Nail fungus, also known as onychomycosis or tinea unguium, is a transmissible fungal infection.
It is caused by
- Dermatophytes (filamentous fungi)
- yeasts,
- molds or
- a combination of several types of fungi
fungi.
The fungal disease can affect various areas of the nail and manifests itself in the deformation and discoloration of the fingernails or toenails.
Nail fungus is widespread in Germany and western industrialized countries. It is one of the most common diseases of the fingernails and toenails. According to estimates, around 12 percent of the population suffer from nail fungus at least once in their lives.
Toenail fungus occurs around four times more frequently than fingernail fungus. The trigger is often an untreated athlete's foot infection that has spread to the nails.
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Nail fungus is caused by parasitic fungal pathogens that spread in the nail bed or under the nail.
The development of nail fungus is caused on the one hand by infection with these fungal pathogens. On the other hand, other conditions must be met for them to thrive. Certain risk factors therefore favor the development of nail fungus.
Nail fungus is transmitted from person to person through a so-called smear or contact infection. A smear infection occurs when there is direct contact between people. In the case of a contact infection, the patient becomes infected through skin contact with contaminated objects and surfaces.
Nail fungus spores prefer a warm and humid climate and multiply particularly quickly there. This is why the risk of infection is particularly high in such places. These include public wet facilities such as swimming pools and saunas, where many people walk barefoot.
Basically, three types of disease-causing fungal pathogens can cause nail fungus:
- Dermatophytes,
- yeasts or
- mold fungi.
In most cases, dermatophytes are responsible for a nail fungus infection.
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Which pathogens cause nail fungus?
Dermatophytes are also known as filamentous fungi. They almost exclusively infect keratinized areas of the body such as the skin and its appendages and feed on keratin. Keratin is the horny substance in skin, hair and nails.
In 90 percent of all cases, nail fungus is caused by dermatophytes of the genus Trichophyton rubrum (filamentous fungi). Other possible, but less common causative fungal pathogens are dermatophytes of the genera Epidormophyton floccosum or Trichophyton mentagrophytes.
In around 3 to 5 percent of cases, dermatophytes of the genus Epidermophyton floccosum are the cause of nail fungus. These dermatophytes primarily infect the skin and subsequently infect the nails. The fungal infection begins on the cuticle and moves towards the tip of the nail.
Yeast fungi multiply by sprouting or splitting and are therefore also called sprouting fungi. A nail fungus infection caused by yeast fungi is usually due to yeast fungi of the Candida strain. This form occurs in particular with a fungal infestation on the fingernails.
Signs of this are a thickening and discoloration of the nails.
Molds only cause nail fungus in rare cases. The molds that can be responsible for a nail fungus infection include Scopulariopsis brevicaulis and Aspergillus spp.
What risk factors promote the development of nail fungus?
The body's own immune system normally prevents the nail fungus pathogens from multiplying. If the immune system is weakened, pathogens have an easier time.
Immunocompromised people are therefore particularly susceptible to nail fungus. The immune system can be weakened by
- age,
- underlying diseases such as diabetes or HIV,
- an operation, transplant or chemotherapy or
- immunosuppressive medication.
The condition of the nails and the immune system progressively deteriorates with age. This makes it easier for germs to attack the nail tissue. The risk of a fungal infection of the nails therefore increases with age. People over the age of 65 are most frequently affected. Almost every second senior suffers from nail fungus.
Arteriosclerosis, colloquially known as hardening of the arteries, is also a risk factor for nail fungus. The poor circulation leads to dry and cracked skin. The risk of infection is drastically increased.
Diabetics suffer from a weak immune system, poor circulation and are prone to sensitivity disorders.
Athletes are at an increased risk of contracting nail fungus. On the one hand, athletes often have direct contact with people who may have nail fungus. Fungal infections can occur more frequently in shared showers and changing rooms due to the humid and warm climate.
On the other hand, wearing sports shoes also creates fungus-friendly conditions. Sweating in shoes softens the skin of the feet. Fungi can easily multiply in non-breathable sports shoes and penetrate the skin, which is poorly protected by moisture.
Athletes such as
- runners,
- tennis players and
- footballers
are particularly at risk of contracting nail fungus.
Nail fungus manifests itself through thickening, deformation and discoloration of the affected nail © Serhad | AdobeStock
A nail fungus infection can affect
- the nail root,
- the nail bed or
- the nail itself
affected. Nail fungus usually starts at the front edge of the nail and spreads from there over the entire nail plate.
Typical symptoms of nail fungus are
- Deformation of the nail,
- brittle and splintering nail layers,
- yellow-brownish discoloration,
- thickening of the nail plate and
- inflammation of the nail bed.
In the case of extreme fungal infestation, the infected nail also emits an unpleasant odor. If the nail fungus is not treated, the risk of it spreading to surrounding toenails or fingernails is very high.
If the symptoms described occur, you should see a doctor immediately. Nail fungus does not heal on its own and should therefore always be treated.
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If nail fungus is left untreated, the infection can spread to other nails and pave the way for other diseases. The tiny injuries and damage to the nails make it easier for bacteria or viruses to penetrate and cause serious inflammation.
In addition, untreated nail fungus can lead to the nail falling out (onycholysis) and destruction of the nail bed.
Symptom categorization according to pathogen
The symptoms depend on the exact type of nail fungus. Nail fungus can be differentiated on the basis of characteristic symptoms and its localization into
- Distolateral subungual onychomycosis
- Proximal subungual onychomycosis
- Leukonychia trichophytica
- Dystrophic onychomycosis
- Onychia et Paronychia candidosa
1. distolateral subungual onychomycosis
Distolateral subungual onychomycosis begins at the anterior edge of the nail. It is by far the most common form of nail fungus. This form of onychomycosis accounts for 90 percent of all nail fungal infections. It usually occurs on the toenails and only rarely on the fingernails.
In this form, the nail fungus pathogens penetrate via the so-called hyponychium, i.e. the germ layer of the skin under the nail plate. From there, they slowly spread towards the nail root (nail matrix).
The nail plate is slowly lifted and becomes yellowish in color.
2. proximal subungual onychomycosis
This rarer form of nail fungus accounts for around 3 to 5 percent of all nail fungus infections. The infection occurs via the skin of the nail wall, i.e. where the nail grows out.
The nail fungus pathogens penetrate from the nail root into the nail plate and slowly spread from there towards the tip of the nail.
3. leukonychia trichophytica
This form of nail fungus is also known as whitish superficial onychomycosis. It is usually the result of an infection with Trichophyton interdigitale. The nail fungus pathogens only spread in the upper layers of the nail keratin, which leads to a whitish discoloration of the affected nail.
4 Dystrophic onychomycosis
In dystrophic onychomycosis, the structure and function of the nail is considerably damaged and severely altered.
Dystrophic onychomycosis can be the final stage of a long-standing nail fungus infection. However, it also develops as a result of chronic mucocutaneous candidiasis. This disease is associated with a congenital immunodeficiency.
5. onychia et paronychia candidosa
This form of nail fungus, also known as yeast onychomycosis, is almost always caused by yeast fungi of the Candida strain. Candida albicans is usually the causative pathogen.
Typical symptoms are
- Chronic inflammation of the nail wall,
- an irregular structure of the nail plate and
- green-brownish discoloration of the nail.
Symptom categorization according to stage
A nail fungus infection can be divided into three symptom stages:
Early stage nail fungus
In the first phase of the infection, those affected hardly notice any symptoms. The nails show the first yellow spots or white streaks. The color changes of the nail are often mistakenly interpreted as a lack of calcium.
Nail fungus of the average stage
Toenails or toenails affected by nail fungus become yellow, thicker and more deformed. The nail begins to separate from the nail bed.
Nail fungus in the difficult stage
In this stage, the nail can now separate completely from the nail bed. Bacteria can therefore enter the unprotected skin unhindered.
In many cases, those affected suffer from additional nail bed inflammation in this phase. The nail is severely curved and is characterized by an unpleasant odour.
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In most cases, the family doctor or dermatologist recognizes a nail fungus infection at first glance.
In order to diagnose the infection without any doubt and determine the predominant type of fungus, the doctor removes a few horny parts from the infected nail.
Before taking the material, the nail is cleaned with 70 percent alcohol and cut back as far as possible. Living fungi are mainly found at the border between the healthy nail plate and the infected nail areas.
The nail sample is best obtained with a cutter, as many small nail particles can be removed in this way. Any local treatment with antimycotics that may have already been started should be discontinued 2 to 4 weeks before the material is obtained. Otherwise, false negative results may occur.
The doctor then applies the nail sample obtained in this way to a microscope slide in order to examine it under the microscope at 10 to 40x magnification. If this microscopic examination reveals fungal growths or fungal spores, the diagnosis of nail fungus is confirmed.
However, it is usually not possible to determine exactly which fungal pathogen is involved under the microscope. For this reason, a so-called fungal culture is often performed in the next step to precisely determine the causative nail fungus pathogen.
This involves growing the nail fungus pathogen in the laboratory on a suitable culture medium at room temperature for around three to four weeks. The fungal colonies grown in the fungal culture can then be used to determine which specific type of fungus is responsible for the nail fungus.
A differential diagnosis is also necessary for a clear diagnosis of nail fungus. This allows the doctor to rule out other diseases as the cause of the nail changes. Symptoms similar to nail fungus can also be caused by diseases such as
- Nail psoriasis,
- eczema nails,
- nodular lichen of the nail (lichen ruber) as well as
- congenital or acquired chronic nail dystrophies.
Nail fungus can heal completely, but treatment is a lengthy process. In many cases it takes several months. Fingernail fungus is cured more quickly than toenail fungus.
Decisive for the adequate treatment of nail fungus is
- clear identification of the type of fungus and
- the severity of the fungal infestation.
The treatment of nail fungus is generally possible with antimycotics (medication) or laser therapy.
Home remedies such as tea tree oil, vinegar or even your own urine have no proven clinical effect. However, they cost valuable time during which you could already be treating the nail fungus effectively.
Treatment of nail fungus with antimycotics
The most important therapy method is drug treatment with so-called antimycotics. These are antifungal medications that kill the causative fungal pathogens
- kill (fungicidal antimycotics) or
- inhibit their growth (fungistatic antimycotics).
are intended.
Antimycotics can be administered by local application directly to the affected area or by means of tablets. Topical application, such as nail varnish, is referred to as topical therapy. Taking tablets has an effect on the entire body, which is why it is referred to as systemic therapy.
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Whether topical or systemic therapy is used depends on the extent of the nail fungus infection.
If the nail fungus infestation is less than 50 percent, topical therapy with fungistatic or fungicidal antimycotics can be initiated. These are often available over the counter in pharmacies.
The clear nail polish is applied to the affected nail and the surrounding skin every evening for several weeks. In addition to the ingredients, the nail polish also protects the skin from moisture. This reduces the risk of infection and the spread of the germ.
In advanced stages of nail fungus, treatment of the nail surface often does not lead to the desired success. In this case, the nail with fungal infestation is softened and detached within three weeks using a keratolytic. A new nail can then form.
If more than three toenails or toenails are infected with a nail fungus, systemic therapy is recommended. The active ingredient administered via tablets can be distributed throughout the entire organism via the bloodstream.
The duration of systemic treatment is three to six months, depending on the severity and resistance of the nail fungus. In special cases, treatment can be continued at intervals for longer.
In most cases, local treatment of the nail is also carried out.
Laser therapy for the treatment of nail fungus
Laser therapy is a relatively new method of effectively treating nail fungus.
The affected nail is irradiated using a pulsed Nd-YAG laser. This inactivates the existing fungal spores. This painless procedure, which only takes a few minutes, does not damage the nail.
If you are considering laser therapy, you should find out the costs in advance. Laser therapy is not reimbursed by health insurance companies.
Laser can be used to eliminate fungal spores © hedgehog94 | AdobeStock
Without appropriate treatment, a nail fungus infection will not heal on its own. Instead, it progresses slowly if left untreated and takes a chronic course.
Nail fungus should therefore always be treated consistently. If treatment is discontinued or not carried out correctly, there is a risk that fungal pathogens will remain and the nail fungus will spread again.
If treated correctly, nail fungus generally has a good prognosis and usually heals completely.
However, nail fungus treatment can be very lengthy and can take up to a year. Once the infection has healed, targeted measures can be taken to prevent the recurrence of nail fungus.
The risk of infection with nail fungus can be reduced relatively well with a series of rules of conduct and preventive measures.
Measures to protect yourself
These include in particular
- Proper hygiene and care of the nails,
- wearing the right socks and shoes,
- avoiding the usual sources of infection and
- strengthening the body's own immune defenses.
Regular washing and care of the feet prevents germs from penetrating the nail. Feet should therefore be washed daily with warm water and a mild soap and moisturized with a special moisturizing lotion.
Shoes with a good fit should be made of a breathable material that quickly wicks away foot moisture. Shoes made of leather or modern microfibers are particularly suitable. Synthetic materials, on the other hand, are not recommended. Feet and toes must not be constricted.
Disinfecting the shoes at regular intervals will kill the germs responsible for nail fungus.
You should always wear socks when trying on shoes. Socks should be made of natural materials such as wool or cotton and washed at 60 degrees. Socks made of synthetic materials can encourage and promote the proliferation of nail fungus pathogens.
Towels, bath mats and bed linen should be washed at 60 degrees. Nail fungus pathogens are killed at this temperature.
You should always wear bathing shoes in public facilities such as saunas, swimming pools, changing rooms, gyms or hotels. Afterwards, it is advisable to wash and disinfect your feet thoroughly.
To strengthen the body's immune system, you should focus on
- a healthy lifestyle,
- a balanced and varied diet and regular exercise.
- regular exercise.
Care should be taken when getting a manicure or pedicure to prevent injuries to the nails. These can provide an easy entry point for fungal pathogens and thus promote the development of nail fungus.
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Measures to protect others
These precautionary measures also prevent the spread of nail fungus if a nail fungus infection is already present.
All objects and surfaces that have come into contact with the infected nail should be thoroughly cleaned and, if possible, disinfected immediately after use. This includes, for example
- Floors,
- carpets,
- door handles,
- used nail scissors or files,
- computer keyboards,
- towels,
- shoes etc.
Always keep your nails short. This also prevents ingrown nails. Disinfect the used nail scissors after use. Healthy nails must not come into contact with the non-disinfected scissors.
People suffering from nail fungus should always use their own towel and wear slippers. Do not visit swimming pools or saunas during the acute phase of nail fungus infection.
Shoes should be thoroughly disinfected with an antifungal agent after each wear. Leather shoes are more suitable as the breathable material transports the foot moisture to the outside. The use of shoe polish is helpful to prevent moisture from penetrating from the outside.
Shoes, ski boots, rollerblades and rubber boots should not be shared with other people.
