Fungal Nails Treatment

Onychomycosis – fungal nail – occurs when there is an overgrowth of fungi in, under or on the nail. The feet are susceptible as fungus tends to thrive more in warm, moist places – such as within shoes.

Rarely painful, patients report visual changes to their nails, which usually prompts them to make an appointment for specialist advice. A few key changes can be seen in the nail when suffering from a fungal nail infection:

• the fungus causes cell damage at the base of the nail so the nail thickens and changes shape 
• white plaques form on the nail’s surface which looks like white crumbly chalk
• as the infection progresses the infected nail/s may discolour to a yellow or brown
• the integrity of the nail structure is compromised and parts of it can break off. Sometimes we see patients where the entire nail is lifting off and this causes swelling and pain in the affected area.

Fungal nail infections are very common, mostly not painful or serious but can take a long time to treat and resolve fully.

Diagnosis of Fungal Nails

We can usually make a diagnosis from the visual appearance of the nail and from the patient’s description of the issue. If we’re not sure then we take a sample clipping of the nail for referral to pathology, which will confirm the diagnosis.

Fungal nail infections usually start at the edge of the nail. As the infection progresses, it spreads to the middle of the nail and changes the appearance of the nail in the following ways:

• White or yellow marks on the nail
• Thick or brittle nail with a rough surface (which is also accompanied by a loss in the usually smooth and sometimes shiny surface of the nail)
• The edges of the nail become jagged or break off
• The nail becomes loose or lifts from the nail bed.

Fungal Nail Treatment

Fungal nail infections can be quite hard to treat and topical solutions aren’t generally effective at resolving them. There are three main options for treatment, depending on the extent and severity of the infection.

1. Topical antifungal medication

Topical medications (or anti-fungal nail lacquers) act on the surface of the nail to eradicate the infection. Using this treatment involves painting a solution on the toes and is most effective when only one or two toenails are infected. This treatment is most suitable for mild infections.

These topical medications can be purchased over the counter at pharmacies. It usually takes a minimum of three to four months to see any changes. The treatment must be applied consistently every day for the duration specified and often patients report quite limited improvement in the condition. This is because fungal cells are less sensitive than other organisms and also much harder to penetrate when they are in the nail plate.

2. PACT Light Therapy

Photodynamic Antimicrobial Therapy (PACT) is the process of exposing the infected toenail/s to high-powered LED light which causes fungal cell death. PACT light therapy is effective in reaching the infection and destroying these less sensitive fungal cells.

PACT is a photochemical reaction between a photosensitive agent (a blue PACT gel or dye), light of specific wavelength which the fungal cells are sensitive to and oxygen which together, cause fungal cell death.

Initial and ongoing PACT treatment consists of these key steps:

Thinning the infected nail first by filing it down
Applying the catalyst gel on the nail and leaving it to be absorbed by the infected nail for 10 minutes
Positioning the LED light over the infected nail for 9 and a half minutes. The gel binds to the fungal cells making them sensitive to the light emitted by the PACT LED lamp and selectively kills the fungus without affecting the surrounding tissues or generating excessive heat.

Depending on how many nails are being treated, the process can last from 20 minutes to one hour.

The number of PACT treatments required will depend on the severity of the fungal toenail infection. We determine the extent of the infection based on an industry recommended checklist and scoring system and then advise patients of their specific treatment regime. Usually we begin with three treatments in the first week, followed by once monthly for a six month period in conjunction with a topical treatment (40% urea cream) applied by the patient themselves at home.

The treatment is painless and doesn’t cause any harm or damage to the surrounding healthy tissue of the feet. The aim is to maintain a consistent program of treatment whilst keeping the area dry and clean so that when a new nail starts to grow through from the nail bed, it’s healthy and eventually the entire nail grows out with no infection in it. Healthy toenails grow on average 15mm a month so it takes at least three months for the nail to regrow enough for the treatment efficacy to be visibly noticeable.

3. Oral antifungal medication

If we see patients where the fungal nail infection goes beyond the nail bed into the base of the nail and all other treatment options have been exhausted, then they may be a candidate for oral antifungal medication.

This is the most effective treatment for the condition when it’s chronic and severe, and the more conservative treatment options have been unsuccessful.

A course of this treatment lasts three months. As with any medications there can be side effects which will need to be discussed with your GP who will take a sample of the nail to confirm that there’s a fungal infection before medication is prescribed.

Patients will be carefully monitored whilst on this strong medication and will usually need to undergo monthly liver tests to check for side effects. If the treatment is able to continue then we usually see patients report the condition clearing up effectively, especially where many toenails are infected as the medication circulates in the bloodstream, working from within the body’s system 24/7.