Onychomycosis to Fungal Superinfection: Prevention Strategies and Considerations

or podiatrists. Nails should be kept neatly trimmed. The cutting of cuticles should be avoided because the abrasions and lacerations serve as a portal of entry for fungal organisms. If toenails or feet are infected, hands and feet should be kept clean to prevent the infection from spreading.^9,15

A non-hospitable environment should be created to prevent fungal growth. The feet should be kept cool and dry, with loose fitting shoes. Drying antifungal powders can be used in the socks on a regular basis, and socks that become wet from perspiration should be changed during the day. Water shoes or flip-flops should be worn in public gyms, locker rooms, and showers. Personal instruments should be brought to nail salons if no guarantees can be given regarding sterility.^9,15

Onychomycosis is a progressive disease. If left untreated, affected nails will worsen and the infection is likely to spread to other nails. Severe onychomycosis is associated with nail dystrophy that may be permanent, even in some cases where patients achieve a mycologic cure.^6,7 Moreover, recent data suggest that early treatment of onychomycosis is more effective than treatment of long-standing disease. Not only is the target nail more easily cured, but the spread to other nails is also prevented.¹⁶

In addition to the local benefit of treating fungal nail infections, there is a more global health benefit as well. The spread of fungal organisms can infect not only other nails but also the skin of the feet. This includes the interdigital web spaces, the soles of the feet, or in severe cases the entire foot.^17,18 Besides the spread of fungal infections, compromised skin provides an entry portal for bacterial superinfections that may lead to cellulitis.^19,20 Superinfections are an especially significant health issue in diabetic patients, as neuropathy and lack of sensation may prevent early detection. Ultimately, diabetics are at a higher risk for foot ulcers, bacterial cellulites, and even osteomyelitis.^21,22 Finally, fungal infections of the nails and skin are rarely associated with allergic, Id, or autoeczematization reactions. Untreated fungal infections have been associated with asthma, atopic dermatitis, urticaria, and erythema nodosum.^19,20

Onychomycosis carries a significant burden and interferes with patients’ quality of life. Half of patients may experience foot pain, and an estimated 30% of patients report that the disease interferes with their ability to wear normal shoes and socks.^19,23 Moreover, patients may experience difficulty walking and be embarrassed about the appearance of the nails. In some cases, especially as reported by females, patients may be so adversely affected that the nail infection interferes with their personal relationships and self-esteem.²⁴

There are 2 primary goals in treating onychomycosis. Firstly, the therapy must eliminate the infection. Secondly, after the fungal infection has been cleared, patients must be left with a normal appearing nail.²⁵ The causative fungal organisms infect the nail itself, along with the skin beneath the nails. Effective therapy relies on both the ability of the drug to kill the fungus and the body’s ability to restore a new, normal appearing nail. Once the nail is infected and dystrophic, it does not return to normal with treatment. Rather, a new, clean, uninfected nail is newly made in the nail matrix. As it grows out, it will replace the infected nail. This is a slow process, and even if the infection is