Nail fungus

and Martina Feichter, medical editor and biologist Updated on

Sophie Matzik is a freelance writer for the medical team.

More about the experts

Martina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.

More about the experts All content is checked by medical journalists.

Nail fungus (onychomycosis, tinea unguium) is a fungal disease of the fingernails and toenails. More than 12 percent of all Germans suffer from it. Men and the elderly are more likely to be affected. Read more about the topic here: How can you recognize nail fungus? What is the most effective way to treat it? How does it arise and what are the risk factors?

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. B37B35

Nail fungus: brief overview

• Treatment: long-term and consistent treatment with anti-fungal agents (antimycotics) in the form of nail polish, cream or pencil, possibly also in tablet form. In addition, laser therapy, possibly surgical nail removal in severe cases.
• Typical symptoms: Depending on the type of fungus, discoloration from the edge or the nail root, complete discoloration or spots, thickening and dissolution of the nail structure or splintering of the upper layers. Often also pain, reddening of the nail fold, inflammation of the nail bed.
• Causes: Infection that is contracted, for example, through shared towels, carpets, beds
• Risk factors: e.g. damp environment in closed shoes ("sweaty feet"), use of communal showers (sauna, sports club, swimming pool), often damp / wet hands, metabolic and immune diseases (e.g. diabetes mellitus, HIV infection), circulatory disorders, smoking, possibly . also vitamin and zinc deficiency
• Diagnostics: Consultation with a doctor and physical examination, microscopic and infectious examination (fungal culture) of a sample of the diseased nail
• Prognosis: good chance of recovery if long-term treatment started early and carried out consistently

Nail fungus: treatment

The nail fungus treatment depends primarily on the type and severity of the symptoms. Local treatment is recommended for all stages of nail fungus. The most effective here is an anti-fungal nail polish because it penetrates well into the nail tissue.

The following table provides an overview of the most important methods and remedies against nail fungus. Before treatment, it can be useful to carefully remove infected nail material. For this purpose, a urea ointment is usually applied once a day, which softens the horny substance of the nail. It can then be carefully scraped off.

It is not advisable to self-treat nail fungus if the nail is already severely affected by the fungus. In such cases, the doctor often prescribes tablets against the infection in addition to locally applicable remedies.

Method / means	Application, advantages and disadvantages	Remarks
Antifungal nail polish (water soluble)	- uncomplicated and quick application - Application on the entire nail surface, on 5 mm of the surrounding skin, and under the free nail edge - Active ingredient ciclopirox: once a day - Active ingredient terbinafine: once a day for four weeks, then once a week - After application, the nail must not come into contact with water for 6 hours - After the 6 hours, paint residues can simply be washed off with water - Antifungal active ingredient ciclopirox also has an antibacterial and anti-inflammatory effect; Terbinafine has similar properties	Active ingredients: ciclopirox or terbinafine available without a prescription do not use cosmetic nail polish at the same time!
Antifungal nail polish (waterproof)	- uncomplicated and quick application - Amorolfin active ingredient: apply once or twice a week - Active ingredient ciclopirox: in the 1st month apply every 2nd day, in the 2nd month at least twice a week, in the 3rd month at least once a week - Paint residues can only be removed with alcohol or nail polish remover - Ciclopirox also has antibacterial and anti-inflammatory effects, but Amorolfine does not	Active ingredients: ciclopirox or amorolfine available without a prescription never use cosmetic nail polish at the same time!
Antifungal cream / ointment	- contains the active ingredient bifonazole (and sometimes urea): is applied once a day (duration: several weeks) - In any case, pretreatment with urea ointment makes sense (to remove the nail) - Bifonazole also has antibacterial and anti-inflammatory properties	suitable for thickened nails and fungal infections under the nail plate available without a prescription
Nail fungus pen	- uncomplicated and quick application - Apply once or twice a day, depending on the product	various active ingredients available without a prescription never use cosmetic nail polish at the same time!
Tablets with terbinafine	- Consumption every day or with breaks in treatment (e.g. intake for 1 week, then 3 weeks break) - Duration of use: max. 4 months - fewer interactions with other drugs than itraconazole and fluconazole, therefore particularly suitable for elderly patients	Standard remedy against dermatophytes (most common nail fungus pathogens) prescription only
Itraconazole tablets	- Consumption every day or with breaks in treatment (e.g. intake for 1 week, then 3 weeks break) - Duration of use: max. 3 months - numerous interactions with other drugs possible	helps against specific nail fungus pathogens against which terbinafine and fluconazole are not effective prescription only
Fluconazole tablets	- Use once a week - Duration of use: 6 to 12 months - less effective than terbinafine and itraconazole, but well tolerated, therefore particularly suitable for children - numerous interactions with other drugs possible	Used when other active ingredients do not help or cannot be taken prescription only
surgical nail removal	- Quick result, but not more promising than other treatments - high risk of relapse - often pain and temporary incapacity for work after the procedure	Is hardly carried out any more. Removing nails with urea ointment is gentler.
Laser treatment	- Hardly any side effects, uncomplicated and effective - expensive and only available in a few dermatological practices	Statutory health insurance companies do not pay for the laser treatment. Private insurers require proof of medical necessity.

Always follow the package insert and, if in doubt, ask your doctor or pharmacist! For example, some preparations are not suitable for children, pregnant or breastfeeding women. Tablets in particular can also have a negative impact on the effects of other drugs.

• Nail Fungus - "You Need Patience"

  Three questions for

  

  Dr. med. Patrick Hering,
  Specialist in dermatology and allergology
• 1

  I have nail fungus - how do I protect my family from infection?

  

  Dr. med. Patrick Hering

  With the right hygiene! For example, you should wash your socks at a temperature of at least 60 ° C. Treat the shoes with special sprays from the pharmacy or drugstore. An important trick when using it: after spraying, store the shoes in a plastic bag overnight. That works better then.

• 2

  Does nail fungus heal on its own?

  

  Dr. med. Patrick Hering

  Unfortunately not - the therapy is also tedious. Nail fungus usually develops from athlete's foot. So protect yourself from athlete's foot! Never walk barefoot in public sports facilities or changing rooms. After showering, dry your feet well - a hair dryer can be helpful here. And: As a precaution, you can treat your feet with special disinfectants after visiting a public facility.

• 3

  What is the fastest way to get rid of the nail fungus?

  

  Dr. med. Patrick Hering

  That depends on the strength of the infestation. If less than 40 percent of the nails are affected, you can usually achieve good results with antifungal nail polishes or creams. In the case of a larger infestation, only tablet therapy or laser treatment will help. Overall, however, the following applies: a nail grows very slowly and that is why the treatment takes time. That can be up to 15 months. Be patient!

• 

  Dr. med. Patrick Hering,
  Specialist in dermatology and allergology

  Dr. med. Patrick Hering was the deputy chief physician at the PsoriSol Dermatology Clinic (Hersbruck). He runs a practice for dermatology, allergology, laser medicine and outpatient surgery in Munich.

Antifungal nail polish, cream and pen

Local fungus treatment with antifungal nail polish, cream or pen can be carried out independently by each patient at home. In milder cases, this self-treatment can be sufficient, i.e. if:

• only one nail is affected,
• a maximum of half of the nail surface is affected and
• the nail root (nail matrix) is not infected (this is the area where the nail plate is formed).

If you are unsure whether these points apply to you, you should seek advice from a doctor or medical podiatrist (podiatrist).

Antifungal nail polish, cream and stick are an uncomplicated help with nail fungus. However, they must be used until the fungus has been safely killed. Recognizing this is not easy for laypeople. Therefore, the following also applies here: if in doubt, see a doctor!

Nail fungus treatment with tablets

See a doctor if independent nail fungus treatment is unsuccessful or if many nails or larger nail surfaces are affected. The local nail fungus therapy usually has to be supplemented by systemic therapy - i.e. by taking antifungal tablets that develop their effect from the inside out and throughout the body.

When choosing a suitable active ingredient (terbinafine, itraconazole, fluconazole), the doctor takes into account the exact type of pathogen and other factors. For example, women should not take terbinafine during pregnancy if possible, even if this is the most suitable active ingredient against thread fungi (the most common pathogens causing nail fungus). Instead, the doctor may prescribe clotrimazole or miconazole to pregnant women.

Elderly patients, on the other hand, should be treated preferentially with terbinafine. With this active ingredient, the risk of interactions with other drugs is much lower than with itraconazole and fluconazole. This is particularly important for older people because they usually have to take several different medications (such as blood pressure medication).

Patients should also conscientiously inform the doctor about any possible illnesses and health complaints. Because with certain diseases, some antimycotics may not be given at all, for example terbinafine for liver dysfunction.

Nail fungus treatment by means of surgery

In the past, the question "What to do about nail fungus in severe / stubborn cases?" often referred to as the option of surgical nail removal. Due to the side effects (such as pain) and the high risk of relapse, this procedure is rarely performed today. In addition, the surgical removal of diseased nails in the treatment of nail fungus is not more successful than other methods.

Laser nail fungus treatment

A new treatment option for nail fungus is irradiation with laser. In several sessions, this can kill the fungal infection, even if you don't yet know exactly how it works.

Another advantage of laser therapy for nail mycosis is that, if done correctly, it hardly causes any side effects. Patients report at most a sensation of warmth or a slight stinging in the irradiated toes / fingers.

However, lasering a fungal nail infection is very expensive and is not covered by statutory health insurance.

You can find out more about laser therapy for onychomycosis in the article Nail fungus laser.

Nail fungus: homeopathy

Many affected people ask themselves the question "What helps against nail fungus other than conventional medicine?" - They want to treat onychomycosis with alternative healing methods. Some trust essential oils or Schüßler salts. Still others rely on homeopathy. However, nail fungus is rarely treated exclusively with alternative medicine. Instead, alternative healing methods are often used alongside conventional medical treatment.

This is what homeopaths call when asked "What helps with nail fungus?" Means such as Acidum hydrofluoricum, Silicea, Antimonium crudum or sepia. Aromatherapy applies roughly the essential oils of Eucalyptus globulus, Origanum vulgare or Thymus vulgaris (Chemotype Thymol) at. No. 5 are considered suitable Schüßler salts against nail fungus Potassium phosphoricum and No. 8 Sodium chloratum. You should discuss with an experienced therapist which remedy is most suitable in each individual case.

Nail fungus: home remedies

Many people think "natural rather than chemical" and prefer home remedies to fight nail fungus. For example, vinegar or acetic acid, lemon, marigold and aloe vera as well as tea tree oil are used. Such natural remedies are considered to be gentle help against the fungal infection. They are mainly used externally directly on the diseased nail.

However, it has not yet been scientifically proven that vinegar, tea tree oil & Co. are really effective against nail fungus. Some doctors advise against it because of this. At least the home remedies should not be used as a substitute, but only in addition to conventional medical treatment.

Read more about the use of home remedies for fungal infections of the nails in the article Nail Fungus Home Remedies.

Nail fungus: symptoms

In general, nail fungus can affect fingernails and / or toenails. However, the latter are affected much more often. There are two reasons for this:

On the one hand, the feet are exposed to greater mechanical stress. This tends to lead to tiny injuries that fungi (and other pathogens) use as entry points. On the other hand, mushrooms love a warm and humid environment, and this is more likely to be found on the feet, for example when walking barefoot in the swimming pool or in communal showers and when feet are sweaty in closed shoes.

The nail fungus often grows on the big toe, but it can also affect one of the other toes or spread over several nails. In the hand, too, the infestation can be limited to one finger or several fingers can extend. In severe cases, all the nails of a foot or hand are affected by the nail fungus.

Nail fungus symptoms vary with the different forms of onychomycosis, as described below. For all of them, however, the following applies: If the infection is not treated or treated too late, the whole nail can eventually be attacked by the fungus and be completely destroyed by it (total dystrophic onychomycosis).

Nail anatomy

Structure of toenails and fingernails

Distolateral subungual onychomycosis (DSO)

About 82 percent of all patients show this type of nail fungus. The pathogen is usually the filamentous fungus Trichophyton rubrum. It penetrates at the free (distal) end of the nail under the nail plate and spreads out on its underside in the direction of the nail root. In the course of this, the following symptoms of nail fungus typically result (without treatment):

At first, the nail plate looks dull and dull before it turns white-yellow. Further symptoms (pain etc.) are usually absent in this phase of nail fungus.

Excessive keratinization under the nail plate (subungual hyperkeratosis) causes the nail to gradually thicken and begin to separate from the nail bed. In some patients, the thickened nail plate can put painful pressure on the sensitive nail bed underneath. With nail fungus on the foot, this can be particularly noticeable when wearing tight shoes and when walking.

There is also the risk that bacteria (in addition to nail fungus) will settle in the damaged tissue and cause nail bed inflammation (onychia). Pain is then also possible and the entire nail is very sensitive to pressure.

Eventually, the affected nail becomes cracked, brittle, and crumbly.

Proximal subungual onychomycosis (PSO)

This form of nail fungus is also mostly caused by thread fungus Trichophyton rubrum triggered. It penetrates the nail wall, where the nail grows out, through the skin into the nail plate and the nail bed. The nail shows a whitish discoloration and cloudiness. This form of onychomycosis almost exclusively affects people with a weakened immune system.

White superficial onychomycosis (WSO)

This nail mycosis is also called leukonychia trichophytica. The trigger is usually the thread fungus Trichophyton interdigitale (T. mentagrophytes). It penetrates directly into the surface of the nail plate. As a result, white spots form in the nail.

Onychia et Paronychia candidosa (Candida paronychia)

The proximal nail wall (where the nail grows out) and later also the lateral nail wall are chronically inflamed due to an infection with yeasts (usually Candida albicans). Typical symptoms of nail fungus are reddening and swelling of the nail wall.

Later, the nail plate changes color in the edge area where the nail grows out and on the sides. The color varies depending on an additional bacterial infection from yellowish to brownish to greenish. Without treatment, the fungus will also spread to the nail matrix and nail bed.

Candida paronychia tends to develop on the fingernails of people who often work with their hands in a damp or wet environment.

Edonyx onychomycosis

For this very rare form of nail fungus are usually thread fungi of the genus Trichophyton responsible. They penetrate directly between the layers of the nail plate and spread inside. The dull, whitish nail plate splinters in a lamellar fashion. With this nail mycosis, the nail bed usually remains intact. In addition, there is no thickening and detachment of the nail plate from the nail bed.

Nail fungus stages

The nail fungus spreads over the nail in three phases.

Nail fungus: causes and risk factors

Nail fungus is mostly caused by thread fungi (dermatophytes). Sometimes molds or yeasts are also responsible for the infection. The latter mainly affects the fingernails.

In principle, the fungi can attack all keratinized parts of the body (skin, nails and hair). There they feed on the main component keratin.

Is nail fungus contagious?

The nail fungus gets on the skin through fungal spores. Spores are microscopic particles of the fungi that can survive for a very long time and are used to spread. The most common route of transmission is from person to person.

In addition, fungal spores can also be transmitted to humans from contaminated objects. These include, for example, towels, bath mats, carpets and beds.

Risk factors for nail fungus

Fungi prefer to grow in warm and humid places - for example on sweaty feet, especially if they are in shoes, from which heat and moisture cannot be dissipated to the outside. The resulting build-up of heat and moisture promotes fungal growth.

The same applies if you don't properly clean and dry the spaces between the toes. This is especially true for people who have a physical disability or, for example, a leg in plaster. You can get a foot and nail fungus more easily. By the way, experts suspect that nail fungus often develops on the feet as a result of an athlete's foot infection (tinea pedis). So many people suffer from both infections at the same time.

Other risk factors that could promote nail mycosis on the feet are:

• frequent contact with nail fungus pathogens, for example in the swimming pool, in communal showers or in the sauna
• Injuries to the nails
• certain skin conditions such as psoriasis
• Circulatory disorders in the legs, for example due to diabetes, peripheral arterial occlusive disease (PAD) or smoking
• weakened immune system, e.g. with some diseases (such as HIV) or when taking medication that suppresses the immune system (such as cortisone)
• familial disposition

Incidentally, diabetics are also more susceptible to fungal diseases due to the high amount of sugar in their blood - the sugar serves as food for the mushrooms.

People who often have damp / wet hands at work are particularly susceptible to nail fungus on their hands. This includes cleaning staff, for example.

Vitamin deficiencies (vitamins A, B1, B2, K, folic acid) and zinc deficiency are also suspected as general risk factors for nail fungus (and also skin fungus).

Nail fungus: examinations and diagnosis

The first point of contact when clarifying nail fungus is the family doctor. But you can also contact a dermatologist (dermatologist).

Medical history survey

The doctor will first take your medical history (anamnesis). To do this, he asks you about your symptoms, any underlying illnesses and other factors that are important for the diagnosis. Possible questions are, for example:

• Since when have the nail changes exist (thickening, discoloration)?
• Are you known to have any chronic diseases (such as diabetes or psoriasis)?
• What do you do for a living?
• Does anyone in your family have or had a yeast infection?

Physical examination

The conversation is followed by a physical examination: the doctor examines the affected nails and surrounding tissue. Thickened, discolored nail plates are often a clear indicator of nail fungus. However, there are other possible explanations for alleged nail fungus symptoms that the doctor must rule out (differential diagnoses):

Psoriasis can extend to the nails and look like a fungus here (nail psoriasis). In addition, nails can be involved in skin eczema ("eczema nail") and other skin diseases such as lichen planus (lichen planus), which can be similar to a fungal infection.

In people with chronic varicose veins, the toenails are often thickened and gray-green in color. This can also simulate nail mycosis. The same goes for nail injuries such as a bruise and bruising of the nail.

Other differential diagnoses are rare chronic nail changes that develop, for example, in circulatory disorders, thyroid diseases, iron, calcium or vitamin deficiencies.

Detection of nail fungus pathogens

A nail fungus test helps the doctor to clarify the nail changes: He disinfects the nail in question with alcohol and then scrapes something off the nail plate. He can dye the tiny nail shavings with a special dye and examine them for fungal spores under the microscope. If he finds any, it speaks for a nail fungus.

What kind of fungus it is cannot be seen under the microscope. The doctor must know this, however, if he wants to prescribe anti-nail fungus tablets for the patient. Because depending on the type of pathogen, certain active ingredients are more suitable than others. To identify the exact type of pathogen, it is grown from the tissue sample in the laboratory (fungal culture). It takes three to four weeks. If the nail fungus is very pronounced, the doctor can start antifungal therapy beforehand - with an active ingredient that acts against a wide range of fungi (broad-spectrum antifungal).

In rare cases, other tests are done for nail fungus. For example, the nail tissue can be examined more closely (histologically) in the laboratory.

What to consider before going to the doctor

So that the doctor can make the correct diagnosis if nail fungus is suspected, you should not wear colored nail polish during the examination.

If you have already tried local fungal nail treatment in advance (e.g. with antifungal nail polish), you should end this two to four weeks before the doctor's visit. Otherwise the result of the fungal culture can be wrongly negative due to possible active ingredient residues on the nail.

Nail fungus: disease course and prognosis

Nail fungus does not heal on its own, it must be treated. The following applies: the earlier nail fungus is treated, the better. In the initial stages, it is usually painless and easier to treat.

On the other hand, advanced mycosis of the nails can cause considerable pain, for example when wearing shoes, when walking or when deformed nails are grown in. The skin around the nail or the nail bed can become inflamed. In addition, the nail fungus can develop athlete's foot or skin, which spreads even further.

If the fingernails are affected by the fungal infection, the fingertip sensitivity can change in such a way that fine motor skills are impaired.

Last but not least, nail fungus is an aesthetic problem that can put a lot of psychological stress on those affected. Therefore, it should be treated as early as possible.

Absolutely persevere in therapy!

Nail fungus treatment is tedious and requires a lot of patience and consistency from those affected. Even in mild cases, it extends from weeks to months. In severe cases, nail fungus therapy lasts up to a year or more. The reason: The diseased nail area must first be completely outgrown before the patient is considered healed.

However, some patients stop the antifungal treatment early if the infestation is no longer visible. However, part of the nail plate may still be infected. Starting from these places, the nail fungus can spread to healthy areas again and again.

In the case of infected fingernails, the treatment is usually more successful than in the case of toenails.

Prevent nail fungus

A nail fungus can be prevented. Fungal spores can be found everywhere in our environment - but the fungi feel particularly at home in a humid and warm environment. The most important measure is therefore to deprive them of the breeding ground:

Correct footwear

You should as rarely as possible wear closed-toe shoes (such as sneakers) in which the feet sweat profusely. Instead, prefer shoes that are more permeable to air (such as sandals or light loafers). Do not put on wet or damp shoes.

You should ventilate your shoes well after wearing them. If you have sweated a lot, you should stuff your shoes with paper after wearing them and let them dry out completely. You can also disinfect the shoes regularly.

Always wear shoes (e.g. bath slippers) in changing rooms, swimming pools, saunas and solariums - you can easily catch foot or nail fungus in such public facilities when you are barefoot.

Socks and stockings

When choosing socks, you should give preference to materials such as wool, cotton or cotton blends and avoid synthetic materials. Change your socks daily or, if you sweat a lot, several times a day. In addition, shoes and socks should never be shared with other people in order to avoid the possible transmission of nail fungus in this way.

Proper foot care

After washing and bathing, dry your feet well before putting on socks and shoes. When drying off, pay particular attention to the spaces between the toes!

Regular and thorough foot care is especially important for people who are particularly susceptible to nail fungus. These include, for example, diabetics and people with immunodeficiency, but also athletes and senior citizens. It often makes sense to visit a medical podiatrist (podiatrist) on a regular basis.

Change laundry and wash properly

Towels and bed linen should be changed regularly. If you already have nail fungus, you should use a separate towel for the affected feet or hands and even change them daily - as well as socks and stockings. Just like shower rugs, wash them at at least 60 degrees Celsius. Use heavy-duty detergents or special detergents that kill fungal spores. These are available in pharmacies and drug stores.

For nail fungus patients: prevent spread

People with nail fungus should not walk barefoot both outside and in the apartment, so as not to spread the robust fungal spores in the area and thus possibly infect other people.

When sleeping, people with nail fungus should wear socks. This prevents the fungal spores from spreading in the bed and possibly reaching other parts of the body or the partner and triggering a new infection there.

Additional information

• Guideline "Onychomycosis" of the working group of the scientific medical societies, guidelines of the German Dermatological Society and the German-speaking Mycological Society (status: 2006)

Tags:  hospital therapies womenshealth