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Let's talk about fungal nails

Tuesday 04 April 2017, 4:34PM
Let's talk about fungal nails

"Would you have a quick look at my nail?" is something pharmacist Ahmad Zareh is often asked, and he is always happy to oblige. 

Mr Zareh, who recently sold his share in an Auckland pharmacy and is buying one in Hamilton, has a special interest in fungal nails and likes to make his customers feel cared for. 

It may not be the sexiest ailment, but when a yellowing toenail is thrust under your nose, he thinks it's good to be up to speed on all things fungal.  

Not only that, fungal nail infections can be embarrassing and uncomfortable for patients, and in some cases have more serious complications. 

Officially called onychomy­cosis, a fungal nail infection can be caused by three different organism types. 

These are yeasts (Candida), moulds and dermatophytes (tinea), with the most commonly seen and treated infection being tinea unguium.  

While it affects both finger­nails and toenails, 70-80% of cases affect the big toe, says Mr Zareh. 

 "It never hurts to have a look," he says, "they get so excited when I want to, so it's good practice." 

He says those most at risk are the elderly, athletes and users of warm wet footwear, and says it's more common than most ­people think. 

While there are plenty of treatment options, many people find a fungal nail infection to be stubborn and hard to get rid of, mainly due to treatment time. 

Mr Zareh says the biggest reason for treatment failure is non-adherence, as it can take from three to seven months to allow for the nail to fully grow out.

He gives some practical advice on how to get a foothold against fungal nails. 

What to be wary of 

While fungal nails are generally more unsightly than risky, there are also times when referral to the GP is necessary, according to adjunct associate professor at the University of Auckland, Dr Amanda Oakley.

 "It's important to know the patient's history as there can be complications for those with conditions like diabetes, a weakened immune system or susceptibility to other infection."  

"Pharmacists need to be careful when diagnosing," she says, as misdiagnosis can mean a different condition gets left untreated, or there can be a risk of the fungus spreading to other parts of the body.

A visit to the GP will have the doctor take clippings for microscopy. For more severe cases, an oral antifungal drug, Terbinafine, is prescribed but, according to Mr Zareh, this can be heavy on the liver and may require a blood test, which puts a lot of patients off. 

Listed below are some symptoms that should act as flags for a GP referral:

weeping or green coloration, which can indicate a bacterial infection

the cuticle is affected - this may indicate the presence of aCandida 

over 70% of the nail is affected

Practical home tips to prevent recurrence 

The most important home tip according to Mr Zareh, is to wear footwear in communal showers or at home if someone is known to have an infection. Others are: 

Wear breathable footwear whenever possible.

Maintain nails regularly, keeping them trimmed and looking for signs of infection.

Fast treatment of athlete's foot, which can easily spread onto the nail.

If you use nail salons, make sure they are thoroughly cleaning equipment between customers.

Use of nail files with treatment is encouraged, but make sure these are disposable to prevent ­re-­contamination.

What treatments are available? 

Fingernails are usually cured more quickly and effectively than toenails, according to Dr Oakley. There are various options available, though, unfortunately, treatment time is long. She says, in many cases, the treatment can be more tedious than the condition itself. 

However, Mr Zareh says mild infections that affect 50% or less of the nail often respond well to topical treatments, and he provides an ­overview of what's available. 

Topical antifungals

These are creams, such as Lamisil and Canesten, which are applied directly to the nail. Unfortunately, they don't absorb easily into the hard nail surface and most people prefer lacquers. 

Topical lacquers

Who said pharmacy wasn't glam? These treatments are polished on twice a week until the nail grows out, and are absorbed much more easily into the nail surface than creams. As well as over-the-counter products, there is a fully subsidised treatment, Loceryl, available on prescription, and its generic, MycoNail. 

A product called Canesten Fungal Nail Treatment Kit emerged a few years ago that guarantees results in seven to eight weeks.

Oral medication

Several months of prescribed oral antifungal medication may be needed to cure a stubborn case, and Dr Oakley says a combination of oral and topical treatment is sometimes required. 


In recent years, there has been new laser treatment developed using PinPointe technology; it involves
three sessions across about 12 weeks. 

"We have been successful in many cases and the trials from the States show a 71% success rate," says John Ringer of Auckland's Laser Nail Clinic, but he explains that there are no data yet on success in New Zealand. 

He also says that for chronic long term cases, the infection can be very hard to clear and it's difficult to achieve success. 


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