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Bay Area Fungal
Nail Clinic

Onychomycosis: A War, Not A Battle

Curing a fungal nail infection (Onychomycosis) is not accomplished in a day, a week, or even a month. “ It is a war, not a battle”, as a patient once said. And it is a war of attrition, best won with a milti-modal approach. Success requires the motivation, and commitment, to adhere to the recommended treatment plan, which is a 6-12 month process, and sometimes longer in severe cases. Severity is determined by the percentage of the nail surface involved, the proximity of the infection to the nail matrix (cuticle area), along with other associated signs and symptoms like thickening of the nail, discoloration, brittleness, and distortions in shape and nail growth patterns. The length of time the infection is present can also play a role. Flaky, crumbly skin surrounding the nail, or a rash along the bottom of your foot, indicates a concurrent fungal infection of the skin, and successfully treating the nails requires treating the skin as well.

Multiple factors make toenail fungus much more common and much harder to treat than fingernails. The early, often subtle changes to the nail can go unnoticed for years, until the infection becomes obvious from five or six feet away, because none of us can look as closely at our toes as we do our fingers. Once noticed, it has often progressed beyond mild, to the point that at-home remedies and over-the-counter medications have little chance of solving the problem. Another factor is the difference in blood flow to our fingers versus our toes. Fingers are one of the best perfused surface areas of the human body. Toes on the other hand are one of the poorest perfused areas. They are the furthest part of the body from the heart, making the blood that reaches them colder, less oxygenated, and less immunologically active. Hence why pedicures can lead to a fungal infection, while manicures generally do not.

During your initial consultation, Dr. Dupont will review with you the different treatment options available and the advantages and disadvantages of each, including the number appointments required, the cost involved, and the likelihood of success. This can range
from simply applying a topical medicine to the nails each day for 6-12 months, to applying a topical medicine combined with periodic laser treatment, the frequency of which will depend on the severity of infection. In severe cases, temporary removal of the nail followed by the application of a topical antifungal as it grows back, provides the highest success rate with the lowest cost. Oral medications are reserved for situations where the patient wants to “throw the kitchen sink at it”, and may require periodic blood testing to monitor liver enzymes.

Before and at 9 months of topical and laser treatment

Successful treatment is achieved by promoting healthy new nail growth over 6-12 months, until the nails have fully grown out and are completely back to normal. Stopping treatment prematurely will allow any dormant fungal spores that might remain in the oldest part of the nail, furthest from the cuticle, to “come alive” and reinfect the healthy new growth. It is a war, not a battle.

The Role of Ingrown Nails
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The Role of Ingrown Nails

We’ve noticed over the years that many of our patients dealing with nail fungus are also battling recurrent ingrown nails that they self treat at home periodically. Cutting the nail back as far as possible on that side and digging into the corner to try to relieve the pressure and pain causes trauma to the nail that will almost certainly lead to a fungal infection eventually. While this home remedy is often successful in the short term, in the long run the ingrown nail usually returns, often worse than before.

These patients are usually unaware that there’s a permanent solution to an ingrown nail. The solution is a partial nail avulsion procedure.

During this quick, minor office procedure the toe is numbed and a thin portion of the nail border is removed along the edge that is ingrown all the way up to, and under, the cuticle. After removal a chemical is applied to the nail root that presents that piece of nail from growing back. Once fully healed there is generally very little cosmetic difference to the nail.

It’s important to address this problem while treating the fungal infection, otherwise there is a much higher chance of a recurrence.

The Role Of Pedicures

After years treating onychomycosis and discussing its etiology with his patients, it became apparent to Dr. Dupont that pedicures were often cited as the cause of a patient’s infection. Dirty instruments or contaminated nail polish, like people often mention, are very unlikely to be the vector for infection. Fungus, or fungal spores, are ubiquitous in the environment. They are on our kitchen counters and bathroom floors. This exposure alone does not normally lead to a fungal infection. Like any infection, fungal or bacterial, the organism needs a point of entry to invade the tissue and begin multiplying. Using any metal instrument, even a sterile one, to push back the nail’s cuticle and aggressively scrape, or “clean out”, around the edges of the nail, interferes with the nail’s natural defences, compromising the physical
barriers that help prevent infection.

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