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skin

Nasty Nails
Nasty Nails They are getting uncomfortable, and I can’t wear my summer sandals.

“I really hate my ugly nails,” Annie said as I walked into the exam room. “They are getting uncomfortable, and I can’t wear my summer sandals.” I told Annie I didn’t have a quick fix, but we could likely improve the situation.

I told her that we first had to find out what was causing her nail problem. Although toenail fungus infection is the most common cause of toenail problems, we had to make certain that we were not missing something else. I suggested that we start with a basic skin exam, since conditions like psoriasis and lichen planus can look just like fungal infections. Unfortunately, these conditions will not improve with fungal treatments. It is also important to look at both hands and both feet for additional clues. Sometimes fungus can cause a “Two Foot One Hand Syndrome.” In this condition both feet are involved with fungus, but the person has only one hand with dry skin or “eczema.” The fingernails may also be involved on only one hand. Next, I do a careful check to look at the skin of the feet and the areas between the toes. Sometimes fungus will invade only the big toenail, usually on the inside edge. When I see this pattern, I usually think of a previous injury to that toe. The injury could be minor like wearing running shoes that are too tight and continually push on the nail allowing the fungus to move in. More commonly, nail fungus is associated with skin involvement of the foot – Athlete’s foot or tinea pedis. Sometimes the groin may also be involved – Jock itch or tinea cruris. Fungus in these areas may look like dry skin or it may make the skin moist, red, or irritated. A common spot for fungus to hide and grow is in the web space between the forth and fifth toe causing a damp, peeling skin. It is important to treat all of the skin areas in addition to the nails. This extra treatment reduces the chance of the fungus growing back in the nail.

If only the skin is involved, we can usually get by with just using creams to treat the infection. However, when the nails are involved, we almost always have to use internal medication in addition to the creams. Sometimes after looking at all of the skin and nails, it is necessary to do some tests to confirm the fungal infection. I can take some of the flakes of skin or clipping of the nails to look at under the microscope in my office to see if I can see the fungus. Other times, I may need to send the tissue to the laboratory for a fungal culture. Even though there may be many changes on the skin and nails, there may be very few fungal elements present. A positive test means fungus is present. Unfortunately, a negative test may mean either fungus is not the cause of the problem, or it just can’t be identified.

If only the skin is involved, we can usually get by with just using creams to treat the infection. However, when the nails are involved, we almost always have to use internal medication in addition to the creams. The older medication, griseofulvin had to be given for a year and cleared the nail only about half of the time. The newer medication terbinafine (Lamisil® by Novartis Pharmaceuticals) produces a mycological cure and a clinical cure in about 60% of the patients. However, many of the other patients have better-looking nails but with some residual fungus. The medication works by building a layer in the new nail that acts as a “firewall” in preventing the fungus from invading the new healthy nail. Unfortunately, the old nail must grow out in order to be replaced by the new nail. The re- growth takes about a year for toenails and six months for fingernails. Sometimes we add a medication to paint on top of the nail to help kill the fungus. Unfortunately, women can’t use nail polish and the paint on medication at the same time. It is also important to keep the nail trimmed as short as possible “down to the quick.” Never try to dig or over clean under the nail because most of the time it will just allow the fungus to grow deeper. Make sure any clippers or files used on the infected nails are not used on the good nails. If you have a professional manicure or pedicure, make sure that your technician follows the same advice.

Annie returned about three months later and was beginning to see the re-growth of her healthy nail plate. She was committed to doing all of the home care to make the treatment a success. A year later, she showed me her great looking toes in her new summer sandals. The pain was gone and she only wished she had treated the condition years ago! After the nails are clear of fungus, it takes a bit of effort to keep the fungus away. If the original fungus got in because of injury, it is unlikely to return unless the nail is re-injured. However, if the fungus involved the skin or more than the big toenails, it may frequently re-infect the area. Some physicians feel that susceptibility for fungal infections is inherited because patients can frequently remember a relative with a similar problem.

There are some simple things to do to help keep the fungus infection away after the prescription medications are completed. Keeping the feet dry is very important. I suggest using a hair drier on a low setting to dry the skin of the feet and between the toes after a bath or shower. I also suggest using an absorbent antifungal powder such as Zeasorb-AF® (Stiefel Laboratory). The powder is applied directly to the feet and between the toes. It also can be sprinkled inside your socks before you put them on and inside your shoes after you take them off. If possible, rotate your shoes, especially sporting ones, to make certain that they totally dry before they are worn again. If foot perspiration is a problem, a prescription strength antiperspirant may help to keep the feet dry and the fungus away. I also suggest talking to your doctor about having some antifungal medication on hand to treat at the first sign of return to the skin. It is important to retreat the entire area again for one month, instead of stopping when it looks or feels better.

Annie returned about three months later and was beginning to see the re-growth of her healthy nail plate. She was committed to doing all of the home care to make the treatment a success. A year later, she showed me her great looking toes in her new summer sandals. The pain was gone and she only wished she had treated the condition years ago!

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"Nasty Nails"
   authored by:
DERMATOLOGY
Dr. Rebecca L. Bushong is both a pharmacist and a board-certified dermatologist. After receiving her BS. in Pharmacy and her Pharm D degree, she returned at age 30 to the Medical School of the University of Kentucky. Following medical school she comp...



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