A A. Once daily for 3 weeks. 5 B B. Twice daily for 6 months, then once daily. The Bio-Equal Carrier System (Clearnail) is safe to use C A 10 A. False C. Twice daily for 4 weeks, then once daily. D B D. Thrice daily for 4 weeks then twice daily. B. True
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