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A fungal toenail occurs when the nail is lifted from the underlying skin allowing the fungus to get under the nail and grow creating a white, yellow, green, or even brown coloring. A fungal nail infection can arise from cutting the edges improperly, tight fitting shoes, trauma, or ingrown toenails.
They are often associated with other foot conditions such as:
Pain ranges from dull to sharp, depending upon the level of irritation and compression of the nail
Good looking toenails are important to so many of my patients...
When it comes to foot fungus, many of my patients have been told myths about fungal infections that are completely untrue (such as the idea that you have some terrible fungal disease that you can spread to family members or whatever). Completely false.
So, let’s start off on what causes a fungal infection in toenails. I tell my patients, there’s some good news and bad news with foot fungus. First, pressure is really the culprit behind some of the thick dark toenails included the dreaded black toenail. And, 9 times out of 10, it’s the pressure against the shoe. For instance, my runners or folks with tight shoes, that constant beating on a toenail will make it thicker because toenails are the same protein as callouses and if you have pressure on a certain area, it will make a thick callous. So, if you have pressure on a toenail, it will respond and get thicker and darker even when there’s not a fungal infection.
Next, and this is a little bit of bad news, there’s a little bit of genetics involved with who is going to get fungal infections. So, for example, if grandma and grandpa have thick discolored nails, there’s a chance that it’s going to passed down to you. And, some of my patients that have more pigment in their skin or darker colored in their skin coloring will produce stripes and also little veins of darkness in the toenail. Remember, this has nothing to do with some sort of some dreaded fungal infection. It’s just from pounding on the toenail again and again over time.
Often, the toenail can actually lift up or become so thick the layers are spread out and then the foot fungus gets in. Before we recommend any procedure or topical medicine, we test samples from the toenail area in question. Then, depending on whether there is or is not a fungal infection, we can make the appropriate medical recommendation (whether that’s a change in their exercise routine or use of one or more foot fungus medications).
On this point, if we determine that you have a fungal infection, I’m a firm believer in the oral anti-fungals. As a foot doctor in Houston for the past 25 years, one of the most frequent concerns that I hear from patients is about these anti-fungal medications and if they will damage the patient’s liver. Here’s the deal on that. First, these medications have come a long way and improved over the years in terms of how they impact the liver and overall body. Second, yes, these antiviral medications do make the liver work harder. But, to put you at ease, so does alcohol. So does Tylenol. And, a lot of these drugs that make the liver work harder just means that it detoxifies the drug and for the vast majority of patients, these drugs are safe and effective for treating foot fungus.
ORAL PILL REMEDY
That said, we do a full examination and check your medications before we prescribe the foot fungus medications for you. Specifically, our electronic computer system will see if there’s any adverse drug interactions with the medications that you’re currently taking. And, then if there’s any questions about a heart patient or someone with any pre-existing liver problems, we will contact their primary care and internal medical doctor or, of course, cardiologist, just to make sure there are not any cholesterol drugs that interact with the antiviral foot fungus medications. Once we feel comfortable that the antiviral drug presents no issues, I can assure you that these antivirals are not dangerous. And, the new standards for these antiviral drugs are so improved now that it is not mandated that we test liver function after administering this drug. Even so, I will still test probably test the patient’s liver function two to three weeks into giving the drug just to make sure that the patient has not had any adverse reaction to the drug.
Therefore, if you have a fungal infection, my recommendation as a foot surgeon and podiatrist is to take the antiviral medications for about three months. In 25 years as a Houston podiatrist, I’ve never had any problems in my clinic with liver problems associated with these antiviral drugs. Specifically, my patients have done very well with this protocol because the antiviral medication gets right into the root then over time, the medication will gradually push the foot fungus up and out of the toe (eliminate the black toenail appearance). (On this point, some patients think that the antiviral medication will circulate around the foot fungus and clear it out throughout the black toenail all at once. It doesn’t work like that. Instead, the antiviral medication starts at the base of the toenail and then slowly grows up pushing the foot fungus out through the top of the black toenail over time.) So, remember, it will usually take 6 to 9 months to push out the entire black toenail and then have a clean new toenail in its place.
This process is worth it. I’ve had a lot of patients that have had great success eliminating their fungal infections. I just tell them to keep your eye on the prize (no more black toenails). Then, I have them measure out the distance of two or three millimeters. I then explain that on average a toenail grows a millimeter a month. So, if they measure out 3 millimeters, they can see the progress they will have in about 3 months. So, in a few months’ time, if you can be patient, you will have a clean toenail that will hopefully flatten out with less thickness as we recommend some lifestyle changes that will reduce any pressure on the toes.
Ms. Montgomery approached our clinic with a fungal toenail infection and concerns about her thick, dark nail condition and wearing sandals. I always instruct my patients that the thickness is from shoe pressure and may not go away with the Lamisil treatment, but the discoloring will go away. Her nails not only cleared up, but they were back to their thin soft shape after the treatment and wearing sensible shoes. Bravo! Proof that if patients do exactly as instructed that treatments like Lamisil can give extraordinary results
A larger, softer shoe can relieve the direct or indirect pressure on toenails. Make sure that the shoe has enough room at the end about the width of your thumb and that the toe box (front of the shoe) is high enough to allow your toes to move freely.
Cutting the nail edges straight across without cutting the corners will prevent the skin at the edges from growing over the nail (becoming an ingrown toenail). Once the nail is ingrown, the painful edge(s) can be angled at the end by a professional to temporarily relieve the pressure and/or infection.
There is an array of over the counter pads that can be placed between the toes or behind the painful nail edge to relieve the pain associated with ingrown toenails.
Anti-fungal medication can be applied directly to the nail (topical creams, gels, solutions). Oral anti-fungal medication will kill the fungus at the nail root, but laboratory tests are needed to assess liver function.
The nail can be removed to relieve the pressure and infected tissue. Topical medication is then applied until the nail completely returns. If the nail thickness and pain persists, a chemical can be applied to the nail root and prevent the nail from returning.
The procedure is performed in the office with local anesthetic or occasionally at an out-patient facility under sedation (e.g. young children, anxiety, bone infection). Full weight bearing is allowed immediately without restrictions.
More information on toenail procedures
These are links to more information on the subject, not intended to imply an endorsement.
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