Nail & Skin Disorders

A Day in the Life of a Nail Expert: Fungal Infections

In response to several questions from readers, Dr. Stern is addressing the topic of fungal infections of the nail and its treatment in this month’s column.   

<p>This is a classic example of onychomycosis. You can see how the yellow and white discolored nail plate is thickened, broken, crumbly, and discolored.&nbsp;</p>

The medical term “onychomycosis” refers to fungal infection of the nail. Nail fungus can be caused by dermatophytes (fungus), yeast, or non-dermatophyte molds. Multiple factors predispose a person to fungal infections of the nail including increasing age, diabetes, suppressed immunity, excessive sweating (hyperhidrosis), poor circulation, and nail dystrophy (irregularly growing nails). Additionally, nail fungus can be acquired from fungal infections at other areas of the body. For example, tinea pedis (athlete’s foot) can spread to the toenail, especially if the nail is damaged or lifted.

<p>This toenail tested positive for typical fungus but there is additionally a bacteria called pseudomonas (often referred to as &ldquo;greenies&rdquo; in nail salons) that is responsible for imparting the green hue to this nail plate.</p>

Although the appearance of nail fungus can be highly variable, generally the nail appears yellow, brown, and/or white, thickened, and crumbly. Often there is significant debris under the nail and the surrounding nail folds and cuticle area can be redder than normal.

Fungal infections of the nail can be challenging to treat. Patients have variable response rates to treatment and no single therapy has a 100% cure rate. Additionally, the oral medication considered most effective (Lamisil), can on rare occasions be associated with risks such as liver damage. In addition, relapses after effective therapy are common. For these reasons, health care providers frequently express ambivalence about treatment leaving both patients and nail technicians rightfully confused about whether effective therapy for nail fungus is even warranted.

<p>Although toenails are about 25 times more likely than fingernails to be infected, the one hand, two feet syndrome of onychomycosis occurs when the person with toenail or foot fungus scratches or picks the feet, usually with the dominant hand.&nbsp;</p>

There are several reasons to consider treating nail fungus. Nail fungus can spread to other areas of the body such as the hands, legs, and back. Those who take medications that weaken the immune system like steroids or chemotherapy are particularly susceptible and although most healthy adults who ignore nail fungus will probably not observe any immediate issues, over time, fungal infection can cause the nails to become thickened, brittle, discolored, and even painful. Additionally, the longer one waits to treat nail fungus, the harder it becomes to effectively treat it.

<p>When the nail is separated (onycholysis), infections such as yeast, bacteria, and fungus can occur.</p>

Nail fungus can also be contagious. In a nail salon setting a client with fungus can spread it to other clients if proper disinfection precautions are not followed. In fact, children who get toenail fungus are more likely to be in a household where there is an adult with fungus. When I treat children with nail fungus I request that the entire household come to the office for examination and, when necessary, treatment in order to effectively eradicate the source. In these instances there is almost always an adult carrier source. Fungus can also create microscopic cracks in the skin where bacteria can lodge and consequently cause serious infections. Diabetics are particularly prone to this phenomenon.

If you suspect that a client has nail or skin fungus, she should be referred to a dermatologist for testing and proper treatment. There are several ways to approach the treatment of fungal infections and fortunately new promising therapies are on the horizon including two new topical treatments that will hopefully be FDA-approved next year.


You can contact Dr. Stern with your questions via Facebook ( or

Twitter (@DrDanaStern). Visit her website at


Read previous “day in the life” articles by Dr. Stern at



Dermatologists treat skin, hair, and nails. I am a board-certified dermatologist and I specialize in the treatment of nail disorders including nail infections, inflammatory diseases of the nail, cosmetic issues related to the nail, cancers of the nail, and sports-related nail injuries. I also perform surgery on the nail including biopsies and excisions.


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The cuticle is a layer of colorless skin that is constantly shed from the underside of the proximal nail fold and attaches to the nail surface as...
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