I believe the podiatry field is in a crisis. With the aging of the baby boomers, we have seen an explosion of patients with diabetes and non-invasive foot care into our offices. At the same time, co-pays are rising steadily while reimbursement decreases bit by bit, and insurance companies are refusing more claims. The results are higher workloads but lower income and profit in our practices. Unfortunately, this duality results in a rise in practice failures. What can we do to solve this dilemma?

In this reading the discussion will be about fungal infection of the nails known as tinea unguium or Onychomyosis. More common is the fungi that causes infection, how you get infected and how you can prevent such infections as well as treating these infections. 

Onychomycosis or Tinea unguium is very common and it is estimated that about 7 to 10 % of adults suffer from these infections. Although these infections can be harmless and do not cause any serious problems these symptoms can cause a decrease in quality-of-life and self-confidence as this can destroy the nails by giving them a very ugly appearance.

Fungal Nail Infections can cause a nail to become discolored thick and more likely to crack and break. That is why it is important to treat them at an early stage.  In the early stages, it becomes very difficult to manage as the topical drugs that are used for the treatment of normal infections of the skin cannot penetrate the nail. Special types of medicines are used for advanced  onychomycosis which we will discuss later in this reading.  

Now lets talk about the fungi that cause these fungal infections of the nails and how you get infected. These fungal nail infections occur from the overgrowth of fungus in, under, or on the nail. 

Fungi thrive in warm, moist environments so this type of environment causes a fungi to naturally  overpopulate. 

The same fungi that causes jock itch, athlete’s foot and ringworm can cause nail infections.

These belong to a group of fungi, that are known as dermatophytes, Trichophyton, rubrum is the most common dermatophyte involved in onychomycosis. 

Other dermatophytes that may be involved are T. interdigitale,  T. voilaceum and Epidermophyton, microsporum. 

Fungi that are already present in or on your body can cause the nail infections. If you come in contact with someone else who has fungal infection you may contracted it as well.

You can also get these infections if you walk barefooted excessively or come in contact with soil or water often. 

You are more likely to develop a fungal infection if you have diabetes or aged above 65.

If you have moist fingers or toes for an extended period of time, if you have a weakened immune system or if you wear closed tied shoes such as tennis shoes or boots for extended period of time.

 Lets talk about onychomycosis and how it presents and what symptoms you can develop.

A fungal infection of the nail may affect only part of the nail, the entire nail or several Nails. Common signs of a fungal nail infection include: a distorted nail that may lift off from the nail bed, an odor coming from the infected nail brittle or thicken nail.

You can also develop a darken nail caused by debris building up under the nail. Nail fungal infection usually begins as a white or yellow spot under the tip of your fingernail or toenail.

As a fungal infection goes deeper, nail fungus may cause your nails to discolor and crumble at the edge and it can affect several nails.

If you visited a dermatologist they can confirm a diagnosis by confirming a few simple tests. Nail  clippings of scrapings are taken and are observed under the microscope. 

If fungi are detected than the diagnosis can be confirmed. Also a culture can be performed to detect the fungi.  

Anti-fungal treatment drugs either taken orally or apply directly on the nails. 

The treatment of fungal infections of the nails usually takes a couple of months or maybe even a 1-year.

Because it is very hard for these anti-fungal drugs to penetrate the nail plate. These anti-fungal include: Itraconazole, Efinaconazole, Terbinafine, Ciclopiroxolamine, Amorolfine. 

 If you only have a superficial or mild infection of the nails which looks something like this you can only apply the topical drugs like anti-fungal creams, lotions or lacquers and Skip oral anti-fungal medicines.

But if you have an extensive involvement with nails or if your nails look something like this you need to take oral anti-fungal medicines.

Nail paints containing Penlac nail lacquer and Nailrox are usually the first in line for treatment. 


The most important point to remember during this treatment  to continue using this nail paint for at least 6 months to 1 year to have a complete cure and prevent recurrences. Amorolfine is also used in the similar way and same duration. 

Studies have shown that signal proximal mean is more effective than Amorolfine the results can vary depending on the patient. 

Efinaconazole new aniti-fungle drug, from the drug is an immersion therapy for the topical treatment of onychomycosis. It comes in a 10% solution that can penetrate easily to The Nail plate and even to nail polish. 

For complete cure 8 – 12 months of the daily solution and reapplication of the solution is recommended.

 These were some  effective topical drugs for the fungal infection of the nails.  Now if you have multiple nail involvement or if your nails look something like this, you need to take oral anti-fungal medicine.

Oral therapy have high cure rates for onychomucosis the most commonly used oral drugs for the treatment of onychomycosis our Griseofulvin,Terbinafine, Itraconazole, ketoconazole.

Terbinafine, Itraconazole, dosage of 250 mg per day is taken once a day, daily for finger nail fungus for (8) weeks, 12 weeks for toenail fungus. 

Itraconazole is considered to be most effective oral anti-fungal drug treatment of nail fungal infections..

 Itraconazole is 200 mg once daily taken continuously for 6 to 12 weeks. 

 Itraconazole is prescribed in pulse dosage of 200 mg taken two times in a day for 1 week per month and this is continued for two to three months for fingernail and 3 to 4 months for toenails. 

Note, that I cannot prescribe these or any fungal drugs over the video or reading because they can also cause side effects! 

Always consult a dermatologist or a physician if you want to start these medicines. 

Side effects of these medicines include a headache, diarrhea, skin rash or elevated liver enzymes which are important to monitor.

Fungal infections of the nail also associated with fungal infections of feet also known as Tinea Pedis and fungal infection that occurs between the toes known as athletes foot.