6 steps to erase nail fungus--for good!

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A lifetime plan to banish a blight that tries to make you look bad

If you don't have it, it can seem trivial, even laughable. If you do, it's no joke---even though it's painless and will never threaten your health. It's nail fungus, and there's nothing like it for making you self-conscious and frustrated.

"Nail fungus is more than a cosmetic problem," says Richard K. Scher, M.D. "If a discolored nail detracts from your appearance on the job or your confidence in a social situation, it can harm your sense of well-being." Dr. Scher, head of the nail-disease section of Columbia Presbyterian Medical Center in New York City, says nail fungus deserves the same serious attention as facial acne.

A nail that's harboring a fungus is thickened and tarnished white or yellow. It pulls away from its pink nail bed at the side or outer edge. The target of fungus is the nail itself, the dry folds at the nail's base and the surrounding healthy skin. Fungus is a microscopic plant form, teeming in your environment. You don't need close contact with someone else's infected nails to pick it up. Fungus may first invade the protective layer of dead cells coating your toes, resulting in athlete's foot. Then it can move into the nails. Experts think it's frequent, sweaty workouts in hot, closed shoes that help fungus get a foothold, not wet locker-room floors.

Another point of entry for fungus infection is a bump that causes a nail bruise. That bruise creates a fungus-friendly pocket between the nail and nail bed. Once one nail is infected, fungus can jump to other nails. The most common pattern is for fungus to blight a big toe then spread from nail to nail, then foot to foot and sometimes to one hand. Experts don't know why, but the second hand often escapes infection. And finicky fungus rarely chooses your fingers only and not your toes. Experts think nail-fungus victims have an immune-system defect that makes them easy prey for the parasite. So even after you undergo successful treatment, you have an enemy in fungus forever. The recurrence rate after treatment is 25 percent in fingernails and 75 percent in toenails. Like a stubborn case of acne, the only solution is to carefully monitor and care for your nails to keep fungus from getting an upper hand.
FIGHTING THE FUNGUS AMONG US

Even if you've been plagued with nail infections before, you can get free of fungus with this regime:

1. Get a diagnosis from your doctor or dermatologist. There's always the possibility you have a nail-fungus look-alike, such as psoriasis.

Diagnosis takes two steps. First, your doctor examines a nail sample under a microscope for fungus' links-of-a-chain shape. Second, if he finds a fungus, he then grows the cells for several weeks to find out if you have a regular fungus or candida, a yeast-type fungus. Diabetics, who are prone to foot problems, need extra-careful diagnosis because fungus can leave them open to serious bacterial infection.

* 2. Shed the infected nail and scaling skin. Treatment involves your doctor clipping back your nail to where it's still attached to the nail bed and scraping away scaling tissue. Special tools let the doctor do a more thorough job in his office than you could do at home. The idea is to physically evict the fungus. "It's like cleaning an abscess," says Dr. Scher. "You can use antibiotics but if you don't drain the abscess first, it won't heal."
* 3. Use a prescription antifungal drug. Removing dead tissue gets rid of most of the infection, but not all of it. Antifungal agents taken internally or painted on your nail can help, but choosing which to use is not easy. Because nails are made of dead cells, topical medications penetrate poorly to the fungus inside, explains Lowell Goldsmith, M.D., dermatology professor at the University of Rochester School of Medicine and Dentistry, New York. The most a cream or lotion can do is keep the area free of new fungus while the nail grows out. Topical drugs clear up infections about 40 to 50 percent of the time.

Oral antifungal drugs work by entering the nail matrix, or nail "root"---the white half-moon from which a nail grows. That way, new nail is armed with an antifungal shield against the invading parasite as it grows out. The problem is, you have to keep taking the drug until an entire new nail grows out---4 to 6 months for fingernails, 12 to 18 months for toenails.

The oral drugs for nail fungus are griseofulvin and a newer drug called ketoconazole (used if your fungus is candida or if your infection resists griseofulvin). Possible side effects from both these are headache, nausea and stomachache. Because the drugs may affect your liver and kidneys, you need an initial blood test and additional blood tests every month. Experts report that ketoconazole has in rare cases caused hepatitis. Dr. Scher says he has treated hundreds of patients with griseofulvin and has seen very few reactions to the drug. Both griseofulvin and ketoconazole can interact with certain prescription drugs and neither should be used by pregnant women.

Specialists differ on using oral drugs for nail fungus. Griseofulvin and ketoconazole work for 80 to 90 percent of people who take them, but some doctors say they're not worth the risk. Most approve oral drugs for two cases: fingernail fungus because it's more visible and has a better success rate, and toenail fungus only if your nail is so thickened that it's painful or infected. (Pain from nail fungus is rare.)

Oral drug users may find an unpleasant surprise shortly after they stop treatment---the fungus may come back. "Fifty percent of patients could have a recurrence of fungus within the next year," says Dr. Goldsmith. For some people, the only way to eliminate a fungus is to eliminate the nail---cutting out both the nail and its matrix so that no nail grows back. But that's a drastic step that doctors rarely take.

4. Step up the pressure at home. Besides daily medication, at-home fungus fighting means keeping your nail clipped or filed back so that no nail protrudes beyond the nail bed. What you're doing is eliminating the fungus' base of operations. Dr. Goldsmith advises using two sets of clippers to avoid spreading the fungus around. Keep one to trim only the infected nail and rinse it in alcohol after each use.

Next to trimming, keeping nails desert-dry is your best antifungal insurance. (See "Tips for Keeping Nails Dry.") Home vigilance is crucial. If you skip even one day, fungus can get the upper hand and start to colonize your nail again.

5. Regularly touch base with your doctor. If you're using topical medication, it's smart to have your doctor do a cleaning every month or two until your nail grows out.

If you're taking oral drugs, you'll need to see your doctor periodically to assess their effectiveness and to have blood tests to check for any liver problems from the drugs.

6. Stay on guard---for a lifetime. Even after a healthy nail grows back, you have to be ever vigilant or risk a recurrence.

The same home care you learned while your nail was growing out should become a permanent part of your daily routine.Your doctor may advise long-term use of a topical antifungal agent. Some experts recommend antifungal drugs containing miconazole. Keep your nails from getting soggy and keep them short. Long nails act like levers, separating nails from their beds and inviting fungus inside. Clip them after bathing when they're soft and you have better control with the clipper. (Dr. Goldsmith says short nails are good anti-fungal protection for everyone.) And at the very first sign of reinfection, go back to your doctor to start treatment again.
TIPS FOR KEEPING NAILS DRY

The best way to fungusproof your nails is to keep them dry. Try some of these techniques:

1. Aim a hair dryer, set on cool, between your toes to dry them completely after bathing.
2. Change your socks several times a day.
3. Sprinkle foot powder into your socks. Avoid powders containing cornstarch, which some experts think feeds fungus.
4. At home, go barefoot or wear just socks whenever you can.
5. In summertime when your feet are more likely to perspire, give them the freedom of open- toed shoes or sandals.
6. In winter, avoid heavily insulated down or sheepskin slippers that make your feet sweat. And instead of wearing wet- weather boots indoors, carry a pair of shoes to slip into.
7. Choose shoes that are well-ventilated. Walking shoes with mesh sections or perforated leather are good choices.
8. Make sure your shoes dry out completely overnight. Air out removable innersoles. Stuff soaked shoes with newspaper and put them near---not on---a heat source. Or, have more than one pair of shoes and wear a different pair on alternate days.
9. After a workout, change out of your sweat-dampened shoes and socks. And if you walk to work, change into fresh footwear once you get there.
10. Use rubber gloves for dishwashing and other soggy chores. Rubber gloves are likely to leave your hands sweaty, so try wearing a pair of thin cotton liners, available in most hardware stores.
11. Wear dry gloves while gardening or doing other extra- dirty chores. 12. Wear sandals or thongs while walking around wet public places, such as gym showers or swimming pools.

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By Gloria McVeigh

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