Fungal Nail Infections (Onychomycosis) Fungal nail infections (also known as onychomycosis or Tinea Unguium) account for 15%–40% of all nail diseases. Prevalence increases with age and the condition affects almost 20% of people older than 60 and over 50% of people in their seventies. The infection actually resides in the nail bed and on the underside of the nail plate. Symptoms can vary but may include: • nail discolouration or white or yellow streaks on the nail • a crumbly or brittle nail edge or lifting or thickening of the nail • complete nail destruction. Either fingernails or toenails may be infected and usually more than one nail is involved. Fungal fingernail infections may occur with paronychia (infection of the nail fold, see below) and fungal toenail infections commonly coexist with athlete's foot (see Foot Care). People with diabetes are three times more likely to develop onychomycosis than people without diabetes. People with diabetes are also prone to complications such as foot ulcers, osteomyelitis, cellulitis and gangrene which may or may not originate from fungal nail infections. Onychomycosis is also more common among people who sweat excessively, athletes, men, people with psoriasis or with immunodeficiencies such as HIV. Dermatophytes are the main group of fungi responsible, although some fungal nail infections may be caused by yeasts (eg, Candida albicans) or moulds (eg, Scopulariopsis brevicaulis). Trichophyton rubrum is the most common dermatophyte implicated, and this fungus is prevalent and hard to eliminate from carpeting, showers and changing-room floors. Paronychia This, usually painful, condition affects the nail fold (skin at the sides of the nail). Redness and swelling are key features of paronychia and sometimes pus or a discharge may be present. Staphylococcus aureus are the most likely bacterial cause. Occasionally, the cold sore virus (herpes simplex), C. albicans, or moulds may be responsible. Risk of paronychia is highest in people who have constantly cold and wet hands (eg, dairy farmers, fisherman, cleaners), after manicuring, and in children who bite or pick their nails. Paronychia may also affect the way the nail grows, especially if it remains untreated for long periods of time. It may cause distortions, ridges, or discolouration of the nail. Topical antibiotics may be needed for severe or prolonged bacterial infection, and it may take up to a year for the nail to grow back after recovery. Initial assessment If the customer has onychomycosis of the toenails, offer to take them to a private area where they can sit down and you can have a proper look at their feet. Determining the severity of the infection is important, as severely infected toenails or fingernails are unlikely to respond to pharmacy-sold treatment products. Some fungal nail infections are also difficult to distinguish from other types of infections or medical conditions, such as psoriasis (usually affects all nails and tends to exist elsewhere on body), dermatitis (fingers or toes are typically TREATMENT OPTIONS Category Examples Comments Topical nail preparations Fungal nails [PHARMACY ONLY MEDICINE] eg, amorolfine (Loceryl Nail Lacquer), bifonazole (Canesten Fungal Nail), ciclopirox (Apo-Ciclopirox Nail Lacquer), poly-ureaurethane (RestoraNail*) eg, Excilor Fungal Nail, Nailclin Antifungal Nail Treatment, Pronail Fungal Nail Pen Discoloured and damaged nails eg, Loceryl Nail Gel eg, poly-ureaurethane (RestoraNail*) Products for infected nails usually work better if most of the infected part of the nail is removed or extensively thinned before application. Application needs to be regular and consistent and according to manufacturer’s instructions. RestoraNail contains poly-ureaurethane, a unique substance that covers and protects the nail, treating both the fungal infection and repairing damage. Excilor and Nailclin contain a mixture of ingredients designed to penetrate the nail plate and alter the pH of the nail bed preventing fungal growth. Loceryl Nail Gel visibly improves discoloured nails and restores natural water content. Also promotes healthy regrowth. It is not an antifungal treatment like Loceryl Nail Lacquer. Natural products Tea-tree oil, garlic Tea-tree oil has been effective at treating fungal nail infections. Garlic reportedly has antifungal properties. Products with an asterisk have a detailed listing in the Fungal Nail Infections section of OTC Products, starting on page 238. TREATS DAMAGED NAILS AND FUNGAL NAIL INFECTIONS Page 76 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION also affected by dermatitis), or Lichen planus (this autoimmune disease causes thinning of the nail plate, and grooves and ridges in the nail. The nails may shed or stop growing altogether). Refer all customers with "yes" answers to the Refer to Pharmacist questions to a pharmacist. Treatment Treatment is important not only for cosmetic reasons. Unsightly nails can have a significant impact on a person's quality of life and can cause significant discomfort, difficulty in walking or wearing footwear, embarrassment, and lower self-esteem. Infected nails also serve as a reservoir for fungi with a potential to spread to the feet, hands, and groin, and to other members of the same household. Interestingly, children rather than spouses of infected people are more likely to become infected, indicating some genetic susceptibility. Treatment of onychomycosis, particularly toenail infections, can be difficult. Options available in a pharmacy are limited to topical antifungal products, but oral antifungal agents, chemical or surgical removal of the nail, and laser or other therapies may also be considered. Pharmacy-marketed topical treatments should only be attempted if the fungal infection involves less than 50% of the distal part of the nail (not the matrix or growth centre), no more than three nails, and the cuticle is not affected. Refer all other customers to a doctor or podiatrist. Unfortunately, topical antifungal agents such as amorolfine 5% and ciclopirox 8% have a clinical cure rate (nail clearing) of only about 8%–38%. The low efficacy appears to be due to inability of the drug to penetrate through the nail plate to the nail bed where the infection resides. Although treatment sheets advise filing of the nail before application, thickening of the nail is often extensive and filing almost an impossibility for some people with limited sight and flexibility. One fungal nail treatment uses urea cream initially to debride the nail before topical bifonazole is applied. Reported clinical cure rates for this combined approach are high, indicating the importance of nail debridement with urea. Despite claims of treatment success within two months or less, make customers aware that although the infection may be gone, it can take six to 18 months for nails to grow back. Other nail treatment solutions are formulated to allow direct penetration through the nail plate and lower the pH of the nail bed, preventing fungal growth. No filing of the nail is required before use. Referral to a doctor is needed for more extensive nail involvement or with treatment failure. Oral antifungal tablets with good distribution in skin and nails include terbinafine and itraconazole. The British Association of Dermatology Guidelines considers terbinafine first choice if not contraindicated, due to a higher efficacy and tolerability. Since both drugs persist in the nail for a considerable length of time after dosing, intermittent or “pulse” therapy regimens are also effective. Several months of treatment is needed. Other fungal nail treatments include laser devices, photodynamic therapy, iontophoresis, and ultrasound. Refer to PHARMACIST Ask specific questions relating to the apparent infection, and refer any “yes” answers or elderly customers to the pharmacist. • Does the person have any other health conditions (eg, immunosuppression, diabetes, is pregnant or breastfeeding)? • Does the infection involve more than three nails or more than 50% of any one nail? • Does the infection involve the matrix (growth part of the nail)? • Is there any oozing, blisters, crusting, swelling, or a foul odour? • Has the person had fungal nail infections before? • Has previous treatment been unsuccessful? • Does the person have any other symptoms (eg, flu-like symptoms, increased thirst or urination)? • Does the person have any allergies to topical medicines? Customer advice Lifelong preventive measures are recommended for people with a history of nail infections once the current infection has resolved. Protective footwear should always be worn in hotel bedrooms, gyms, and changing rooms of public bathing facilities where T. rubrum commonly resides. Absorbent antifungal powders should be used regularly in shoes and on the feet. Nails should be kept as short as possible and nail clippers should not be shared with family members or friends. Advise customers to wear comfortable, well-fitting shoes to avoid trauma to the nail and to discard old and mouldy shoes to prevent reinfection. Frequent manicures and pedicures predispose many people to a variety of nail problems and customers should be advised to only choose nail salons with good sterilisation techniques. Treats the damage Easy and convenient Treats the fungal infection Covers and protects the nail Proven to kill fungal infections in as little as a month 1 Reference: 1. Nasir, A., Swick, L., et al., “Clinical Evaluation of Safety and Efficacy of a New Topical Treatment for Onychomycosis”. J. of Drugs in Dermatology. 2011;10;10;1186-1191. RestoraNail Nail Solution (Poly-ureaurethane 16% in organic solvents, 15mL) is a nail treatment solution for use with nail dystrophy and fungal infections. AFT Pharmaceuticals Ltd, Auckland. TAPS 1733HA Page 77
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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