Fungal Nail Infection

Who gets fungal nail infections?

About 3 in 100 people in the UK will have a fungal nail infection at some stage. Toenails are more commonly affected than fingernails. It is more common in people over 55, and in younger people who share communal showers such as swimmers or athletes.

How do you get a fungal nail infection?

• Spread from a fungal skin infection. For example, athlete's foot is a fungal skin infection of the toes. This may spread to the toenails if the skin infection is not treated early.
• Fingernail infection may occur after a toenail infection has become established. The fungus may spread to a finger if you scratch your itchy toes and toenail.
• Fingernail infections are also more likely to occur if you wash your hands frequently, or have them in water a lot. For example, if you are a cook or a cleaner. Constant washing may damage the protective skin at the base of the nail. This may allow fungi to enter.
• A nail that has recently been damaged is also more likely to become infected.
• You have an increased risk developing a fungal nail infection if you have various other conditions. For example: diabetes, psoriasis, poor circulation, a poor immune system (for example, if you have AIDS or are on chemotherapy), or general poor state of health.
• Nail infections are more common in people who live in hot or humid climates.
• Smoking also increases the risk of developing a nail infection.
• In some cases there is no apparent reason. Fungus germs (fungi) are common and an infection can occur 'out of the blue'.

Often the infection is just in one nail, but several may be affected. At first the infection is usually painless. The nail may look thickened and discoloured (often a greeny-yellow colour). Commonly, this is all that occurs and it often causes no other symptoms. However, it can look unsightly.

Sometimes the infection becomes worse. White or yellow patches may appear where the nail has come away from the skin under the nail (the nailbed). Sometimes the whole nail comes away. The nail may become soft and crumble. Bits of nail may fall off. The skin next to the nail may be inflamed or scaly. If left untreated, the infection may eventually destroy the nail and the nailbed, and may become painful. Walking may become uncomfortable if a toenail is affected.

Do I need any tests?

Other nail conditions can sometimes look like a fungal infection. Therefore, to confirm the diagnosis, a doctor will usually take a nail clipping and send it to the laboratory for testing.

What is the treatment for a fungal nail infection?

Not treating
This is an option if the infection is mild or causing no symptoms. For example, a single small toenail may be infected and remain painless. Also, some people may prefer not to take medication as, although rare, there is a small chance of serious side-effects from antifungal medication. The option to treat can be reviewed at a later date if the infection becomes worse.

Medication
Antifungal tablets will often clear a fungal nail infection. However, you need to take the tablets for six weeks for fingernail infections, and for 12 weeks for toenail infections, sometimes longer. The medication will also clear any associated fungal skin infection such as athlete's foot.

Studies suggest that in about 5 in 10 cases the nail will look fully normal again after treatment. In about a further 2 in 10 cases the fungus will be cleared from the nail after treatment, but the nail does not look fully normal again. Fingernails tend to respond better to treatment than toenails. One reason for treatment to fail is because some people stop their medication too early.

Antifungal nail paint
This is an alternative, but tends not to work as well as medication taken by mouth. It may be useful if the infection is just towards the end of the nail. This treatment does not tend to work so well if the infection is near the skin, or involves the skin around the nail. The nail paint has to be put on exactly as prescribed for the best chance of success. You may need six months of nail paint treatment for fingernails, and up to a year for toenails.

Nail removal
If other treatments have failed an option is to have the nail removed by a small operation done under local anaesthetic. This is combined with treatment with antifungal medication.

The fungi that are killed with treatment remain in the nail until the nail grows out. Fresh, healthy nail growing from the base of the nail is a sign that treatment is working. After you finish a course of treatment, it will take several months for the old infected part of the nail to grow out and be clipped off. The non-infected fresh new nail continues growing forward. When it reaches the end of the finger or toe, the nail will often look normal again.

Fingernails grow faster than toenails, so it may appear they are quicker to get back to normal. It may take up to a year after starting treatment before toenails look completely normal again and six months for fingernails to look completely normal.

Consult a doctor if there does not seem to be any healthy new nail beginning to grow after a few weeks of treatment. However, the infection can still respond to treatment even after you finish a course of medication. This is because the antifungal medication stays in the nail for about nine months after you stop taking medication.

Take medication as directed, and do not give up without discussing this with a doctor. Side-effects are uncommon with modern medication, but tell a doctor if you notice any problems with treatment.

Tips on nail care if you have a nail infection, with or without taking medication, include the following.

• Keep your nails cut short, and file down any thickened nail.
• Use a separate pair of scissors to cut the infected nail(s) to prevent contaminating the other nails. Do not share nail scissors with anyone else (for the same reason).
• Avoid injury and irritants to your nails. For example, if fingers are affected use cotton and vinyl gloves for wet work. Use heavy cotton gloves for dry work.
• If toenails are affected, wear properly fitted shoes with a wide toebox.
• Keep your feet as cool and dry as much as possible.

Studies suggest that in about 1 in 4 cases where the infection has been cleared from the nail, the infection returns within three years. One way to help prevent a further bout of nail infection is to treat athlete's foot as early as possible to stop the infection spreading to the nail. Athlete's foot is common and may recur from time to time. It is easy to treat with an antifungal cream which you can buy from pharmacies, or get on prescription. The first sign of athlete's foot is itchy and scaling skin between the toes.

Also, try to avoid injury to nails which may increase the risk of developing a nail infection.

© EMIS and PIP 2006   Updated: January 2006   PRODIGY Validated