Toenail Fungus

ASK THE PODIATRIST

 

Toenail Fungus

--Dr. Jay C. Goldstein

 

Q. My toenails are thick and discolored. Could they be fungus toenails?

 

A. During the past seventy years, fungus toenails have significantly increased in the United States. It is caused by an organism that grows in the skin, toenails, and (less frequently) fingernails. Unfortunately, some doctors make the diagnosis without testing for the organism. I disagree with this practice, because:

  1. Other problems can mimic fungus toenails, such as runner's toenails, psoriasis, and eczema.

  2. The treatment is not quite that easy, so one would not want to venture the cost and effort to eliminate an organism that may not be present.

 

HOW TO DIAGNOSE FUNGUS TOENAILS

 

  1. Look at a small piece of the nail under the microscope. This is relatively fast, but, in my opinion, not quite as accurate.

  2. Culture the toenail, which is not as fast, but may offer a greater likelihood of capturing the organism, and also yields information about the specific type of organism.

  3. Send some of the toenail to a lab for a special stain (PAS), which is not very specific, but identifies the presence of an organism. It is a more expensive test.

 

HOW TO TREAT FUNGUS TOENAILS

 

  1. Decide not to treat it. This is a reasonable consideration for a geriatric, especially if s/he is in poor health and/or is on multiple medications. On the other hand, the younger the patient, the more beneficial I believe it is to treat the problem (since it may spread and/or cause other problems), especially if diabetes or an immune disorder is present.

  2. Topical medications have a low success rate. Most studies demonstrate a positive outcome of less than 6%.

  3. If only one toenail is involved, and it is very thick, temporary removal of the nail would significantly increase the success rate of topical medications.

  4. Permanent removal should be considered in select cases if the toenail(s) is very deformed and only one or two toenails are involved.

  5. During the past few years, the cost of some oral medication has dropped from over $1000 to about $10! The most recent generation of oral medication has been shown in studies to be more effective and safer than its predecessors.

  6. Laser treatment is getting a lot of publicity. It is expensive and may need to be repeated. The success rate is being established by ongoing studies, few of which are available in the year 2011. If it proves to be successful, the frequency of this treatment will increase and perhaps the cost will decline.

 

WHILE UNDERGOING TREATMENT

 

  1. Do not scrape your toenails with your fingernails.

  2. Do not cross contaminate other toenails by using the same clippers on non infected toenails (or fingernails!).

  3. Decontaminate your shoes.

  4. Do not wear tight shoes.

 

CONCLUSION

 

In the absence of diabetes or immune problems, fungus toenails are not usually dangerous. On the other hand, they usually (slowly) get worse with time, and they are not the prettiest condition in the world. They have never been more treatable.

 

Dr. Goldstein is Board Certified in Podiatric Surgery, Podiatric Orthopedics, and in Podiatric Medicine. He has been running for more years than he has not been running, but has not done triathlons for as long as he has been running. Fortunately for his wife, he does not have any fungus toenails. When not running or resting, he can be found at his Podiatry office in Portland, Oregon.