Nail fungus isn’t the most pleasant of topics, but it’s an important discussion to have, particularly if you also have diabetes. We summarize an article about nail fungus and diabetes, published in Skin Therapy Letter in April 2017, written in collaboration by a dermatologist and a podiatrist. The perspective of the article has been changed to reflect on the needs of the patient rather than to educate a healthcare professional.
Introduction: What is Nail Fungus?
Fungal infections of the nail account for nearly 50% of all nail problems, and about a third of all fungal infections. It can affect anyone, but prevalence increases with age. Other risk factors include smoking, psoriasis, excessive perspiration/wearing occlusive tight footwear, weakened immune system, and heavy exercise or frequenting high-risk areas like public showers and swimming pools where fungi are more likely to be transferred. Nail fungus is caused by fungi called dermatophytes which feed off of the keratin in the nail. As fungi are everywhere, there is no practical way to guarantee protection from possible infection; there are only ways to reduce the risk of infection.
Typical symptoms include discoloration (yellow or white), brittle nails, deformity, and crumbling of the nails. Nail fungus is progressive, although the rate of progression varies widely from individual to individual. Toenails are affected much more often than fingernails. While nail fungus is rarely painful (until the infection is advanced), it is visually disconcerting and affects patients socially and psychologically. Many patients shy away from social occasions where their toenails may be exposed, such as swimming, sauna, yoga, or dance classes as a result of the appearance of their nails.
Nail Fungus and Diabetes
Diabetes is a critical topic when discussing nail fungus. Patients with diabetes are at a higher risk of nail fungus infection, but more importantly, they are at a higher risk of serious complications arising from their fungal infection. At worst, the risk includes the necessity of limb amputation. Nail fungus should always be treated properly by a doctor, but if you have diabetes, it becomes absolutely critical that you do so as it turns a primarily cosmetic issue (although it can impair function if it advances) into one that has serious medical and functional consequences.
Diabetic patients are at higher risk due to several possible factors. The sensation at the peripheries may diminish with diabetes, leading to patients missing some of the warning signs of infection. Broken skin provides a portal for bacteria and can trigger a cascade of complications. Management can become as complex as nail fungus treatments will need to be supplemented with diabetes treatment. Early treatment and intervention including diabetic prophylactic foot care are important due to the elevated risk of diabetics, and the progressive nature of fungal infections. As can be seen in the graphics, there is a substantial increase in risk among diabetic patients so screening is a must.
What to Expect at Assessment and Diagnosis:
Diagnosis of nail fungus (onychomycosis) is generally based on a combination of a visual examination and test results. As nail changes can be caused by a variety of factors, tests are used to confirm the visual diagnosis.
In practice, topical treatments are often started before the test results are in to start the treatment as early as possible. This is because topical treatments have little risk of side-effects, unlike systemic therapies. Further confirmation is necessary before systemic treatments are prescribed as they have other risks of side-effects. It’s also noteworthy that nail fungus could also exist with other disorders like psoriasis, which needs to be treated separately from the nail fungus.
Your health care provider may also check for relevant medical history, such as your history of nail fungus or even athlete’s foot, age, diabetes, cancer, or renal disease, as well as the history of inflammatory diseases like psoriasis. All of these may affect your treatment plan. Other topics that may come up at consultation include your recreational activities (spas, pedicures, sport) that are relevant to nail fungus, as well as how you are coping with the condition as well. Nail fungus and diabetes are both straining in social and psychological ways as well, and it’s important that patients can communicate their challenges with health care providers about these issues as well.
Treatments: What to Expect
You may consult with a general practitioner, or a specialist such as a podiatrist, chiropodist, or dermatologist. They should provide you with advice on specific steps to prevent, maintain, evaluate and treat the condition. You may have tried several home remedies or Internet advertised treatments up to this point. Your doctor may advise you about the pros and cons of some of these options. Depending on your specific case, your health care provider will likely put you on one of the following treatment plans:
Topical Therapy: Low-risk treatment. These options are usually chosen when the nail fungus is mild to moderate, or if the patient is not suitable for systemic therapy. Patients should expect the treatment course to take up to a year.
Systemic Therapy: Systemic means orally ingested drugs – and are the recommended standard treatment when the nail fungus is considered severe – affects more than 60% of the nail plate. Drug interactions and possible side-effects will be explained. In some cases, monitoring may be necessary while you are taking the drugs.
Laser Therapy: The evidence for laser therapy is still a subject of debate. It may be used in conjunction with other treatments to help improve clinical appearance as part of treatment.
Conclusion and Takeaways
Nail fungus is a progressive condition (although how it progresses is highly individual) that should prompt you to see a specialist as soon as possible. Early treatment will provide you with the best chance of recovery with minimal damage. If you have diabetes or other medical conditions, it is absolutely critical that you see a doctor as soon as possible.
Diabetic foot ulcer guidelines identify nail fungus as a high-risk factor for complications and even amputation. Early diabetic foot examination should also include screening for nail fungus and are likely to include dermatological evaluation, vascular assessment, neurological evaluation, and biomechanical review. This is to identify any associated risk factors and to assess the patient’s overall risk levels.
As a patient, it’s important that you educate yourself on all aspects of treatment. Include your family members as well as any caretakers in the conversation about foot care if you have diabetes.
1http://www.skintherapyletter.com/onychomycosis/transungal-podiatrist/ Under: Systemic Treatment
2For those interested in the cited studies: A word document can be downloaded from this link: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jdv.15204