Posted on Friday, February 23, 2018
Singapore’s weather of rain and humidity can have many effects on the feet; creating optimal conditions for fungus to spread in the skin and toenails. Undetected to the naked eye, fungal spores are opportunistic in nature and latch onto any possible host. They thrive in moist environments, causing itchiness, flaking, red spots and dryness to the skin of the foot.
When the fungal skin infection further worsens, a condition called ‘foot rot’ can develop. This causes the development of a bacterial infection on top of the fungal infection, often leading to bleeding, pus, open wounds, and pain. If ignored or incorrectly treated, foot rot can worsen into a medical emergency. It is also contagious and can be transmitted to friends and family in close proximity.
Figure 1: Fungus presents on toenail before Podiatrists in-clinic treatment
The presence of skin fungus is closely related to fungal nails. If one has a chronic fungal skin infection, it is likely to be accompanied by a fungal nail infection, or vice versa. Fungal nails are more difficult to treat than the skin; the nail plate offers the fungus a perfect hiding place from topical treatments.
Nail fungus presents in many different variations. The superficial fungus appears as a white or yellowish discolouration across the top surface of the nail. Given time or opportunity, fungus tends to invade the underlying nail bed, causing the nails to become thick, crumbly and lifted. The colour of the nail appears as dark yellow, brown, greenish or white. Once nail fungus invades the nail bed, it is difficult to treat and eradicate. Leaving the fungus for too long will allow it spread to all ten toenails, as well as to others around you.
Prevention is important. Ensure the feet are always dry, especially in between the toes. Rotate the use of footwear regularly, allowing aeration of the shoes. Wear socks with closed footwear at all times, and change them at least once or twice daily. Avoid sharing nail clippers, files, polish or other products with other people. Refrain from salon pedicures as cross-contamination can occur if the instruments are not properly sterilised; some pedicure enthusiasts prefer to bring their own instruments to their salons. Most importantly, pay good attention to the state of your feet and nails by checking them daily.
If you notice changes or discolouration to the nail or skin, it may be that a fungal infection has started. However, there are numerous other conditions which can bear similar appearances to fungal infection, ranging from psoriasis to even skin cancer. It is essential to receive a proper diagnosis of the condition, to ensure that correct treatment is prescribed. Monitored treatment by healthcare professionals would ensure that the problem is fully addressed.
Home remedies are mostly not strong enough to eradicate stubborn nail fungus. There is a variety of over-the-counter options claimed to be effective for resolving nail fungus. Tea tree oil, apple cider vinegar and more, are common items which many patients have tried in order to eliminate nail fungus. These products often do not have strong antifungal ingredients. The infection may seem to clear up for a period of time, but the chances of recurrence are very high.
Topical medications with a strong antifungal ingredient have proven to be effective if the nail fungus is still mild or superficial. A consistent and diligent application is still required, for a minimum period of 6 to 18 months. Topical treatment can come in various forms such as ointments, creams, drops and lacquers. Topical products tend to have minimal or no effect for severe infection, as the fungus has already attacked the deep layers of the nail plate and the nail bed, or even the nail matrix (nail root) itself.
It can be an uphill battle in Singapore’s climate, yet fungal nails can be cured if intervention is prompt. Chronic fungal infections can be treated with oral antifungals. Oral drugs such as terbinafine (Lamisil) and itraconazole (Sporanox) are commonly prescribed. They act to help healthy nail grow out from the nail matrix in replacement of the infected ones. A minimum course of three months is usually needed to improve or resolve the condition. Because oral antifungals are potent drugs, the most significant side effect is liver toxicity.
Hence, monthly blood tests are required to monitor the patient’s liver function. Oral antifungal medications can also interact with anti-depressants and beta-blocker medications. Patients with liver and heart problems are usually contraindicated for this form of treatment.
With the advancement of medical technology, laser and light therapies have become more common in recent years. They have proven to be effective with little to no side effects. Patients have found a preference for this treatment modality as it avoids the disadvantages of oral and topical drugs while providing relatively fast results. Photodynamic Antimicrobial Therapy (PACT) is one such treatment option offered in our practice: Fungal cells possess a cell wall, unlike human cells. A photosensitizing gel specifically targeting fungal cell walls is applied to the nail, causing the fungus present to be vulnerable to a specific wavelength of light. Direct exposure to the specific light then destroys the stained fungus, even those which have become resistant to the strongest antifungal medications. Just like a course of antibiotics, a number of sessions are required for effectiveness. Top-up sessions may be required depending on the treatment progress.
A surgical option for resolving fungal nails is often used when the entire nail bed has been deeply infected by fungus. Surgically removing the entire nail plate is known as a total nail avulsion. This is carried out to achieve a “blank canvas” for the nail bed, giving a new nail the best opportunity to grow out clear and fungal free. Healing time for the surgical wound usually takes one to two weeks. As part of this treatment strategy, immediately after the wound is healed the patient is required to follow through with a course of PACT therapy to ensure that fungal spores are completely eliminated from the nail bed.
Figure 2a: Podiatrist removing portions of the fungus in preparation for PACT Treatment
Figure 2b: Toenail after first treatment using Podiatric methods
There are many treatment options to consider. Patients hoping to be free of stubborn fungal infections should dedicate full compliance once treatment has started, in order to ensure success. Eradicating fungus is often not 100%, especially in Singapore’s tropical climate. Without proper clinical treatment, there is a high possibility of re-infection. Timely treatment is key to preventing the spread of fungus from toenail to toenail.
Author: Emily Mah, Podiatrist at East Coast Podiatry (Singapore)
Editor: Michael Lai, D.P.M.