Perseverance is called for

A fungus infection of individual nails turns out to be a long, protracted illness. The fungi, especially dermatophytes, mostly enter at the end of the nail into the underside of the nail plate and slowly spread into a matrix. Typical signs: the nail loses its shine, thickens, becomes deformed and shows white or yellowish-brown discolouration. At its later stage the nail plate can start crumbling and lifting from the nail bed. The nails mostly affected are toenails, particularly the big toe. Fingernails are far less affected. A nail mycosis may not be dangerous but when walking can cause pain at the toe nails and pose a considerable cosmetic problem.

A warm and humid climate inside shoes or in protective gloves as well as mechanical damage to the nails can pave the way for the infection. Previous and untreated foot fungus infections can also spread to damaged nails. Diabetes mellitus, circulatory disorders, immunodeficiency and peripheral neuropathies foster the infection.

Laymen cannot recognize if the changed nail surface is due to a fungus infection or perhaps a psoriasis of the nail, an eczema or a nail-wall inflammation. These illnesses look very similar. For this reason, the person affected should have the symptoms checked by a dermatologist as quickly as possible. For, the sooner the treatment starts the higher the success rate and the shorter the therapy. Slight illnesses can be easily treated locally by self-medication. If more than half of the nail plate is affected or if the patient is in poor health, an additional systemic therapy with oral antimycotics, available only on prescription, can be used.

The treatment of nail mycosis requires patience. The duration of the therapy depends on the speed of the nail growth. If the afflicted nail is not removed the duration of treatment of a fingernail mycosis will take at least three months; in the case of a toenail mycosis, six and more months are to be expected. Patients need to know this so that they do not mistakenly stop the therapy too early. On the contrary, it is recommended to continue the treatment a little longer than absolutely necessary so that the fungus will not have another chance if remaining spores become active again. Nail mycoses on a foot are frequently associated with a foot fungus. This also needs to be treated consistently so that the nails do not become infected again.

For the local treatment three active substances in particular are possible: amorolfine, ciclopirox and bifonazole. The first two are available as medical nail varnish. Varnish is often easier to handle in day-to-day life than adhesive bandages and can better withstand mechanical stress. Basically, one needs to differentiate between water-soluble and water-insoluble lacquer bases. Both have in common that the entire nail has to be carefully painted over and not only the visibly ill area. When using water-insoluble amorolfine nail varnish (for example amorolfine nail cure Heumann, Loceryl®), the nail plate is being treated once a week. Prior to the application, the user should remove destroyed nail material with a one-time nail file and, if necessary, remove varnish remains from the previous application with an alcohol swab.

After the solvent has vaporized, the varnish forms a waterproof layer with an occlusive effect. This helps the active ingredient to penetrate the nail substance.

In the evenings the water-soluble varnish Ciclopoli® containing Ciclopirox is painted on the affected nail. Varnish remains can be easily washed off in the mornings. In contrast, the application of the water-soluble nail varnish Batrafen® A or Ciclopirox Winthrop depends on the stage of the therapy. During the first month it is applied every second day to saturate the nail with the active substance. During the second month of treatment the application can be reduced to at least twice a week and from the third month onwards to once a week. During the entire duration of the application the whole layer of the varnish is removed with alcohol swabs once a week. The patient should take this opportunity to remove as much as possible of the changed nail material using a one-time nail file.

A more complex but faster treatment concept is offered by the combination of highly dosed urea and an antimycotic such as bifonazole in the form of an ointment. The urea dissolves the nail plate without causing any pain. The preparation is applied to the ill nail as thick as the back of a knife and then sealed water- and airtight with a plaster. After twenty-four hours the dressing is taken off and the softened nail substance removed by the user, and the treatment is repeated. It takes mostly one to two weeks until the ill part of the nail has been completely removed. This must be followed by another four weeks of antimycotic treatment using a urea-free bifonazole cream once daily.

By the way, the widely dreaded »nail pulling« which was common in the past is today obsolete. It led to injuries of the nail bed far too often and to lasting growth disorders of the nail. In this respect patients have nothing to fear now and can relax.