What is the picture of health? Is it bulging muscles or a firm tummy? Is it healthy glowing skin or lustrous hair. Many would say it’s the absence of disease. A healthy heart and perfect blood pressure. But can you be healthy and harbor disease concurrently, all at the same time? Many Americans do, but how to know? One possibility: look at their feet!

Approximately 14% of the American population harbors various resistant microorganisms inside their shoes, setting up shop, making a nice home for themselves. Where are these bugs? They are residing in plain sight, in, around, and under, your toenails. We’ve all seen the ads with those hideous, unsightly little creatures. (As an aside, scientifically-speaking, fungal microorganisms behave more like plants while bacteria are more animal-like, especially in their rate of growth). This is a ubiquitous condition increasing in incidence yearly. Indeed the Center for Disease Control considers onychomycosis, nail fungus, to be of epidemic proportions. As to why this is, no one knows for certain, although naturally theories abound.

Certain occupations are more prone to onychomycosis, especially those working in wetter conditions. Naturally, genetics play’s a part in one’s susceptibility to fungal organisms. Surprisingly, subtle but repeated trauma to the nail can help a fungus get started. Yet, micro-trauma (that’s a real term) can lead to all manner of changes in the appearance of a nail, making it look much like a fungally-infected nail. Differentiating one from the other is sometimes impossible without testing.

An additional challenge with these infections is recurrence. If one is able to resolve the infection, they will often re-develop it. The reasons for this are many. People are exposed to fungal organisms in many of their day-to-day activities, such as at the gym, hotel rooms, or at the pool. In the senior population, the prevalence of onychomycosis is believed to be as high as 60%, and increases with age. PAD, peripheral arterial disease, is a factor, but not as much as physical trauma, which is a major component in the elderly. One of the most common routes of infection is within households, from one family member to the next. This latter fact has been proven in studies analyzing the genetic make-up of nail specimens amongst family members.

Naturally, genetics plays a part in recurrence. The ability of our immune system to fight off fungal infections varies greatly from person to person. Anything which reduces the effectiveness of immune function can play a part. Long term use of steroids is well known to cause this kind of change. Although this facet of the disease is not given enough “press”, diabetes is well known to negatively alter immunity. Diabetics are well recognized to have problems fighting off bacterial infections, but they also tend to have more severe and more rapidly advancing fungal nail infections. Most any disease causing a compromised immune system can lead to progressive fungal nail infections.

Many sufferers choose to ignore nail disease. Indeed, because of the slow, inexorable nature of this condition, it is easy to do. The changes initially are subtle and not particularly obvious. This is of particular importance when it comes to resolution since the success rate is directly tied to the severity of involvement. In other words, the longer it is present, the more established it becomes and the more difficult to resolve.

Having mentioned the frequency with which this condition is found, the really exciting part of this discussion concerns the challenges of treatment. To preface this particular topic, I should mention this is one of the most resistant infections known to mankind. This is due partially to the fact that fungal infections, in general, are extremely hardy. They are able to go into, what amounts to, a state of hibernation. Specifically, they form spores, which are resistant to hazardous or difficult environmental conditions. Another reason is the presence of that all-important protective barrier to medication: the nail.

Is there hope for those afflicted? We have had various treatment options for many years, but the success rate has been poor. Topicals are relatively inexpensive but provide a cure only when the infection is caught extremely early in the process. Several oral medications are approved for this condition, but there is the potential for liver damage. Newer dosing regimens have reduced those concerns, but still…..it’s hard to say there is no potential whatsoever. Regardless, many attempt to treat their nail fungus with pills. Unfortunately, too often they are not informed of the improved success rate with concurrent use of a topical preparation to the nail, professional reduction of nail thickness, and a shoe sterilization program.

A technique more common in Europe might be summarized as a light activation therapy. Used for years to treat many skin conditions is Photo-Dynamic Therapy, aka PDT. While PDT for the treatment of nail fungus is rare in the US, it is fairly new to the treatment of nail fungus. The positive’s include the lack of side effects and lack of discomfort. The success rate appears above that of the oral meds, but is very dependent on the degree of fungal involvement.

Most exciting of all is the development of a radically new laser technology. The old nail lasers attempted to kill the fungal organisms present under the nail with heat. Yet the studies used to document their benefits were both small and flawed. Minimally effective, these could cause some discomfort during application. The latest device uses a completely different concept. Two different laser systems are used, one which produces a wavelength of laser light which is deadly to fungal cells. The other laser present in the device stimulates a natural immune response, improving blood flow to the tissues, as well as the health of the tissues around and under the nail.

Of tremendous importance in evaluating this new method, like any newer technology, is the quality and quantity of the studies documenting its use. These have been excellent, including having large numbers of people in the studies, and strong statistical analyses. Another study is underway which may lead to a real milestone, the ability to obtain FDA approval for the use of the phrase “fungal cure”. This has never been achieved. Like the ability to regrow joint cartilage in orthopedics, the ability to cure nail fungus is the ‘holy grail’ of dermatology. Could the technology of the future be here?

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.