Toenail fungus treatment in Barcelona

How can I tell if I have nail fungus and what are the symptoms?

You cannot tell with certainty from appearance whether a nail has fungus: the clinical guide of the General Council of Official Associations of Podiatrists (CGCOP) recommends a mycological examination (a test of the nail looking for fungus) to rule out other similar conditions, such as a knock to the nail, lichen planus or psoriasis.¹

The symptoms described by MedlinePlus are these:²

• A brittle, thickened nail or one that crumbles at the edges.²
• Yellow or white streaks on the side of the nail.²
• A change in the shape of the nail and loss of shine.²
• Debris trapped under the nail, or a nail that loosens or lifts.²

The NHS adds that the infection usually spreads to the whole nail, which thickens and turns white or yellow, and that sometimes the nail comes off and the skin around it swells and hurts. According to that source, these infections are not serious, but they can take a long time to treat.³

The cited sources do not describe the stages of the infection one by one.

I have nail fungus, what can I do?

If you think you have nail fungus, the first thing is to confirm that it is.¹ The NHS says a pharmacist may suggest an antifungal nail paint that is painted on the nail, daily or weekly, for 6 to 12 months.³ MedlinePlus says that over-the-counter creams and ointments generally do not work for the nail infection.² The cited sources do not mention vinegar or bicarbonate of soda as a treatment.

What tests confirm that it is fungus?

Nail fungus is confirmed with mycological tests, which look for the fungus in a sample of the nail. The CGCOP guide mentions microscope examination with potassium hydroxide (KOH), culture, PCR (detection of the fungus's genetic material) and histopathology (study of the tissue under the microscope), after examination of the nail and your history.¹

Microscopy and culture are the most common tests, but they give many false negatives (results that fail to detect a fungus that is there), which is why histology and PCR have gained weight.¹ According to MedlinePlus, the culture result can take 4 to 6 weeks.² Before prescribing antifungal tablets, the doctor may ask for a sample of the nail and a blood test to monitor the liver.³

How is toenail fungus treated?

Toenail fungus is treated with topical antifungals (applied to the nail), oral antifungals (tablets), laser or photodynamic therapy (a light-based treatment).¹ Topical treatments are used in mild or moderate cases, or together with tablets in more extensive ones, and oral ones, such as terbinafine, itraconazole or fluconazole, in severe forms.¹

The treatment is chosen by the professional after confirming the diagnosis, because other nail conditions look similar.¹

Pharmacy, prescription or laser: what the evidence says about each option

Each option has different support in the sources, and the cited evidence does not favour laser over medicines.²

• Pharmacy antifungal nail paint: it is painted on the nail daily or weekly for 6 to 12 months and can take several months to show an effect. It may not be suitable for under-18s or during pregnancy or breastfeeding.³
• Over-the-counter creams and ointments: they generally do not work for the nail infection.²
• Prescription tablets: they are taken for 2 to 3 months for toenails, need tests to monitor the liver, and the fungus goes away in about half of the people who try them.² If pharmacy products have not worked, the doctor may prescribe them for up to 6 months, so the sources do not agree on the duration.³
• Nd:YAG laser: the CGCOP guide describes it as a safe option, applicable to almost all patients and without associated side effects, alone or combined with other treatments.¹ MedlinePlus notes that some lasers can eliminate the fungus, but that they are less effective than medicines.²
• Removing the nail: severely infected nails sometimes need to be removed in a small procedure under local anaesthetic.³ The cited sources do not detail its risks.
• Photodynamic therapy: it is listed among the options with evidence.¹ The cited sources do not detail its effectiveness or its risks.

How long does a nail fungus take to clear up?

A nail fungus takes months to clear up. According to MedlinePlus, the infection clears when a new, uninfected nail grows, and that can take up to a year even if the treatment works.²

With topical treatment on the feet, the CGCOP guide gives 6 to 12 months depending on how much of the nail is affected, with check-up visits every 2 to 3 months because the nail grows slowly.¹ With tablets, the sources give 2 to 3 months according to MedlinePlus² and up to 6 months according to the NHS.³ The cited sources do not detail how many laser sessions are given.

What risks and side effects do the treatments have?

All nail fungus treatments have drawbacks, and the infection often comes back: recurrence is around 10% to 53%, and is related to wrongly prescribed or badly applied treatments, poor hygiene habits and not following the treatment.¹

Oral antifungals

• They can damage the liver (hepatotoxicity), and those in the azole group interact with many other medicines.¹
• The NHS lists headache, itchy rash, stomach ache, nausea and diarrhoea.³
• They cannot be taken with some liver or kidney diseases, and may not be suitable during pregnancy or breastfeeding.³
• They need tests to monitor the liver, and the fungus goes away in only about half of those who try them.²

Topical treatments

• The pharmacy nail paint may not be suitable for under-18s or during pregnancy or breastfeeding.³
• They can take several months to show an effect.³

Laser

• The cited sources do not detail its adverse effects, and they do not agree: the CGCOP guide describes it as safe and without associated side effects,¹ while MedlinePlus considers it less effective than medicines.²

Removing the nail

• It is done under local anaesthetic for severely infected nails.³ The cited sources do not detail its risks.

Treating without confirming the diagnosis

• Other nail conditions, such as a knock, lichen planus or psoriasis, look similar to fungus, which is why a mycological examination is recommended before treating.¹

How can I avoid nail fungus or stop it coming back?

To avoid nail fungus, or to stop it coming back after treatment, the NHS advises these measures:³

• Treat athlete's foot as soon as possible, so that it does not spread to the nails.³
• Keep the nails short and the feet clean and dry.³
• Wear clean socks every day and footwear that does not make the feet sweat.³
• Wear flip-flops in gym and swimming pool showers.³
• Do not share towels or nail clippers.³

When should you see a podiatrist or a doctor about nail fungus?

See a podiatrist or a doctor about nail fungus when the infection does not go away or spreads, when pain, redness or pus appear, and also if you have diabetes or a weakened immune system.²³

For any adult

1. Signs of infection: the toes become painful, turn red or drain pus.²
2. The fungus does not go away: MedlinePlus advises contacting the professional if the nail fungus does not go away.²
3. Diabetes or a weakened immune system: the NHS advises seeing a doctor if you have diabetes or a weakened immune system.³
4. Severe infection or one that does not respond: the NHS recommends seeing a doctor if the treatment has not worked or if the infection has spread to other nails.³

If you are pregnant

Tell the professional that you are pregnant or breastfeeding before starting any treatment, because the pharmacy antifungal nail paint and the tablets may not be suitable during pregnancy or breastfeeding.³ The cited sources do not detail whether waiting until after the birth makes the infection worse. The prevention measures can be followed at any time.³ In addition to the signs of infection already mentioned,² there are signs unrelated to the nail that require medical attention:

1. Sudden swelling of the face, hands or feet: it may be a sign of pre-eclampsia, and the NHS recommends telling the midwife, the doctor or the maternity unit immediately. Swelling that comes on gradually is not usually harmful.⁴
2. Throbbing pain and swelling in one leg only: it may be a deep vein thrombosis. Pregnancy and the six weeks after the birth increase the likelihood, and the NHS asks for urgent medical attention if it is suspected.⁵
3. Sudden shortness of breath, chest pain or coughing up blood, even if your leg does not hurt: it is an emergency, because the clot can reach the lungs and endanger life.⁵⁶