Health Coach
The Office
Ask the Coach

Subject: Possible Athletes Foot + Nail Fungi

From: Pro


What can you recommend coach ? p. s. Do you make house calls ?

Reply from Dr. Bazos:

Dear Pro:

First of all I recommend that you be checked out by a medical physician to establish a diagnoses before you run off to the pharmacy and pick up some over the counter (OTC) antifungal cream. You may be better off purchasing nail polish as you'll see why below.

Human fungal infections may be divided into topical skin and systemic. This discussion will concern itself only with the former. Fungal skin infections include dermatophytes (Greek word meaning 'skin plants") and the yeast-like fungus Candida albicans, confined to superficial skin and mucous membranes.

The dermatophytes are a group of fungi responsible for the so called "ring-worm" infections. It is very easy to become totally confused with the terminology used in relation to fungal infections. The term "ring-worm," followed by "of the feet, of the groin, of the scalp," etc., is a simple way of indicating the location of the infection. If you feel more classical (Latino is very now and happening) you may use the term 'tinea' (Latin meaning "a gnawing worm") followed by "pedis, cruris, capitus," etc. Dermatophyte infections affect the skin, hair and nails. The living epidermis layer of the skin is not invaded. The infection is usually acquired by contact with keratin debris carrying fungal hyphae. Both Athlete's Foot and nail fungus are uncommon before puberty.

Now, Athlete's Foot (Tinea Pedis) is the commonest of the dermatophyte ('ring-worm') infections, and usually presents as scaling, itchy areas in the web spaces between the toes, particularly between the 4th and 5th toes. it is usually acquired from contact with infected keratin debris on the floors of swimming-pools and showers. This infection may spread locally onto the soles of the foot or the top of the foot as itchy, scaling reddened area. Athlete's foot typically involves only 1 foot, whereas other foot eczemas often involve both. Other similar looking conditions such as psoriasis, erythrasma, and foot dermatitis should be differentiated by your attending medical physician prior to therapy.

Toenail fungus (Onychomycosis or Tinea Unguium) is very common in adults, and is invariably associated with Athlete's foot. The toenail involvement usually starts at the end of the nail (distally) as yellowish streaks in the nail plate, but gradually the whole nail becomes thickened, and tan colored crumbly debris accumulates beneath the separated portion of the nail. The big toes are often the first to be involved, and pressure from footwear on the thickened nails may produce considerable discomfort. Your doctor (whom we'll assume is also a 'Pro') should differentiate whether you do indeed have nail fungus as opposed to other disorders which may appear similar (e.g. psoriasis, candidiasis (yeast), lichen planus or hereditary nail dystrophies to name a few). Treatments of each of these is different, so you should have your toe(s) checked out accordingly. Fingernails are less commonly affected. The changes in the nail plate are similar to those seen in toenails.

Also called Tinea cruris, is mainly a fungal infection of adult males and is usually accompanied by Athlete's foot. Mode of transmission is almost invariably from bathtowels, wiping groin after drying feet. The nasty mean red rash involves the groin folds and inner thighs and may extend to the back buttock crease. The penis and scrotum are not involved.

Tinea capitis, or ring-worm of the scalp, is mainly a disease of children characterized by focal scaling and hair loss.

Presumptive diagnosis is made on clinical grounds (inspection by a physician) and confirmed with scrapings. Skin scrapings, nail clippings and plucked hair can be examined by your physician or collected and sent off to a laboratory for fungal analysis. Differentiating dermatophytes ('ring-worm') from Candida ('yeast') is left to the physician as their treatments vary. Dermatophyte fungi consists of septate hyphae which form a branching network (mycelium or 'long rows of railway wagons' appearance when seen under low power microscopy with 10 - 20 % KOH and a coverslip, whereas Candida albicans (yeast) consists of round or oval cells which divide by budding and may produce pseudohyphae in a linear arrangement under KOH treated slide microscopy. If you wait for definitive culture results from a lab it takes 2 to 6 weeks.

1. GENERAL: Now, Pro, continuous treatment of chronic palm or sole fungus (Athlete's foot) possibly decreases the likelihood of spread to nail fungus which is very difficult to cure. A word of caution Pro; well-established onychomycosis is difficult to cure, often with a poor prognosis and significant possibility of relapse, not to mention the high cost of therapy, or high risk of side effects with less expensive oral agents.

After discussing your situation with your doctor, you may decide to forgo treatment. Regardless, try to keep the nail neatly clipped and buffed flat (with file or pumice stone) for both cosmetic appearance and to prevent painful pressure by shoes.

2. TOPICAL THERAPY: There are a number of broad-spectrum topical antifungal agents available for the treatment of dermatophyte infections, including miconazole 2% (Monistat-Derm, Micatin), clotrimazole (Lotrimin)1%, Naftifine (Naftin), ketoconazole (Nizoral), ciclopirox (Loprox), Iodoquinol (Vioform Hydrocortisone) and terbinafine (Lamisil). These agents are usually applied thinly, twice daily until clearing occurs and 2 weeks longer to minimize recurrence. It's best to use cream delivery system if the infected area is dry. Solutions, lotions and aerosols are best for moist areas (groin or toe web spaces) or hairy areas, because they leave little residue and are drying.

Powders are poor delivery vehicles for antifungal agents. As already mentioned, first use solutions in moist areas; a bland powder (talc) should then be used if necessary to reduce chaffing. Antifungal powders are effective for prophylaxis and prevention of fungal spread from web space areas.

For very symptomatic, scaly or very itchy areas are to be treated with cool compresses. Topical steroid creams in combination with the above antifungals gives rapid symptomatic relief and does not affect or reduce the antifungal efficacy or cure rate.

Most topical antifungals are available in 15- and 30-gm sizes, and a few are available in 60- or 90-gm sizes. Lamisil, Naftin, Nizoral, and Spectazole may be more cost effective because they are approved for once-daily use, whereas the other products must be applied twice daily. Naftifine (Naftin) and terbinifine (Lamisil) are cidal (fungal killing) rather than static (prevent further proliferation and growth), so they may work faster than the other agents.

3. SYSTEMIC THERAPY: Systemic antifungal agents (e.g. pills) are indicated if the infection is:

i. On the scalp or in a very hairy area
ii. Widespread
iii. Resistant to the above topical measures
iv. In the nails (finger or toe)

Most topical agents are of little if any benefit for nail fungus. For nail fungus really need systemic therapy, but then again be aware of high relapse rates (80%) for toenails within a few years after therapy is stopped. Relapse rate lower (50%) for fingernails.

a. Griseofulvin
For many years griseofulvin was the gold-standard oral antifungal agent. The original preparation was of a large particle size requiring large doses; 1 to 2 grams daily by mouth. This has been superseded by a smaller particle sized tablet, which is better absorbed and taken in smaller doses.

- Micronized, microsize, or ultra-fine form is taken in a dose of 500 to 1000mg daily (usually divided in a twice-daily dose)
- Ultramicronized form is taken in a dose of 125 mg twice daily

Response to griseofulvin is slow; clinical improvement is not seen for 1 to 2 weeks. Most infections require 4 to 6 weeks, or 1 to 2 weeks after apparent clearing. Topical steroid creams may be given in the meantime to relieve itching without compromising efficacy or cure. Fungal resistance to this drug can occur.

Side effects of greseofulvin are common and numerous and include the following:

- Gastrointestinal upset (common), which can be severe
- Headache, usually unresponsive to aspirin
- Mood changes, anorexia, insomnia, and nightmares
- Numbness of your hands and feet
- Allergic rashes
- affects the liver which alters blood levels if concurrently taking blood thinners (coumadin), anti-epileptic agents (Phenobarbital), oral contraceptives and other drugs
- reported cases of bone marrow suppression (aplastic anemia) has been reported with early usages of this agent but uncommon nowadays
- chronic administration in rats has produced liver cancers (hepatomas)

b. Ketoconazole (Nizoral)
Nizoral is active against systemic fungal infections, Candida, dermatophytes and deep fungal infections. The adult dose is 200 mg (one tablet) daily. 

Side effects occur in less than 5% of patients; the most common problems are stomach upset and generalized itchiness (pruritus). Transient rises in liver enzymes levels have been reported in some patients, so your doctor should monitor your blood liver function while on this medication. Care should be taken in prescribing Nizoral to patients likely to be at risk of intolerance, including older women, those with a history of liver disease, and those patients taking other concurrent drugs affecting the same liver pathways as those mentioned above in the Griseofulvin section.

c. Terbinafine (Lamisil)
Lamisil has been approved for the treatment of nail fungus (onychomycosis). Available in 250 mg tablets, the recommended dosage is one tablet daily for 6 weeks for fingernail fungus and 12 weeks for toenails. A common alternative schedule is 1 tablet twice daily for one week, repeated once a month for 4 months. The first schedule consumes 84 pills; the second, 56. This is a significant cost savings with similar cure rates, as the price per pill is about $7.00 per pill! Unlike the above oral anti-fungals, Lamisil has little potential for causing liver disease and does not interact with other drugs using the liver enzymes as mentioned above. It can occasionally cause stomach upset however.

d. Fluconazole (Diflucan)
Diflucan is approved for systemic candidiasis, but it is also effective against dermatophytes. A brief dose is deposited into the keratin of the skin and nails, so benefit may increase after treatment has stopped. It does not appear to have the liver side-effects as do Greseofulvin or Nizoral mentioned above. Other side-effects are also far and few. Skin fungal infections are treated with 100 mg daily for 1 to 3 weeks. A common course for nail fungus (onychomycosis) is 150 mg once weekly for 6 to 12 months or until the nails are clear. Doses come in 50 mg; 100 mg; 150 mg; and 200 mg capsules. This is also expensive each capsule costs about $15 before dispensing. 

e. Itraconazole (Sporanox)
Sporanox is approved for deep fungal infections in the immunocompromised host and also for nail fungus (onychomycosis), but it is also effective against dermatophyte (ring-worm) infections and yeasts. For dermatophyte infections, a dosage of 200 mg daily for 1 to 2 weeks is commonly used and successful. For nail fungus, a popular regimen is 200 mg twice daily for a week, then once a month for 3 months. Once again, not cheap stuff, costs about $7.00 per 100 mg tablet.

4. SURGICAL THERAPY: Nail avulsion. You can't heal without cold steel, so we yank out the nail which hopefully (with some luck) allows a 'normal' nail to grow again in its place. This can be done in your doctor's office as an out-patient with topical ring block anesthesia (without epinephrine). This is painful surgery, especially administering the anesthetic. The relapse rate is high with this method, especially if more than 1 nail is involved or if the sole is involved and not treated. If you decide to go this route, then you should really treat the regrowing nailbed with topical antifungal solution or even consider oral antifungal agent during the regrowth period.

So Pro, what can I say? To treat or not to treat? If left alone nail fungus usually lasts a lifetime and rarely heals spontaneously. Well established nail fungus are often difficult to cure, and it is best to be warned of this up-front before you go digging deep into your wallet. Discuss your options and prognosis, first with your doctor, then next with your financial advisor as therapy is by no means cheap.

You may consider nail polish, after all, this is primarily a cosmetic problem and it's much cheaper, and these days anything goes. If you don't believe me ask the rock star Steve Tyler from Arrowsmith.

Thank you for your question Pro.

P.S. Yes, I do make housecalls, but I don't do windows (or nails!).

(Note: In view of the possibility of human error or advances in medical knowledge, neither Dr. Bazos, nor his staff nor any other party involved in providing this website, warrant that the information contained therein is in every respect accurate or complete and they are not responsible nor liable for any errors or omissions that may be found in such information or for the results obtained from the use of such information.
     You are encouraged to consult your licensed medical physician regarding any advice given in this website pertaining to any medical diagnosis, treatment or referral.
     If erroneous or otherwise inaccurate information is brought to our attention, a reasonable effort will be made to correct or delete it. Such problems should immediately be reported to Dr. Bazos.)