Onychomycosis (OM) is a common fungal infection that affects either your toenails or fingernails. It’s also referred to as tinea unguium. While it might sound like a minor issue, these infections can be uncomfortable and disfiguring, impacting your overall well-being.
Among the different types of onychomycosis, total dystrophic onychomycosis (TDO) represents the most severe form. In TDO, the infection has progressed to the point where it has completely destroyed the nail plate. This advanced stage can have a profound impact on a person’s life, extending beyond physical discomfort to affect their social interactions, emotional state, and even their ability to perform certain jobs.
This article will explain the causes of TDO, how it’s diagnosed, and what can be done to treat it. We’ll explore what you need to know about providing effective care for people experiencing this condition.
What causes onychomycosis?
Several kinds of microscopic fungi can cause onychomycosis, including: You can identify these fungi by picture.
- Dermatophytes
- Nondermatophyte molds (NDMs)
- Yeasts
Dermatophytes
Dermatophytes are the most common culprit. Trichophyton rubrum causes the most cases of onychomycosis worldwide. Trichophyton mentagrophytes is another dermatophyte that causes onychomycosis. Of all onychomycosis cases, dermatophytes account for about 90 percent.
Nondermatophyte molds (NDMs)
NDMs are increasingly recognized as a cause of onychomycosis. It’s becoming more important to identify NDMs accurately because infections from them are becoming more common.
Yeasts
Candida albicans is a yeast that often causes onychomycosis, especially in people who have health conditions that lower their immune system function. Onychomycosis from candida is often connected to paronychia, which is an infection of the skin around the nail.
Who gets onychomycosis?
Around the world, about 5.5 percent of people have onychomycosis. In the United States, about 10 percent of the population has it.
Onychomycosis is more common in adults, especially older adults, and people with certain health conditions.
Risk factors include:
- Older age
- Diabetes
- HIV
- Peripheral vascular disease
- Any health condition that causes immunosuppression
- Trauma to the nail
- Wearing footwear that’s too tight
- Exposure to damp environments
How does onychomycosis progress to total dystrophic onychomycosis?
Typically, a toenail fungus infection begins as either distal lateral subungual onychomycosis (DLSO) or white superficial onychomycosis (WSO). But if you don’t treat it — or if you don’t treat it correctly — the infection can spread to total dystrophic onychomycosis (TDO).
When this happens, fungal hyphae invade the entire structure of the nail, causing it to thicken, crumble, and change color.
Why does a fungal infection progress to TDO? Several factors play a role, including:
- A delayed diagnosis
- Inadequate treatment
- Not following the doctor’s instructions
- Underlying conditions like diabetes or peripheral vascular disease, which can make treatments less effective
If your toenail fungus reaches the TDO stage, you might experience pain, have trouble walking, and develop secondary bacterial infections. Plus, the disfigured nail can cause mental and emotional distress.
Clinical Presentation and Diagnosis of Total Dystrophic Onychomycosis
Total dystrophic onychomycosis (TDO) has some clear characteristics that make it possible for a trained health professional to diagnose.
Clinical Features of TDO
Complete Nail Destruction
The main sign of TDO is that the nail plate is almost completely destroyed. The nail may be:
- thickened
- deformed
- separated from the nail bed (called onycholysis)
Discoloration and Debris
The nail is often severely discolored, and the color can range from yellow-brown to black. Debris builds up beneath the nail plate, which causes it to thicken and separate from the nail bed.
Pain and Discomfort
TDO can hurt, and it can be tender to the touch. It can also make it hard to wear shoes.
If there’s a secondary bacterial infection, the pain and inflammation can get worse.
Diagnostic Methods
The diagnostic methods for TDO include:
Clinical Examination
A health professional can look at the nail and see the key characteristics of TDO. They’ll also look for inflammation, signs of secondary infection, and whether the infection has spread to nearby tissues.
Mycological Testing
Mycological testing includes:
- Potassium hydroxide (KOH) preparation: With a KOH preparation, a health professional can look at a sample from under the nail with a microscope to see if there are any fungal elements. If the test is positive, that confirms that there’s a fungal infection.
- Fungal culture: It’s important to do a fungal culture to find out exactly which organism is causing the infection. The culture can help tell the difference between dermatophytes, non-dermatophyte molds, and yeasts.
Nail Biopsy
A nail biopsy might be necessary if the diagnosis is unclear or if the health professional suspects that something other than a fungus is causing the problem. A biopsy can show fungal hyphae (strands) within the nail tissue.
Ruling out other causes of nail problems
If you’re having nail problems, it’s important to make sure it’s actually total dystrophic onychomycosis. A few other conditions can cause similar symptoms:
- Psoriasis: Nail psoriasis causes pitting, thickening, and separation of the nail from the nail bed. If you have psoriasis, you likely have skin lesions and joint pain.
- Lichen Planus: Lichen planus can cause your nails to get thin or develop ridges. You may also have lesions on your skin or in your mouth.
- Nail Trauma: If you drop something on your toe, that can cause nail problems, too. If you’ve had a recent injury, the nail changes may be from the trauma and not a fungal infection.
- Other Conditions: Other conditions, such as yellow nail syndrome, tumors, and onychogryphosis (thickening and curving of the nail), can also cause nail problems.
That’s why it’s important to see a doctor for a proper diagnosis. They may need to take a sample of your nail to test for fungus.
How do you treat total dystrophic onychomycosis?
Because TDO is so severe, it takes a multi-pronged approach to get rid of it. Here are some of the treatments your doctor might suggest.
Debridement and nail avulsion
Debridement refers to removing as much of the infected nail as possible. This reduces the amount of fungus you have to fight and also helps medicine get where it needs to go.
There are a few ways to debride:
- Mechanical debridement. This just means using tools such as clippers and files to cut away and file down the infected nail. You can do this at home or have a professional do it.
- Chemical avulsion. This involves putting a special chemical on the nail that softens it so you can peel away layers. Urea is one such chemical.
- Surgical avulsion. In this procedure, a doctor removes the entire nail. This is usually a last resort when other treatments don’t work.
Topical antifungal agents
You can buy antifungal creams and lacquers over the counter, but they don’t always work against TDO. That’s because the thickened nail plate prevents the medicine from getting to the fungus.
Still, your doctor may recommend topical antifungals as an add-on to other treatments, especially after nail avulsion or debridement. A couple of options are amorolfine and ciclopirox nail lacquers. Efinaconazole solution is a newer topical agent that may penetrate the nail better.
Systemic antifungal agents
These are oral medications that work throughout your body to kill the fungus. Common ones include:
- Terbinafine
- Itraconazole
- Fluconazole
Terbinafine is often the first choice because it tends to work well and doesn’t require as long a treatment period as some of the others. Itraconazole is also effective and can be taken in pulses, which some people find easier to stick to. Fluconazole is less common because it’s not as effective.
Keep in mind that oral antifungals can have side effects and may interact with other medications you’re taking. Your doctor will likely want to monitor your liver function during treatment.
Combination therapy
Sometimes, the best approach is to use both topical and systemic treatments. This way, you’re attacking the fungus from all sides. For example, you might take oral terbinafine or itraconazole along with a topical medication like amorolfine or ciclopirox. Nail avulsion or debridement can also be part of the plan.
Novel therapies
Researchers are always looking for new and better ways to treat onychomycosis, including natural remedies. Some newer options include:
- Laser therapy. This uses focused laser energy to kill the fungus in the nail.
- Photodynamic therapy. This involves putting a special chemical on the nail that makes it sensitive to light, then shining a light on it to destroy the fungal cells.
Prognosis and prevention of recurrence
Let’s be real: TDO is a tough nut to crack, and a complete cure isn’t always possible. How well treatment works depends on what’s causing the infection, how bad it is, and how well you stick to the treatment plan. Plus, nails grow slowly, so it can take a long time to see a real difference.
Recurrence rates for nail fungus range from 10% to more than 50%, so preventing it from coming back is vital. Here’s what you can do:
- Wear the right shoes: Protect your feet in public places.
- Practice good foot hygiene: Keep your feet clean and dry.
- Avoid nail trauma: Be careful not to injure your nails.
Your doctor might also prescribe topical antifungals as a maintenance therapy to keep the infection from returning. Basically, prevention is key!
Frequently Asked Questions
Why is onychomycosis so difficult to treat?
Onychomycosis, or nail fungus, is notoriously difficult to treat because the infection is located deep within the nail bed, making it hard for topical medications to reach. Oral medications, while more effective, can have potential side effects, and the infection often recurs even after successful treatment.
What happens if onychomycosis is left untreated?
If left untreated, onychomycosis can worsen, causing pain, discomfort, and difficulty walking. The infected nail can thicken, become misshapen, and even separate from the nail bed. It can also spread to other nails and even other people.
How do you treat total dystrophic onychomycosis?
Total dystrophic onychomycosis, the most severe form, often requires a combination of approaches. Oral antifungal medications are usually necessary, sometimes combined with topical treatments. In some cases, nail removal may be considered to allow for direct application of medication to the nail bed.
How do you fix a dystrophic toenail?
Fixing a dystrophic toenail involves treating the underlying cause, often onychomycosis. This can include oral or topical antifungal medications, nail debridement (trimming or filing the nail), and in severe cases, nail removal. Once the infection is cleared, the nail may gradually grow back normally, though it can take a long time.
Why does Vicks VapoRub work on nail fungus?
While anecdotal evidence suggests Vicks VapoRub may help with nail fungus, it’s not a proven treatment. The camphor and eucalyptus oil in Vicks might have some antifungal properties, but it’s unlikely to cure the infection, especially in severe cases like total dystrophic onychomycosis. It’s best to consult a doctor for effective treatment options.
Closing Thoughts
Total dystrophic onychomycosis is the most severe kind of nail fungus. It completely destroys the nail.
To diagnose it, your doctor will need to examine the nail and test it to find out what kind of fungus is causing the problem.
Treating TDO can be tough. It usually takes a combination of removing the infected nail tissue, using antifungal medications on the surface of the nail, and taking antifungal medications by mouth. Newer treatments are also being developed.
If you have TDO, it’s important to understand how to prevent the infection from spreading and to stick with your treatment plan to get the best results and avoid having the infection come back.
Researchers are always working on better ways to treat nail fungus, including new antifungal drugs and ways to get the drugs into the nail more effectively.