Fungal toenails are a common problem in the United States. While about 36 million people in the United States are estimated to have onychomycosis (medical term for fungal nails), only about 6.3 million have had their condition been diagnosed by a physician. Recent statistics show that of the 6.3 million who have been diagnosed, only 2.5 million people per year are actually being treated for this disease. That means there are some 33 million people with this disease who are not being treated. Furthermore, of those 35 to 36 million people who have onychomycosis, 90 percent of them do not even know what the condition is called.

According to WebMD, You are more likely to get a nail infection if you:

• Are older than 60
  
• Have diabetes or a weak immune system.
  
• Have a nail injury like a hangnail or an ingrown toenail.
  
• Wear shoes that make your feet moist or sweaty.
  
• Live or work in a hot, humid place

Five subtypes of onychomycosis are recognized:[ Baran R, Hay RJ, Tosti A, Haneke E. A new classification of onychomycosis. Br J Dermatol 1998; 139: 567-71.] distal lateral onychomycosis, proximal subungual onychomycosis, superficial onychomycosis, total dystrophic onychomycosis, and endonyx onychomycosis.

It is interesting that onycholysis (thicking, yellowing, or separation of the nail from the nail plate), a commonly reported sign in onychomycosis, did not reach statistical significance as a predictive sign. Although often traumatic, onycholysis was present in 73% of the nails which were found to have positive mycology results (positive test for fungus) Perea S, Ramos MJ, Garau M et al. Prevalence and risk factors of tinea unguium and tinea pedis in the general population in Spain. (J Clin Microbiol 2000; 38: 3226-30)

What Mimics Onychomycosis? Toenail fungus may be confused with other nail dystrophies such as traumatic damage, psoriasis, senile ischemia, a tumor of the nail bed, peripheral vascular disease, atopic dermatitis, contact dermatitis, lichen planus, and yellow nail syndrome (i.e., discolored nails, lymphedema, lichen planus).[2Hainer BL. Dermatophyte infections. Am Fam Physician. 2003;67:101-108] Hypoalbuminemia, cirrhosis, and striate leukonychia can induce whitening of the nails resembling a fungus.

Treatment Options:

There are multiple options for the treatment of fungal toenails. The gold standard for the last several years has been Lamisil (terbinafine, 250 mg/day). Lamisil is metabolized in the liver and may (in rare cases) cause the elevation of the liver enzymes. Standard treatment with this drug is to monitor these levels with an initial blood test, and a follow up blood test half way through the 90 day therapy. Currently Lamisil is available on the $4 drug list at many major pharmacies for a total cost of treatment between $10-12.

Multiple topical therapies are available such as Penlac (ciclopirox topical solution) also on most $4 drug lists. This medication requires daily treatment for 6-12 months and effective rates vary, but are generally very low. Other topicals such as Fungisil are available online or in our office.

The latest treatment option for nail fungus is laser therapy. Click here to read the latest research on fungal nails and laser therapy. This technology works by applying a laser to each toe for up to 10 minutes. It is reported to be pain free, and allows the nail to grow out in 6-12 months without the fungus. There are several issues with regards to the laser treatment. First, it is not covered by insurance, and can cost over $1000.00. Second, it is not FDA approved for toenail fungus. Both lasers available in the United States have been approved for either dental or septal surgery, but not for nail surgery. Third, do you really have fungus? If you only have onycholysis, the laser will not work. Forth, you have to treat the cause of the fungus, such as creating a fungal free space by ultraviolet light for your shoes, and antifungal powders to your feet which can make the costs much greater. Fifth, the studies that show this technology works are small, non-evidence based, non-blinded studies. Currently there are studies underway, but the results will not be available until 2010 at the earliest. Sixth, the laser does nothing to prevent reinfection of the nail. Seventh, no data exists to determine which type of onychomycosis the laser treats. Please read this article from the NY times about laser treatment.

Fungal Nails are a very difficult medical problem to treat. It is our goal to provide you information about the condition and answer any questions that you may have. The doctors at www.wetreatfeet.com are available for consultation in and around Baltimore, MD. Please call our office to schedule an appointment.