Introduction
Nail fungus is a common condition that begins as a white or yellow spot under the tip of fingernail or toenail. As the fungal infection goes deeper, nail fungus may cause discolouration, thickening and crumbling at the edge of the nail. It can be present at one or more nails.
If the condition is mild and not much disturbing, treatment is not needed. If the nail fungus is painful and has caused thickened nails, self-care steps and medications may help. But even if treatment is successful, nail fungus often comes back.
Nail fungus is also called onychomycosis. Fungi are tiny organisms which can be seen only through a microscope. Many different types can cause a nail infection. Sometimes they live on the skin and don’t make any trouble. But if there are a lot in one area in a person with weak immune system it might cause infection. When fungus infects the areas between the toes and the skin of the feet, it’s called athlete’s foot (tinea pedis).
Fungal nail infection can develop in people at any age, but it’s more common in older adults. As the nail ages, it can become brittle and dry. The resulting cracks in the nails allow fungi to enter. Other factors — such as reduced blood circulation to the feet and a weakened immune system — also may play a role.
Toenail fungal infection can start from athlete’s foot (foot fungus), and it can spread from one nail to another. But it is uncommon to get an infection from someone else.
Signs & symptoms
Nail fungus infection can be suspected if one or more of the nails are:
- A white or yellow spot under the nail, in the beginning which spreads over time and can turn the whole nail discoloured, such as yellow, green, or black.
- The nail may thicken and could be hard to trim.
- It may start to curl up or down or loosen from the nail bed.
- The nail could become brittle and crumble upon touching.
- A slightly foul smell.
- Due to absence of pain, fungal nail infections may be ignored at first. But if not treated well, the infection gets bad enough, it could even become hard to walk. Nail fungus can affect fingernails, but it’s more common in toenails.
Causes
Nail fungus is an infectious condition caused by various fungal organisms(fungi), most common among them are dermatophytes.
Yeast and moulds also can cause nail infections.
Risk factors
Factors that can increase the risk of developing nail fungus include:
- Being older, owing to reduced blood flow, more years of exposure to fungi and slower growing nails
- Sweating heavily
- History of athlete’s foot
- Walking barefoot in damp communal areas, such as swimming pools, gyms and shower rooms
- Having a minor skin or nail injury or a skin condition, such as psoriasis
- Having diabetes, circulation problems or a weakened immune system
There are four main kinds of fungal nail infection. Each looks slightly different:
- Distal or lateral subungual onychomycosis. This is the most common kind. It results from a fungus called a dermatophyte. You can get it in your fingernails or toenails. It starts in the nail bed, underneath the nail. You’ll see a yellowish coloured area that spreads from the edges of the nail to the centre, and places where it comes apart from the nail bed.
- White superficial onychomycosis. This is less common and only affects the nail surface, mainly on your toenails. It starts as white spots, which become powdery and cause the nail to crumble.
- Proximal subungual onychomycosis. This appears first as white spots in the centre of the nail bed at the cuticle. They move outward as the finger or toenail grows. It’s rare and usually affects people who have immune system problems, like HIV infection.
- Candidial onychomycosis. Yeast causes this infection that usually affects your fingernails. The area around the nails is often swollen and inflamed, and the nails may come off entirely. It tends to happen to nails that have been damaged by an injury or another infection.
Pathophysiology
Causative organisms can be cultured from hotel carpets, public showers, and pool decks. In most cases, onychomycosis is preceded by an asymptomatic, dry hyperkeratotic tinea pedis. Over time, the dark, warm, moist environment of shoes and micro traumatic pressure on the nail unit compromise and break the hyponychial seal, allowing penetration of the dermatophyte into the nail bed. Repeated exposure to water in wet work compromises fingernails. Dermatophytes only live on the keratin of dead corneocytes in skin, nails, and hair. In the foot, the dermatophytes produce keratinases that begin the infection between the lesser toes, spread to the hyperkeratotic sole, and gradually extend to the distal hyponychial space of micro-traumatized nail units. Once the distal nail hyponychium is breached, the dermatophytes infect the nail bed, spreading proximally as onycholysis and subungual hyperkeratosis.
The primary site of the infection is the nail bed, where the acute infection occurs with a low-grade inflammatory response and progresses to a chronic phase of the nail bed infection as total dystrophic onychomycosis. Histologically, the acute lesion of onychomycosis manifests as spongiosis, acanthosis, papillomatosis with oedema, and hyperkeratosis. These signs resemble the pathology of psoriasis. As in most infections, a dense inflammatory infiltrate develops. Onychomycosis does infect viable nail matrix. Onychomycosis secondarily damages the nail matrix as the nail bed becomes hyperkeratotic and thickened in an effort to shed the fungal infection. The dermatophyte also invades the overlying nail plate, detaching and distorting it over time. The nail plate becomes elevated and misaligned as the infection enters the chronic total dystrophic clinical stage of onychomycosis (TDO). At this chronic stage of the infection, there are large amounts of compact hyperkeratosis, hyper granulosis, acanthosis, and papillomatosis with sparse perivascular infiltrate. Dermatophytosis and subungual seromas can occur. Zaikovska et al. found high levels of cytokines interleukin-6- and interleukin-10-positive cells in the nail bed as well as the bloodstream in onychomycosis. A significant number of fibres containing human beta defensin-2 were found in the bed and plate of the mycotic nails.
Case history
Physical examination
Scraping a piece of skin around nails and microscopic evaluation of it.
Treatments
A long-term medication and treatment are needed to get rid of nail fungus completely. Treatments include:
- Oral antifungals
- Topical antifungals
- Surgery
- Laser or photodynamic therapy
It is important to follow preventive measures to stop recurrence. The following habits can help prevent nail fungus or reinfections and athlete’s foot, which can lead to nail fungus:
- Wash your hands and feet regularly. Wash your hands after touching an infected nail. Moisturize your nails after washing.
- Trim nails straight across, smooth the edges with a file and file down thickened areas. Disinfect your nail clippers after each use.
- Wear sweat-absorbing socks or change your socks throughout the day.
- Choose shoes made of materials that breathe.
- Discard old shoes or treat them with disinfectants or antifungal powders.
- Wear footwear in pool areas and locker rooms.
- Choose a nail salon that uses sterilized manicure tools for each customer.
- Give up nail polish and artificial nails.
Prognosis
Nail fungus usually is difficult to treat. It has a bad prognosis with high recurrence. The treatment can take up to 18 months. Relapse and reinfection are common. So, prevention is very important.
Complications
- Recurrence of infection.
- Permanently discoloured or disfigured nails.
- Spread of infection to other parts of the body.
- In people with diabetes, or cellulitis, any relatively minor injury to your feet — including a nail fungal infection — can lead to a more serious complication.
Disease & Ayurveda
Kunakha
Nidana
Abhighata-injury or external factors
Purvaaroopa
Not mentioned
Samprapti
Not mentioned
Lakshana
Krishna-khara-rookshanakha – Blackish, hardened, and dry nails
Divisions
Not mentioned
Prognosis
Krichrasadhyam
Chikithsa
Samana
Parisheka with ushnambu-washing with warm water
Sastrakarma-extraction
Raktamokshana-Blood letting
Dhaara(pouring) with chakrataila
Avachoornana(sprinkling) with sarjachoorna
Sodhana
Not mentioned as it is a localised infection.
In severe cases, agnikarma (cauterisation) is advised.
Commonly used medicines
Thriphalachoornam
Chuvanna kuzhampu
Brands available
AVS Kottakal
AVP Coimbatore
SNA oushadhasala
Vaidyaratnam oushadhasala
Home remedies
Applying turmeric and holy basil paste
Cleaning with hydrogen peroxide
Applying lime juice
Avoid walking barefoot on wet and moist places
Keep the nails dry
Diet
- To be avoided
Heavy meals and difficult to digest foods – cause indigestion.
Junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine
Carbonated drinks – makes the stomach more acidic and disturbed digestion
Refrigerated and frozen foods – causes weak and sluggish digestion by weakening Agni (digestive fire)
Milk and milk products – increase kapha, cause obstruction in channels and obesity
Curd – causes vidaaha and thereby many other diseases
- To be added
Light meals and easily digestible foods
Green gram, soups, honey
Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc
Behaviour:
Protect yourself from cold climate.
Better to avoid exposure to excessive sunlight wind rain or dust.
Maintain a regular food and sleep schedule.
Avoid holding or forcing the urges like urine, faeces, cough, sneeze etc.
Avoid sedentary lifestyle.
Yoga
Yoga and exercises improve circulation and immunity. It helps reduce chances of infection and promtes healing. In persons with chance of recurrent infections, regular stretching and mild cardio exercises are advised. Also, specific yogacharya including naadisuddhi pranayama, bhujangaasana, pavanamuktasana is recommended.
Regular exercise helps improve bioavailability of the medicine and food ingested and leads to positive health.
Yoga can maintain harmony within the body and with the surrounding system.
Pavanamuktasana
Nadisudhi pranayama
Bhujangasana
All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.
Research articles
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