What Is the Main Idea?

Onychomycosis is a fungal infection that deforms and discolors the nails. Through this post based on the free-access review article “A Paradigm Shift in the Treatment and Management of Onychomycosis” in the journal Skin Appendage Disorders we highlight and explain different aspects of the treatment procedure that we should know and which are required to ensure the success of keeping the fungus away.

What Else Can You Learn?

To ensure complete removal of the fungal infection in the long term, it is important to take a holistic approach. What is this approach? You will understand the importance of diagnostics, different treatment procedures, and, most importantly, sanitization and lifestyle changes required for long-term care.

Understanding Onychomycosis

Onychomycosis is a fungal infection that primarily affects nails of both hands and feet. The infection causes the nails to be deformed (thick and brittle) and discolored with white or yellow patches. Though it is a low-risk infection, it has a significant emotional and social impact. The sufferers feel socially excluded, embarrassed because of the appearance, and are also worried about spreading the infection. In some countries, approximately 5–10% of the population have reported having had onychomycosis, and the rate goes up to 20% or more for the 60 years and older category. This higher rate in the older population is mainly due to reduced blood circulation, comorbidities like diabetes, and weakened immune system. Onychomycosis also occurs often along with another fungal infection called athlete’s foot (tinea pedis) which affects the skin between the toes.

Why Is a Holistic Approach Required?

Treatment for onychomycosis has been mainly through antifungal medicines and topical therapies. While the therapies help get rid of infections in most cases, there are issues of antifungal treatment resistance and reinfections in many cases (10–53%). The authors of the article “A Paradigm Shift in the Treatment and Management of Onychomycosis” describe how there needs to be a shift by healthcare professionals from treating patients with just antifungal agents to a holistic, patient-centric approach. This approach requires starting from testing and making a proper diagnosis to administering appropriate treatment and finally avoiding reinfection by looking beyond just the nail.

Test, Identify, and Diagnose Onychomycosis

Doctors traditionally identify onychomycosis by visual inspection or with simple laboratory tests using microscopy, fungal culture, and biochemistry tools. This infection is most often caused by fungi that infect keratinous tissue like nails but in some cases, fungi that do not depend on keratinous tissue can also cause the infection, or there could be a mixed infection of both fungi. The clinical diagnosis of these fungi that do not depend on keratin is different and identifying it through proper testing and diagnosis becomes relevant for treating it.

There can also be cases where the first line of antifungal treatment (terbinafine therapy) does not work. In these situations, testing for susceptibility of the infected fungi to different antifungal agents and the concentration required to get rid of the infection needs to be identified by using laboratory testing and diagnostic tools.

Find Appropriate Treatment Methods

When the routine treatment strategy fails, the fungus is considered resistant to the treatment. Using the diagnostic reports, the treatment strategy will have to be modified. The reasons for failure could be due to:

  • the treatment itself not being effective because of the wrong diagnosis, drug concentration issues, treatment length or the patient not taking medicines as prescribed,
  • the fungus having learned to live in the presence of the antifungal agent.

In the first case, as described above, changing treatment based on diagnostics and ensuring compliance to medication can correct the treatment course. In the second case, a different class of antifungal agents (azoles) can be tried as an alternative treatment strategy. This holds true for infections with the other classes of fungi and mixed infections, too. In some cases, combination therapy of different antifungal agents or oral medicine along with topical medication might be required to get rid of infections when other techniques fail. In those cases where the patient also has athlete’s foot infection, it is required to treat that simultaneously to be able to successfully treat onychomycosis.

Continue with Post-Treatment Care

The rate of relapse and recurrence of onychomycosis is high and can occur within 30 months of treatment of the previous infection. It could be due to family history and physiological reasons or environmental and lifestyle issues. Hence, it is as important to follow post-treatment care as it was following antifungal therapy.

What Does Post-Treatment Care Involve?

Firstly, ensuring that footwear and clothes are sanitized. With sweat and skin cells trapped in the footwear, they can act as a source of fungal reservoirs. Hence, it is recommended to replace contaminated footwear with a new pair and to change socks frequently (1–2 times/day). It also helps if the socks are of absorbent material or made of antimicrobial fabric like copper-impregnated socks. Footwear can be sterilized by devices developed for this purpose, including those that use techniques like ozone gas disinfection or ultraviolet sanitization. Clothes require to be laundered at high temperatures, and it needs to be ensured that contaminated clothes are separated from sterile ones to reduce further contamination. The laundry machine also needs to be kept properly sterilized.

Secondly, certain lifestyle changes need to be made. It is important to keep nails short and clean. Footwear needs to be worn in high-risk areas like swimming pools where chances of catching infections are high. Keeping feet dry and wearing footwear of the right size is also important.

Lastly, to prevent recurrence of infection, the person could continue topical or oral antifungal treatment at a lower dosage for weeks to years based on the person’s health and doctor’s suggestion. Concurrently, preventive treatment of athlete’s foot using all of the above methods is also required.

Treat Onychomycosis Holistically

Onychomycosis occurs in a significant percentage of the population, affecting their normal life. It is important to treat it by using a holistic approach. This involves ensuring required laboratory tests are done and correct diagnosis is made specifically regarding resistant infections. Post active antifungal treatment, the healthcare professionals should continue to advise the patient to make appropriate lifestyle adjustments and take preventive treatments to avoid relapse and reinfections.

Note: Some of the authors of the paper declared that they have received grants and personal fees from pharmaceutical companies for work outside the review article. It is normal for authors to declare this in case it might be perceived as a conflict of interest. More detail can be found in the Conflict of Interest statement at the end of the referenced paper.

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