How do you cure onychomycosis

Successful therapy in daily practice

Fungal pathogens are diverse and well adapted to civilization. They attack people from head to toe. The most common are mycoses of the feet and nails. Children are also becoming increasingly ill, which was rare years ago. The suffering of the patients who go to the doctor is high. However, it's not just a visual problem, but most of all an infection that is communicable. The pathogens are detectable. Equally impressive is that any yeast infection can be cured, no matter how stubborn. The present work would like to encourage that this also succeeds in the general practitioner practice.

Onychomycosis is a serious disease that needs treatment. It is by no means a "game with fear, for the benefit of the pharmaceutical industry", as some media claim [1]. Fig. 1 shows severe toenail infestation in a 15-year-old schoolboy. The picture illustrates that foot and nail fungus belong together. There are two stages of the same infection. If left untreated, the infection will spread even further.

The pathogen usually comes from the family

The reasons for onychomycosis to develop are now more diverse and cheaper than ever. In older patients - around every second 65-year-old is affected [2] - the feet are colder and the nails also grow more slowly. The most common pathogen, Trichophyton rubrum, prefers such circumstances. On the other hand, it can never cause an internal mycosis. Genetic predisposition plays a major role, especially the question of whether there are receptors for the pathogens on the skin. For young people, factors such as plastic shoes and stress from games and sports are most important. The pressure forces on the nails are enormous when dancing, tennis or soccer, and the humidity is high. Footballers in particular are often severely affected. In addition to these circumstances, there must also be contagion. Only when both factors, the disposition and the pathogen, come together, leads to mycosis. Most often the pathogens come from the family environment. Mostly from grandparents or parents who do not treat each other. Since most local drugs were left to pay for yourself, politicians also have their share in the increase in mycoses and nail fungus now also occurring in children. Older people in particular do not treat each other for cost reasons.

What if it's not a mushroom?

The nail affected by the fungus is either thickened or atrophied. Individual nails resist the disease, which is characteristic (Fig. 2). The most common non-infectious disease is nail psoriasis (Fig. 3). In blood pressure patients it can be triggered by ß-blockers, ACE inhibitors or AT1 antagonists. Such a nail often looks like a fungal attack (Fig. 4). This also applies to congenital nail changes such as the so-called wooden, claw or glacier nails (Fig. 5). In contrast to the mushroom nail, such an onychogrypose is always "rock hard". If there is any doubt about the clinical diagnosis, a sample should be obtained. To do this, it is sufficient to use blunt scissors to scrape as many fine chips as possible from different suspicious locations onto a piece of paper and send them to a laboratory. Please do not cut off large pieces, do not disinfect beforehand and allow the patient to pause for about 4 or 8 weeks with topical or systemic therapy before taking the sample.

Every onychomycosis is curable

Therapy is still difficult, but the chances of recovery are better than ever. In children, the nails always heal. The family doctor should not let this sense of achievement be missed and should treat every onychomycosis patient himself. The need for therapy arises from the nature of the infection, which is communicable. The key to successful healing often lies in the interplay of external and internal therapies. Basically, the topical therapy is mandatory, the internal one is added. Local treatment is important because no internal drug is able to reach the pathogens from within in the peripheral foci of infection. If the nail is thickened, the infected nail mass should definitely be removed. The germs have to be eliminated thoroughly because there is no immunity to fungal pathogens and the infection can recur at any time for this reason. The therapy takes place in 3 steps.

1. Remove the infected nail mass

The only method that can be carried out with high efficiency, painlessly and on your own is the application of a 40% urea ointment with bifonazole until the diseased nail is removed, for about 1 - 2 weeks. Bifonazole has the advantage that the nail material removed by the urea is no longer infectious - in contrast to the files used in some nail polishes. The urea removes the infected nail mass, like a scalpel, within a few days. The healthy nail portion is retained like a curb.

Surgical nail extraction is no longer up to date. Alternatively it can be milled. Basically, the urea replaces the burr and the surgeon. The therapy continues until there is no longer any visibly diseased nail substance, which is often the case after just a few applications. An overnight treatment is sufficient. The nail supplied with urea ointment is covered with a plaster so that it does not get into the bed linen. Because of the painless treatment, the urea method is particularly suitable for children and is approved from the age of 2. If necessary, the local therapy can and should be repeated at any time. It is therefore advisable to keep the local medication until it is completely cured. If the urea does not work, it is not a mycosis. It is therefore also an important differential diagnostic tool.

Lasers instead of pharmaceuticals?

The light and laser therapy introduced with high expectations should be viewed critically. The initial euphoria has given way to disillusionment. There is a lack of clinical evidence. The method is still expensive and it is not covered by health insurance companies.

2. Local long-term therapy

The "nail wound" exposed by the urea must be treated consistently daily with topical antimycotics in the further course. For this purpose, preparations with broad active ingredients such as bifonazole and ciclopirox are suitable in order to record all possible pathogens. This should be done for as long as possible until all fungal spores have been eliminated and the nail has grown out completely healthy. Bifonazole can be sprayed precisely onto the nail and binds well. Another advance in the local treatment of onychomycosis is a water-soluble varnish with the direct sporocidal ciclopirox [3]. In contrast to all other varnishes, it can also be applied directly to the nail surface exposed by the urea. Ideally as a long-term prophylactic beyond the healing success in order to achieve the lasting healing success hoped for by the patient. Then once a week, "so that the fungus doesn't come back".

3. Systemic therapy

Internal therapy comes into play when a nail is affected over two thirds or more than 3 nails at the same time [4]. Only the combination of both forms of therapy, the local and the internal, enables 100% healing success for many patients, which also applies to major infections of the feet and hands as well as tinea corporis generalisata. In this form, the pathogen is "gripped" from two sides. Since the healing rates of systemic therapy are around 60%, no systemic therapy should be given without local treatment.

Rapid progress

Modern internal therapy for onychomycosis has changed radically and is better tolerated than ever [5]. After a few days, it is only done with one dose per week (Table 1).

Another revolutionary innovation concerns the well-known, broadly effective and first systemic antimycotic for the treatment of onychomycosis, itraconazole. Due to its recently discovered anti-tumor effect, it was the first systemic substance to be embedded in a polymer. This method, known as SUBA (super bioavailability) technology, increases the solubility, bioavailability and absorption of the antimycotic to such an extent that the dose in onychomycosis therapy can be reduced from 400 to 200 mg / d, in children even to 100 mg / d, which further increases the acceptance of systemic therapy [6]. This still has an unfounded bad reputation. The azoles are excellently tolerated even in higher doses and are a compulsory part of therapy in children with the increase in tinea capitis caused by immigration [7].

Internal therapy is not only carried out in gentle doses today, but also until the nail has healed completely, while maintaining the local therapy. In children, full clinical success occurs after about 6 months, in adults it is not uncommon for more than a year. Patients should know that the speed of nail growth cannot be accelerated. In order to achieve lasting healing success, it is advisable to treat the shoes with a spray from the pharmacy. Simultaneous athlete's foot should initially be treated daily for 2 weeks with one of the active ingredients mentioned as a cream, solution or spray. Likewise all affected family members (Fig. 6).

Onychomycosis is common and not always easy to treat. It is important to eliminate the pathogen thoroughly. In difficult cases, the key to success lies in the interplay of topical and systemic therapy. Thanks to the gentle dosage and modern galenics, the latter is very well tolerated and therefore much better than its reputation.

(1) Hackenbroch V .: Playing with fear. Der Spiegel 2002, 36: 154
(2) Abeck D, Haneke E, Nolting S, Reinel D, Seebacher C. Onychomycosis. Current data on epidemiology, spectrum of pathogens, risk factors and the influence on quality of life. Dtsch Ärztebl 2000, 97: 1984-1986
(3) Baran R, Tosti A, Hartmane I, Altmeyer P, Hercogova J, Koudelkova V, Ruzicka T, Combemale P, Mikazans I: An innovative water-soluble biopolymer improves efficacy of ciclopirox nail lacquer in the management of onychomycosis. J Eur Acad Dermatol Venerol 2009, 23: 773-781.
(4) Seebacher C, Brasch J, Abeck D, Cornely O, Effendy I, Ginter-Hanselmayer G, Haake N, Hamm G, Hipler UC, Hof H, Korting HC, Mayser P, Ruhnke M, Schlacke KH, Tietz HJ ( 2007): Onychomycosis. Mycoses 2007, 50: 321-7
(5) Tietz, HJ. Antifungal drugs from A-Z. 5th, revised and expanded edition, Ligatur Verlag für Klinik und Praxis, Stuttgart 2011
(6) Tietz H-J: Modern onychomycosis therapy with SUBA-Itraconazole and Ciclopirox: Advances in galenics lead to lasting healing success. 2016, derm 4: 300-08
(7) Tietz H-J: Mycoses of the skin. New pathogens and advances in therapy. MMW 2017, 236: 50-55
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(2) Meissner G .: fungus formation in the nails. Arch Physiol Heilkunde 1853, 12: 193-196.
(3) Virchow R. On the normal and pathological anatomy of the nails and epidermis.
Negotiation Physikal Med Gesellsch Würzburg. 1854; 5: 83-105

Institute for Fungal Diseases and Microbiology

Conflicts of Interest: The authors have not declared any.

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