Nailing a stubborn problem

Nail infections are common and unpleasant, but a leading dermatologist explains how they can be beaten.

nails 88 (photo credit: )
nails 88
(photo credit: )
Fingernails are handy: They're part of our sense of touch, protect our fingertips, help us manipulate objects, and make us feel good if they look healthy. They also provide a diversion (biting) when we're nervous. Toenails are dandy too (albeit a little harder to bite). But many people don't have perfect nails. Bodily disorders can be reflected in the state of your nails. An estimated 10 percent of Israelis (700,000 people) suffer from onychomycosis (nail fungus) and other chronic disorders of the nail. Nearly a third of all consultations with dermatologists involve nail problems, usually for toenails. Having healthy nails isn't just a matter of ego. When a toenail develops a fungal infection, it typically turns yellow or brown and becomes thick and overgrown. Foul-smelling debris may accumulate under the nail, especially at the sides and tip. As the infection worsens, the nail may either crumble gradually and fall off or become so thick that the affected toe feels painful in shoes, causing mobility problems. Complications can lead to the disfigurement or even destruction of a nail, serious infections, pain and disability. Because of Israel's warm and often moist climate, nail diseases are more common here than in colder countries; in the US, prevalence ranges from 3% to 5%. And some Israeli populations and vocational groups get it more often than others. Haredi newspapers usually carry many ads for clinics that purport to "miraculously" cure nail fungus. The main reason for the high rate of toenail fungus in the ultra-Orthodox community is that during the hot months, most of the men, women and children wear closed leather shoes - with moisture and heat encouraging the growth of organisms - rather than open sandals, which are more suited to this climate. IT CAN TAKE more than a year to cure nail disease, as nails grow very slowly - around three millimeters per month on the hands and 1.5 mm. on the feet. A thumbnail renews itself in four to six months, and a big-toe nail between 12 and 18 months. Of all the toenails, those on the big toe and little toe are the most likely to develop a fungus. This may be because these digits are constantly exposed to friction from shoes. Dr. Robert Baran, a leading dermatologist and nail expert from Cannes, France, visited Israel recently for 24 hours as a guest of Taro, a pharmaceutical company that makes drugs for nail conditions (among others). Baran, formerly head of the dermatology department at Cannes General Hospital, now has a private practice and specializes in nail disease. A member of the American Dermatology Society and American Academy of Dermatology, he has published 450 articles in medical journals. In an interview with The Jerusalem Post, he described the various nail diseases and their treatments. Nail disease, Baran says, is quite unusual in young children, but the older one gets, the more likely it is to appear. In the elderly and in diabetics of any age, circulation to the fingers and toes may be impaired, thus promoting the growth of fungus or other pathogens under the nails. In older people and in HIV carriers and AIDS patients, the immune system weakens, enabling pathogens to take control of tissues more easily; about half of people over 70 have nail disease, which is more likely to affect men than women. Nail fungus is also common among sportsmen (due to sweat and contamination in locker rooms and swimming facilities), professional dishwashers, housecleaners and others who often have their hands in water. Nail trauma may promote fungus. Joggers are at higher risk, and toenail fungus is often accompanied by athlete's foot. Wearing nail polish, unless it is very thick, is usually not a problem, he says. But the current fashion of applying artificial acrylic nails and polymerizing the glue with ultraviolent light can promote onychomycosis, which constitutes half of all nail disorders. Baran discourages the use of false nails by those who suffer from nail infections Onychomycosis can be caused by several types of fungi (microscopic organisms related to mold and mildew) that thrive in the dark, moist and stuffy environment inside shoes. As they multiply, fungi feed on keratin - the tough protein that makes up the surface of toenails. In most cases, the fungus belongs to a group called dermatophytes, which include Trichophyton rubrum, Trichophytoninterdigitale, Epidermophyton floccosum, Microsporum audouinii, Microsporum canis, Microsporum gypseum, Trichophyton mentagrophytes, Trichophyton rubrum and Trichophyton schoenleinii. Candida yeasts can also infect nails, and bacteria can make them turn green or black. . MANY PEOPLE try to treat themselves, and pharmacies are happy to sell them various preparations, usually a yellow concoction based on tea tree oil (melaleuca oil), which is an antifungal agent. But Baran says these are of little use compared to prescription medications, both topical (applied to the nail) and oral. "They are useless compared to real drugs, but there is a tendency to want natural things. These may help a little, but if there is a significant infection, these remedies will not cure patients, and if the fungus does go away, it is likely to return." But Baran says that diluted vinegar, because it's an acid, can kill off Pseudonomas bacterial infections, which can make a nail green and smell bad. Nail fungus will rarely heal by itself, and can often spread to other nails. So it is best to go to a dermatologist, as the actual microorganism that causes the disease should be identified and any underlying causes diagnosed. Because psoriasis sometimes can cause nail problems that look like a fungal infection, your doctor may ask whether you or anyone in your family has psoriasis. In some people with psoriasis, the nails - rather than the skin - are the only part of the body affected, but there can be double trouble, with both psoriasis and a fungal infection affecting the same nail. To confirm a diagnosis, dermatologists will often take small samples of the affected nails and send them to a lab. In very serious cases, when toenail fungus is resistant to treatment, it may be necessary to remove the nail surgically. If the infection is limited to one nail, your doctor may prescribe a medicated nail lacquer (polish) containing either amorolfine (commercially known as Loceryl) or ciclopirox (Loprox). Loceryl, made by Taro, has been available for several years abroad, and is being launched in Israel over the coming weeks. Available only by prescription and not included in the basket of health services, a little bottle will cost NIS 150, but it should last for six months to a year, as this lacquer is applied only once a week. The drug, says Baran, is effective against a broad spectrum of dermatophytes, yeasts and molds. Amorolfine, which leaves a film on the nail, kills fungi and yeasts for at least a week after application by interfering with their cell membranes, preventing fungi from producing a substance called ergosterol, Baran explains. The disruption in ergosterol production disrupts the cell membrane which keeps substances from entering the cells and stops the cell contents from leaking out. As amorolfine disrupts the cell membranes, it kills the fungal cells. Loceryl is painted onto unvarnished infected nails like nail polish, and as it's resistant to soap and water it stays on, allowing the medicine to penetrate into the nail bed and attack the infection. Baran notes that if only a small area of the nail was invaded by fungus, the lacquer can cure the condition in three months, but if the area is larger, it takes longer. It is important to continue the treatment without interruption until the infected section of nail has completely grown out; otherwise the infection will return. In most cases, it can take six months to clear up a fingernail infection and nine to 12 months for toenails. It is recommended that you see your doctor every three months during treatment to make sure the medication is working correctly. If the infection affects a wide area of the nail, or several nails, your dermatologist will probably prescribe an oral antifungal medication such as itraconazole (Sporanox) or terbinafine (Lamisil). Either itraconazole or terbinafine can be taken daily for 12 weeks, or a higher dose of itraconazole can be taken for one week per month for three months. Both itraconazole and terbinafine occasionally cause troublesome side effects, especially affecting liver enzymes, and itraconazole has the potential to produce serious drug interactions. Blood tests to ensure that liver function has not been affected are sometimes required before and during treatment with oral drugs. After successful treatment with itraconazole or terbinafine, the fungus returns in approximately 10% to 20% of people. A drug called ketoconazole was the first first oral drug for managing nail fungus infections, but it's no longer in use here as a first-line therapy because of the risk of adverse reactions. Baran notes that in more extensive cases, oral and topical treatments are combined. IN ANY CASE, preventing nail disease is better than treating it. To help head off toenail fungus, keep your toenails trimmed; wear comfortable shoes with good support and a wide toe area together with stockings or socks, and sandals during hot weather that allow your feet some breathing space; wear shoes, sandals or flip-flops in community showers or locker rooms; wash your feet daily and dry them thoroughly; and keep your nails cut short, filing down any thick areas. Always disinfect manicure and pedicure tools with soap and hot water or alcohol before use. If you have your nails professionally manicured, you should bring your own files and trimmers. Wear waterproof gloves for wet work, and 100% cotton gloves for dry work. If you wear socks, pure cotton is best. Change your socks when they get damp from sweat, or if your feet get wet. Put on clean, dry socks every day. You can put over-the-counter antifungal foot powder inside your socks to help keep your feet dry. Now more than ever, it is possible to walk away from nail infections.