Onychomycosis is a very common fungal infection which occurs in the nail, the toenail or the fingernail. Mainly caused by dermatophytes, a special type of fungi who love warm and humid places. Gupta et al. (2020) confirm that dermatophytes are the most common cause of onychomycosis. Depending on the type and the surface of affected nails, the fungus can cause several characteristics like thickening of the nail plate hyperpigmentation (usually brown or yellowish) and finally weakening of the nail, sometimes causing the whole nail plate to be detached from the nail bed. Which may look not so cute and sometimes can even be causing some discomfort.
There are certain risk factors that increase the chance of developing a fungal infection of the nail. Some of the risk factors include age. The nails tend to grow slower with age and are generally weaker and less resistant to microbial invasion due to weaker immune response. Vlahovic (2016) mentions that people with diabetes mellitus are at higher risk for developing onychomycosis due to the higher glucose levels in their blood, which damages nerves and affects blood circulation in the feet. Microfungal infections can then quickly develop. Immunocompromised individuals are at a higher risk for fungal infections of the nail and onychomycosis. Immunocompromised individuals include those suffering from HIV/AIDS, as well as those who have been treated with chemotherapy.
Infections can occur through many routes, but often start from fungal spores coming into contact with the skin or nails. This often occurs in public places such as pools, gyms, or shower rooms, as fungi thrive in damp conditions. The fungus may not give an active infection but can instead reside on the skin or nails until it finds the right conditions to penetrate in. Contributing factors that can increase susceptibility to fungal infections include increased sweating, nail trauma and the use of tight shoes.
Fungal infections such as onychomycosis are caused in part by environmental factors. Fungi typically thrive in warm, humid environments. This makes locations such as public showers or spas prime areas for spreading the fungal infection of onychomycosis. Other factors that contribute to an increased risk of getting onychomycosis include poor foot hygiene and not fully drying the skin and feet after washing them.
Understanding the cause of onychomycosis may ultimately help in the prevention and management of this condition. As shown in the previously discussed findings, increased knowledge of the risk groups of onychomycosis (e.g. elderly and diabetic individuals) and the fungal habitats (e.g. swimming pools, showers) could contribute to more focused and therefore potentially more effective public health education. Moreover, early recognition of symptoms is crucial and will potentially result in faster treatment and less disruption to daily life., Onychomycosis is an infection by fungi in the nail. The signs and symptoms can greatly affect the quality of life of sufferers. For instance, a study by Beuscher & Kelechi (2019) showed the common characteristics of the infected nails were discoloration, thickening and brittleness. Fungal infections to the nails cause them to change colour to yellow or to white and they start to become significantly thicker and sometimes fragile, prone to cracking and crumbling.
The psychological effects of onychomycosis should not be underestimated. According to Gupta et al (2018) people with onychomycosis may feel stigmatised due to the visibility of their nails, which can give rise to feelings of embarrassment and shame. This in turn can affect their social interactions. They may exclude themselves from social events because they are ashamed of the appearance of their nails. They also may be wary of being teased or ridiculed by others. Being self-conscious and feeling embarrassed about one’s appearance as a result of having unsightly nails can lead to low self-esteem. Having attractive nails is an important aspect of personal grooming and hygiene. An infection affecting the surface of the nails can result in the person feeling that they are not a presentable or attractive person, giving rise to feelings of being unclean.
The study by Leung et al. ( 2020) noted that in severe onychomycosis cases, the impact is likely to be more than just cosmetic. The authors said that, in addition to the potential for embarrassing and visually unsightly appearance, pain and discomfort can develop as symptoms of the infection. The authors attributed such occurrence to a reaction to the infection such as reddening inflammation around the nail or ingrown nail resulting in the feeling of pain and discomfort. This therefore makes functional activities such as walking, exercising, even shoe putting a task that is a challenge to such patients who as a result have to limit participation in many daily tasks and activities. For instance, such cases could affect a long distance runner who cannot afford to be without his running shoes for a long period due to the discomfort associated with infected nails.
Although usually regarded as trivial the psychological consequences of onychomycosis can greatly affect a sufferer’s daily social and mental activity. Consequently, a patient who is embarrassed by a nail disorder can withdraw from many common social and occupational activities which are important for normal psychological well-being. Thus the infected foot may not be worn without constraint in the home or at work and the sufferer may give up enjoyable activities like gardening, sport and swimming or even refrain from going to the beach and walking on sandy shores. Many infected patients suffer depression, leading to a considerable diminution in the quality of life which has been drastically modified by an embarrassing infection from which there is little hope of cure or which may not even be diagnosable by empirical therapy.
Daily living is affected in a number of ways by onychomycosis, so it is very important to look at the impact of the disease and plan the treatment of the lesion to improve the quality of life of the patient. The management of the local lesion is important, but also the psychological and social impact of the disease must be considered in the clinical management of the condition by the clinician and the multidisciplinary team of healthcare professionals. By raising awareness of the impact of onychomycosis on the patient’s quality of life, the patient will be able to be managed in a more holistic way and there will be a reduction in the societal stigma associated with chronic infection resulting in visible changes to the skin and nails. The current therapeutic options available for the management of onychomycosis include both topical and systemic therapies. Topical therapy involves the application of drugs as nail lacquers or as creams to the affected nail. Although both the topical and systemic treatments vary in their efficacy, the main advantage of topical therapy is that it is less invasive and the drug does not enter the systemic circulation; hence, the compliance of the patient is better, as the drug needs to be applied to the nail surface for consistently for 6–12 months. On the other hand, the advantage of the systemic therapy is that it is highly effective in the management of thickened nails, and in cases where the nail plate is heavily infected, it is the preferred treatment, although the side effects associated with these drugs must be taken into consideration.
The current treatments are apparently effective. Piraccini & Alessandrini (2015) reported that even though the infection may be brought under control, many cases relapse. There are many possible reasons. In our opinion it is however important to recognize that a patient who does not comply with the treatment schedule recommended by the dermatologist, may not achieve an effective treatment and in any case may not eliminate completely the causative agents. Hence, as mentioned also by Gupta et al. (2017), a good compliance to a treatment regime will determine not only the likelihood of obtaining the desired outcome but also of preventing the treatment failure and subsequent relapse. Therefore it is also important for the physician to have the patient fully aware of the instructions and the relevance of each step of the prescribed treatment schedule.
The prevention of onychomycosis is equally important to manage and reduce the occurrence of fungal nail infection. Practicing good foot care and choosing appropriate shoes are some simple measures to reduce the incidence of fungal nail infection. Zaraa et al. ( 2024) emphasize the importance of foot care stating that keeping the feet clean and dry, and by wearing ventilated shoes and avoiding wearing tight shoes which can cause the humidification of the foot. Also, regular monitoring of the nails to detect any change or fungal infection at the earliest is a good practice.
Onychomycosis Awareness Raising awareness for onychomycosis is crucial for prevention. Falotico & Lipner (2022) underscore the necessity of educating people about this condition. Many are not even conscious to the signs and symptoms that may suggest they have developed onychomycosis and do not recognise onychomycosis to be preventable. Improved awareness is key to promoting better preventive measures, leading to earlier diagnosis and a reduced incidence of onychomycosis. When people have the right foot care knowledge, are made aware of the severity of untreated fungal infections and the efficacy of treatments that can clear the infection, this will subsequently lead to a reduction in the incidence of onychomycosis. Education empowers the at-risk population as well as those affected by onychomycosis and subsequently improves their quality of life.
Citations:
Gupta, A.K., Stec, N., Summerbell, R.C., Shear, N.H., Piguet, V., Tosti, A. and Piraccini, B.M., 2020. Onychomycosis: a review. Journal of the European Academy of Dermatology and Venereology, 34(9), pp.1972-1990. https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.16394
Vlahovic, T.C., 2016. Onychomycosis: evaluation, treatment options, managing recurrence, and patient outcomes. Clinics in podiatric medicine and surgery, 33(3), pp.305-318. https://www.podiatric.theclinics.com/article/S0891-8422(16)30013-1/abstract
Beuscher, T.L. and Kelechi, T.J., 2019. Onychomycosis: diagnosis, treatment, and prevention. Journal of Wound Ostomy & Continence Nursing, 46(4), pp.333-335. https://journals.lww.com/jwocnonline/fulltext/2019/07000/Onychomycosis__Diagnosis,_Treatment,_and.15.aspx?context=FeaturedArticles&collectionId=3
Gupta, A.K., Mays, R.R., Versteeg, S.G., Shear, N.H. and Piguet, V., 2018. Update on current approaches to diagnosis and treatment of onychomycosis. Expert Review of Anti-Infective Therapy, 16(12), pp.929-938. https://www.tandfonline.com/doi/abs/10.1080/14787210.2018.1544891
Leung, A.K., Lam, J.M., Leong, K.F., Hon, K.L., Barankin, B., Leung, A.A. and Wong, A.H., 2020. Onychomycosis: an updated review. Recent patents on inflammation & allergy drug discovery, 14(1), pp.32-45. https://www.benthamdirect.com/content/journals/iad/10.2174/1872213X13666191026090713
Yousefian, F., Smythe, C., Han, H., Elewski, B.E. and Nestor, M., 2024. Treatment options for onychomycosis: efficacy, side effects, adherence, financial considerations, and ethics. The Journal of Clinical and Aesthetic Dermatology, 17(3), p.24. https://pmc.ncbi.nlm.nih.gov/articles/PMC10941855/
Piraccini, B.M. and Alessandrini, A., 2015. Onychomycosis: a review. Journal of Fungi, 1(1), pp.30-43. https://www.mdpi.com/2309-608x/1/1/30
Gupta, A.K., Versteeg, S.G. and Shear, N.H., 2017. Onychomycosis in the 21st century: an update on diagnosis, epidemiology, and treatment. Journal of cutaneous medicine and surgery, 21(6), pp.525-539. https://journals.sagepub.com/doi/abs/10.1177/1203475417716362
Zaraa, I., Dehavay, F. and Richert, B., 2024. Onychomycosis. Hand Surgery and Rehabilitation, 43, p.101638. https://www.sciencedirect.com/science/article/pii/S2468122924000070
Falotico, J.M. and Lipner, S.R., 2022. Updated perspectives on the diagnosis and management of onychomycosis. Clinical, Cosmetic and Investigational Dermatology, pp.1933-1957. https://www.tandfonline.com/doi/abs/10.2147/CCID.S362635
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