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Today's best treat persistent fungus infections

Regular pedicures might make your feet look in the pink. But unfortunately, smoothed and painted nails don't get you anywhere in the fight against nail fungus. Fungi, a category of plants that includes yeasts, molds and dermatophytes (skin fungi), may seem like a minor nuisance. But they pose a major challenge to people who are genetically vulnerable--which may include a significant percent of the population.

Fungi may not only disfigure your nailS, but on rare occasions they may even cause physical pain and impair your ability to work. Nail fungi afflict toenails about four times more frequently than fingernails. And once fungus finds a foothold, it can spread from nail to nail, from foot to foot and even to your hands and fingernails.

The blight is not easily stopped. Not only do fungi hang out anywhere there's moisture, but they are probably present in our bodies all the time. For those of us with immune systems that can't resist its onslaught, a fungus--like a diamond--is forever. Once we succumb, the infection may recur even after prolonged and (seemingly) successful treatment. Fortunately, several new treatments are at hand.
NAILING DOWN THE CAUSE

The first step in the battle against nail fungus is determining which kind of infection you have, says Paul Kechijian, M.D., chief of the nail section at New York University Medical Center in New York City.

Both bacterial and fungal infections develop when moisture gets trapped. Natural nails are porous and allow the moisture to evaporate. But artificial nails and nail polishes trap excess moisture and turn the nail bed under the nail into a breeding ground for moisture-loving bacteria or fungi.

Usually, doctors rely on two conventional diagnostic tests: microscopic examination of scrapings taken from under the nail and/or test-tube cultures of these scrapings. Unfortunately, neither is 100 percent accurate. According to Richard K. Scher, M.D., head of the division for the diagnosis and treatment of nail disorders at Columbia-Presbyterian Medical Center in New York City, about 30 percent of these test results suggest no infection, when in fact there is one. For best results, samples should be sent to labs that specialize in nail fungi.

Warren S. Joseph, D.P.M., chief of infectious diseases at the Pennsylvania College of Podiatric Medicine in Philadelphia, adds that fungus cultures may take as many as six weeks to grow, so that treatment must often proceed before test results are in. In those cases, most doctors will begin with conservative measures, trimming back the infected nail and prescribing a topical antifungal cream or liquid for daily use.

In cases of severe infection, when a definitive diagnosis is required to tailor oral medication treatment, Dr. Scher includes a biopsy of the nail and nail bed. This highly accurate test involves a local anesthetic and removal of a small section of the nail and nail bed.
FOUR FUNGAL INFECTIONS

Researchers have identified four common fungal infections, each calling for somewhat different treatment.

DSO: The most common form usually starts as a case of athlete's foot, then spreads to the nails. This infection is referred to simply as DSO (short for distal subungual onychomycosis). The fungus, usually a dermatophyte, invades the space between the tip of your toe and the nail tip or the skin-folds at the sides of your nails. Your toenails turn yellow and separate from the nail bed beneath them. You may notice some brownish debris collecting under the nail as well. The nail bed beneath the nail begins to thicken, making your nails look thicker too. And in some cases the nail itself may even thicken.

In severe and chronic cases of nail infection, treatment with a systemic drug may be called for and partial or total temporary removal of the offending nail may be necessary to promote healing. Some doctors may opt for permanent removal of the nail since currently approved drug treatments may only be successful in some cases. Your doctor may also prescribe a topical ointment or gel to use on the exposed nail bed.

WSO: White superficial onychomycosis, or WSO, is less common than DSO. It affects only the surface of the nail, turning it white and crumbly in spots or all over the nail surface. It is the most easily treated of the bunch. The fungus can simply be scraped off the nail and a topical antifungal medication applied.

PSO: The least common form of nail fungus is called proximal subungual onychomycosis, or PSO. This infection may first appear as a white or yellow spot on the nail close to your cuticle. From there it may progress into a plaque that collects on the underside of the nail. Eventually, debris may collect trader the nail and the nail may lift off its bed and even be shed entirely. This infection is usually treated with a systemic drug.

Candida: The fourth form of nail fungus is caused by the yeast candida. It more commonly afflicts fingernails than toe-nails. At first, candida infection may look like DSO. Later the entire nail plate is affected. The infection may turn the nail yellow or green or the nail may look opaque. This infection can be treated topically. If it fails to respond, oral drugs are prescribed.
TREATMENT TRADE-OFFS

Topical ointments and antifungal powders may help contain a fungus infection, but they won't cure most cases of DSO, PSO and stubborn yeast infections. Since the fungus has penetrated the nail and its bed, effective medication must do likewise. That's a task most OTC products can't do, but it's where oral antifungal drugs come in. These medications enter the nail matrix, the white half-moon from which a nail grows. As new nail grows, the saturated cells form an antifungal barrier. Newer drugs act quicker by penetrating directly into the nail from the nail bed.

Two oral antifungals have been around a while--griseofulvin and ketoconazole. They're FDA-approved and can be fairly effective against nail fungus (80 percent cure rate for fingernails; 50 percent for toes). Unfortunately, treatment can take 4 to 18 months, and the drugs can have side effects ranging from bothersome (minor stomach upset) to serious (liver toxicity in rare cases).

Even with these oral drugs, about half the toenail-fungus cases come back within a year. As Dr. Joseph points out. "feet encased in shoes and socks all day live in a nice warm, dark, moist fungus-breeding environment. So if you're susceptible to fungus infection, it's difficult to escape recurrences."
PROMISING NEW DRUGS

Fortunately, several new drugs show promise in shortening treatments, minimizing side effects and preventing recurrences. Two of these drugs--irraconazole, sold as Sporanox, and fluconazole, sold as Diflucan--are now used to treat systemic fungal diseases. Originally developed to treat the fungus infections common in AIDS patients and others with compromised immune systems, they are effective against yeasts, molds and dermatophytes.

Dr. Joseph cautions that this usage is still not ap-proved in the United States by the FDA. Patients should be aware of this. The drugs are quite expensive, too.

Dr. Scher expects itraconazole to win FDA approval to treat nail fungus within a year or so and fluconazole within the next two to three years. A third antifungal, terbinafine, is sold as a topical cream called Lamisil but is being tested in oral form. It has been successfully used in Canada, Mexico and Europe as an oral drug and will probably be FDA-approved within the next few years, says Dr. Scher. Itraconazole can be taken in what is called pulsed dosing. Patients take a high dose daily for just one week a month for several months. Its cure rate for nail fungus is reported to be as high as 80 percent in toenails and higher than 90 percent in fingernails.

Researchers have not yet reached consensus on fluconazole's dosage. In a study in which patients took it once weekly for about nine months, it effected a 100 percent cure rate in fingernails and a 90 percent cure rate in toenails. In both cases, however, the infected nails had to be removed before treatment. (Since the method of removal was chemical, the nails will grow back.) Terbinafine is the only new drug that is being studied for exclusive use as a nail-fungus treatment. It has achieved an 80 percent cure rate in toenail infections when given daily for only three months. It worked just as well on fingernails when used for only six weeks. It is less effective against yeasts than the other drugs. Terbinafine's side effects are minimal. Patients occasionally report stomach upsets and skin rashes. Rarely, the drug can interfere with the ability to taste, but that resolves when the drug is discontinued.

Each of these three drugs is significantly more effective than griseofulvin and ketoconazole in treating dermatophyte nail infections, and they require much shorter courses of treatment to work. Since they penetrate the nail more quickly and remain there for months after the drug is stopped, they medical-care update act more rapidly and result in longer-lasting cure rates. And they have far fewer side effects than griseofulvin and ketoconazole.

Keep in mind that with any oral antifungal drug, symptoms of liver damage--nausea, vomiting, abdominal pain or a change in urine color--are grounds to stop treatment. And since no antifungal drug guarantees 100 percent cure in susceptible people, the oral treatment should be followed up with daily home care (see "Nail Care's Healthy Dozen ") to prevent further toe or finger woes.

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by Jan Bresnick with Michele Stanten

NAIL CARE'S HEALTHY DOZEN

Preventing fungus infections and recurrences requires a regimen of perpetual care. So say nail experts Richard K. Scher, M.D., Paul Kechijian, M.D., and Warren S. Joseph, D.P.M., who recommend the following measures.

1. Keep your nails clipped or filed back so that they do not extend beyond the tips of the fingers or toes. People with diabetes should consult with a podiatrist or family doctor before cutting their own toenails.
2. Use separate sets of clippers for infected nails and healthy nails, to avoid spreading the fungus.
3. Keep manicure and pedicure tools disinfected after each use by wiping them with gauze or cotton bails saturated with alcohol. Watch especially for the jaws of the clippers, even more than the teeth, since that's where the infected debris tends to accumulate.
4. If you treat yourself to salon manicures and pedicures, make sure the salon autoclaves their instruments or unwraps a fresh package of tools for each client. Better yet, bring your own.
5. Keep hands, feet and nails clean and dry. Wash hands and feet with soap and water every day and dry well.
6. Wear cotton-lined work gloves when you submerge your hands in water or soil.
7. Powder your feet with antifungal powders. Avoid cornstarch; it can encourage fungi to grow.
8. Don't let your cuticles get so dry they crack, leaving openings for infection. Keep cuticles moisturized with petroleum jelly or cuticle cream.
9. Choose shoes and hosiery made of materials that breathe. Make sure shoes fitwell, with plenty of toe room. Avoid tight hosiery.
10. Alternate shoes daily so each pair has a full day to dry between wearings.
11. Change socks frequently. Don't worry about washing your socks with those of fungus-free family members-machine washing in hot or cold soapy water kills the nail fungus in fabric.
12. If you're prone to fungus infections, ask your doctor to prescribe a topical anti-fungal ointment or gel. Apply a preventive dose every day as directed.

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