As summer approaches, many Americans will be exposing a condition to others by wearing sandals or going barefoot. This condition of the nail plate is unsightly, disfiguring, and, at times, painful. It is onychomycosis of the nail plate.

Millions of Americans are affected by this disease. There are many options available to treat and possibly cure the fungal nails. These options range from regular reshaping of the nail plate, oral antifungal agents, topical antifungal solutions, and surgical ablation of the nail. Any of these options are readily available, but not entirely foolproof.

The disease must be differentiated from other finger and toe nail disorders such as psoriatic nail involvement. This differentiation is typically diagnosed by taking a sample of nail plate tissue and exposing it to a proper growth medium. This isolates the primary fungus that wrecks the structure of the nail plate and indicates the appropriate antifungal agents. Generally, the same types of fungus that cause athlete’s foot (Tinea Pedis) will cause onychomycosis. Only after these organisms are identified can the Podiatrist select an appropriate antifungal agent to successfully combat the specific organism present in each case.

Presently there are two primary agents that are actively marketed to Podiatrists and patients. These are Sporonox and Lamisil, both of which are available in the form of oral medication. It is important to note that neither medication is without side effects, nor are they inexpensive. Each drug does, however, offer a success rate of approximately 85%. Other oral agents, namely Diflucan and Griseofulvin, are not as effective. All of these medications need continual monitoring of liver enzymes and white blood cells.

Sporonox (Itraconazole), manufactured by Janssen Pharmaceutical, has a pulse dose regimen. The patient takes 200 mg twice daily for one week, stops taking the medication for three weeks, then resumes taking the medication for one week, repeating this cycle for three months. The drug is absorbed into the soft tissue and provides a steady state of concentration after the drug is no longer being taken. This drug should not, however, be taken with Seldane, Hisminal, Mevcor, and other drugs, as fatalities have been reported (see P.D.R. or speak with your physician regarding possible counter indications). The cost of the pulse dose itself is approximately $800 to $900, in addition to the cost of lab work and active physician care.

Lamisil (Terbinafine HCL), is manufactured by Novartis, has less drug interaction, and costs slightly less than Sporonox. The spectrum of activity of Lamisil, however, is also less than that of Sporonox. This means that Lamisil does not inhibit as many other pathogens as Sporonox, although the success rate of each drug is reported to be the same. Lab work and physician care costs are the same and both drugs are in the same price range, although Lamisil’s dosage is 250 mg once daily for 90 days. See P.D.R. for full disclosure about Medications!

If nail fungus is not destroyed by taking Sporonox or Lamisil, the pharmaceutical company that manufactured the drug will reimburse the patient for his financial investment for the drug. It is important to know that taking the medication might destroy the nail fungus yet still leave the nail discolored and disfigured. This would leave the patient with an unaccomplished goal. Despite the fact that the nail does not appear normal, the pharmaceutical company would not reimburse the patient for the cost of the drug, as the fungus would no longer be present. Fortunately, this happens in a relatively small percent of all cases, only 10 to 15%.

Another treatment option available to patients with fungal nails includes the use topical antifungal agents. Topical antifungal agents only work on the superficial spreading of onychomycosis. Characteristically, this variety of fungal nail disease has superficial pitting with whitening of the nail plate. In order to effectively treat this condition, one must also keep foot moisture at a minimum. Drying agents, powders, and the use and frequent changing of cotton socks often help to dry the foot. The majority of topical nail fungicides are over-the-counter. These are Fungi Nail, Mycocide, and Restore AF. These agents are not as successful in the treatment of nail fungus as the oral antifungal agents.

Surgical intervention has great merit when chronic ingrown nails, thickened (dystrophic) nails, and pain are associated. The goal of the surgery is to remove all or part of the nail matrix (root) so that the nail plate is permanently destroyed. This method offers a success rate of about 95 to 99%. There is minimum discomfort post-operatively, and it is easily performed in the Doctor’s office under a local anesthetic. Remember that if the nail plate is removed, the nail disease is also removed.

Onychomycosis (fungal nail) is not considered to be a strong contaminant. Rather, it is considered to be a condition that some individuals are more susceptible to than other individuals. Factors that permit this disease include the pH level of the skin, trauma to the nail, hygiene of the foot and susceptibility of the patient. The fungus is prevalent and opportunistic. The treatments available are dependent on cost, ease, lifestyle, and effectiveness of the eradication of this nail disease.

The condition of fungal nails can be treated successfully, but can reoccur later. Your choice of treatment should be decided by you and your Podiatrist so that compliance, expectations, and results of therapy are realistic. Should you suspect that you have this condition of your toenails, please consult a podiatric specialist and ask questions regarding all treatment options available. This will allow you, the consumer, to be informed of which treatment will be most suited for your needs.

Dr. Graham has been in private practice in Effingham since 1989 and is on staff at St. Anthony's Memorial Hospital and Effingham Ambulatory Surgical Treatment Center. He is Board Certified by the American Board of Podiatric Surgery and American Board of Podiatric Orthopaedics and Primary Podiatric Medicine. Dr. Graham is a Fellow of the American College of Foot and Ankle Surgeons, the American College of Foot and Ankle Orthopaedics and Medicine, and American Professional Wound Care Association. He is also a member of the American Podiatric Medical Association and the Illinois Podiatric Medical Association.

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