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Paging Dr. Frischer - Nail fungus
WRITTEN BY :   Dr. Alan Frischer

Today, let’s discuss a non-fatal but highly annoying problem – I encounter it among my patients several times every day. It’s the disfiguring problem of onychomycosis, better known as…nail fungus.
Nail fungus might first show up as a white or yellow spot under the tip of your finger or toenail. As it spreads deeper, the nail may discolor, become thicker, and develop crumbling, ragged edges. There could be distortion in shape, dull color without luster, and darkening with debris building up under the nail. The nail might separate from the nail bed, and there may be pain and even foul odors.
What is a fungus? It is a microscopic organism that does not need sunlight to survive. Some fungi can be beneficial, but others cause illness and infections. Fungi prefer to live in warm, moist environments, including showers and swimming pools. They invade the skin through a tiny cut, or through a small separation between the nail and nail bed. They multiply and cause problems if a nail is continually exposed to warmth and moisture. Note that the fungus is primarily in the nail bed and not the nail itself, so any treatment is directed at the nail bed.
Nail fungus occurs more often in toenails then in fingernails. Think about it: toenails spend much of their time in confined, dark, warm, moist places; just perfect for fungi. Our toes spend time in contact with the ground, and are washed less frequently than are our fingers. In addition, our toes have poorer circulation than do our fingers, making it more difficult for our body’s immune system to detect and eliminate the infection.
Who is more likely to get nail fungus? Age is the most significant risk factor. As we age, our blood circulation diminishes, we have had more years of exposure to fungi, and our nails grow more slowly and thicken, increasing their susceptibility. Men are more likely than women, and there appears to be a genetic component. Other likely victims include those who perspire heavily, work in a humid or moist environment; have psoriasis; wear socks and shoes that hinder ventilation; walk barefoot in damp public places such as swimming pools, gyms and shower rooms; have athlete’s foot; or have a minor skin or nail injury, damaged nail, or another infection. It affects a whopping one-third of those with diabetes.
The diagnosis is usually made by a simple clinical exam. If the exam is unclear, then your doctor can scrape debris from under the nail and have it examined under a microscope or cultured in a lab. Psoriasis sometimes looks similar to a fungal infection, and yeast and bacteria can also infect the nail.
Nail fungus can be a major issue for those with a weakened immune system or a chronic disease. They pose the greatest risk to, among others, those with leukemia, AIDS, organ transplants, or diabetes. Diabetics have poor circulation to the feet, putting them at greater risk for cellulitis, a potentially serious bacterial skin infection. Bacterial infections can spread to bones or travel throughout the body. For a diabetic, any minor injury to the feet, including a fungal toenail infection, can lead to serious problems.
Fungal nail infections may seem low-tech, but they are quite difficult to treat! Over-the-counter medicines are available but not very effective. If you are in the higher risk group for more serious complications due to having diabetes or a history of cellulitis, or are experiencing pain or discomfort, then your doctor is likely to recommend one of the more effective oral antifungal medications, such as Lamisil. Even then, it may take four months or longer to eliminate the fungus, and recurrent infections are possible.
Another option for treatment is Penlac, an antifungal nail lacquer. Penlac is painted onto the infected nail and surrounding skin, and could take up to a year of daily use to clear up the infection. If the nail infection is severe or very painful, surgery may be recommended in order to actually remove the nail. A new nail will grow in its place, which takes a long time – and may again be infected! A newer treatment known as photodynamic therapy uses a laser. This approach may be successful, but is not yet widely available.
Home remedies include vinegar, and Vicks VapoRub. There are no conclusive scientific studies that either will cure nail fungus, although some studies do show that Vicks may inhibit growth of certain bacteria, and there are many anecdotal reports that it does work.
When should you see a doctor? Keep in mind that once a nail fungal infection begins, it can persist indefinitely if not treated. See your doctor at the first sign.
The best approach to avoiding nail fungus, as with so many of our health issues, is prevention:

*Keep your nails short, dry and clean.
*Wear socks that keep your feet dry. If possible, try alternating open and closed-toed shoes.
*Use an antifungal spray or powder if you are prone to fungal infections or spend time around a pool or locker room.
*Avoid going barefoot in public places.
*Wear rubber gloves to protect your hands from overexposure to water.
*Go to reputable nail salons that carefully sterilize their instruments. Better yet, bring your own.
*Avoid artificial nails, as they may trap fungus underneath and allow the infection to grow.
*Wash your hands after touching an infected nail.

Enjoy these summer months, but keep those hands and feet clean, cool, and dry!
Dr. Alan Frischer is former chief of staff and former chief of medicine at Downey Regional Medical Center. Write to him in care of this newspaper at 8301 E. Florence Ave., Suite 100, Downey, CA 90240.

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Published: Aug. 8, 2013 – Volume 12 – Issue 17



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