MMA im. I.M.Sechenova
The term “mycosis of the feet” refers to mycotic lesions of the skin and nails of the feet of any nature. As a rule, mycosis of the feet is caused by dermatophytes: trichophyton red (Tr. rubrum), trichophyton interdigitale (Tr. interdigitale), epidermophyton inguinal (E. floccosum). The frequency of foot lesions caused by various dermatophytes varies widely: Tr. accounts for 70-95% of cases. rubrum, from 7 to 34% - on Tr. interdigitale and only 0.5–1.5% on E. floccosum [1].
Clinically, the lesions proceed in the same way. The place of primary localization of the pathogenic fungus is, with rare exceptions, the interdigital folds; as the mycotic process progresses, the damage goes beyond their limits. There are several clinical forms of mycosis of the feet.
The erased form (highlighted by L.N. Mashkilleyson) almost always serves as the beginning of mycosis of the feet. The clinical picture is scanty: there is slight peeling in the interdigital folds (often in one), sometimes small superficial cracks. Neither peeling nor cracks cause any concern to the patient, so the erased form is more often detected when the patient is examined by a doctor.
The squamous form is manifested by peeling, mainly in the interdigital folds and on the lateral surfaces of the soles. Signs of inflammation are usually absent. Occasionally, skin hyperemia occurs, accompanied by itching. The skin of the soles is congestively hyperemic and lichenified; the diffusely thickened stratum corneum gives it a lacquered shine; the skin pattern is enhanced; the surface is dry, covered (especially in the area of skin grooves) with small lamellar scales (Fig. 1). The lesion may involve interdigital folds, fingers, lateral and dorsal surfaces of the foot; It is natural that nails are involved in the mycotic process. Subjectively, the patient does not experience any concerns. It is proposed [2] to designate this form as the classic form of foot rubrophytosis.
The hyperkeratotic form is manifested by dry, flat papules and slightly lichenified nummular plaques of a bluish-reddish color, usually located on the arches of the feet. The surface of the rash (especially in the center) is covered with layers of grayish-white scales of varying thickness; their boundaries are sharp; along the periphery - a border of exfoliating epidermis; Upon careful examination, you can notice single bubbles. The rashes, merging, form diffuse foci of large sizes, which can spread to the entire sole, lateral and dorsal surfaces of the feet (Fig. 2). When localized on the interdigital folds, eflorescence can occupy the lateral and flexor surfaces of the fingers, and the epidermis covering them acquires a whitish color. Along with such scaly lesions, there are hyperkeratotic formations of the type of limited or diffuse yellowish calluses with cracks on the surface. The clinical picture is similar to that of psoriasis, tilotic eczema and horny syphilides. Subjectively, dry skin, moderate itching, and sometimes pain are noted. Squamous and hyperkeratotic forms are often combined (squamous-hyperkeratotic form).
The intertriginous form of mycosis of the feet is clinically similar to banal diaper rash (Latin intertrigo - “diaper rash”). The interdigital folds between the third and fourth, fourth and fifth fingers are most often affected. The skin of the folds is deep red, swollen, with weeping and maceration, often erosion and rather deep and painful cracks (Fig. 3). Intertriginous mycosis is distinguished from a banal diaper rash by rounded outlines, sharp boundaries and a whitish fringe along the periphery of the exfoliating epidermis. Detection of mycelium during microscopic examination of pathological material helps to make a final diagnosis. Subjectively, itching, burning, and pain are noted.
The dyshidrotic form is manifested by numerous bubbles with a thick tire. The predominant localization is the arches of the feet. The rash can affect large areas of the soles, as well as interdigital folds and skin of the fingers; merging, they form large multi-chamber bubbles, when opened, wet erosions of a pink-red color appear. Usually the blisters are located on unchanged skin; with an increase in inflammatory phenomena, hyperemia and swelling of the skin are added, giving this type of mycosis of the feet a resemblance to acute dyshidrotic eczema. When inflammation subsides in a large focus of dyshidrotic mycosis on the arch of the foot, 3 zones are formed: the central zone is represented by smooth pink-red skin with a bluish tint and a few thin scales; in the middle zone, on a hyperemic and slightly edematous background, numerous erosions prevail with the separation of scanty serous fluid, and Vesicles and multi-chamber bubbles predominate along the periphery. Subjectively, itching is noted.
An indispensable companion to mycosis of the feet is damage to the nails (onychomycosis). In domestic mycology, there are 3 types of onychomycosis: normo-, hyper- and atrophic (onycholytic). In the 1st case, only the color of the nails changes (spots and stripes from white to ocher-yellow appear in their lateral sections, gradually the entire nail changes color, maintaining shine and unchanged thickness), in the 2nd case, increasing subungual hyperkeratosis joins (the nail loses shine, becomes dull, thickens and deforms up to the formation of onychogryphosis, partially collapses, especially from the sides; patients often experience pain when walking). The onycholytic type of the disease is characterized by a dull brownish-gray color of the affected part of the nail, its atrophy and rejection from the bed; the exposed area is covered with loose hyperkeratotic layers; the proximal part of the nail remains without significant changes for a long time (Fig. 4).
The classification of onychomycosis accepted abroad is based on a topical criterion - localization of the mycotic process in the nail: distal onychomycosis with pachyonychia or onycholysis; lateral with onycholysis, hypertrophy or the formation of transverse grooves; proximal; total. In addition, white superficial onychomycosis (mycotic leukonychia) is distinguished, characterized by opal-white spots at the back of the nail, and then along its entire surface. Such onychomycosis is typical for HIV-infected people. Nail damage does not occur simultaneously; the same patient may have different variants of onychomycosis (Fig. 5, 6).
Exacerbation of exudative intertriginous or dyshidrotic mycosis of the feet can lead (depending on the type of fungus) to acute epidermophytosis or acute rubrophytosis, which can be considered as manifestations of high sensitization to pathogenic fungi [3] and interpreted as acute mycosis of the feet. The disease begins with the rapid progression of exudative mycosis, combined with hypertrophic onychomycosis. The skin of the feet and legs becomes intensely hyperemic and sharply swollen; abundant vesicles and blisters with serous and serous-purulent contents appear, the opening of which leads to numerous erosions and erosive surfaces; maceration extends beyond the interdigital folds and is complicated by erosions and cracks (Fig. 7). Erythematous-squamous spots and papulovesicular rashes spread throughout the skin. High body temperature, bilateral inguinal-femoral lymphadenitis, lymphangitis, and ulceration are noted; general weakness, headache, malaise, and difficulty walking develop.
Rice. 7. Acute form of mycosis of the feet
Course of mycosis of the feet
Mycosis of the feet is characterized by a chronic course with frequent exacerbations. Exacerbations and exudative clinical manifestations are characteristic of young and mature patients, while a monotonous course of the “dry type” is characteristic of elderly and senile patients.
Mycosis of the feet in the elderly is usually a long-term mycotic process (a disease acquired in youth lasts a lifetime). The soles and interdigital folds are mainly affected; their skin is pinkish-bluish in color, dry, covered with small scales, especially along the furrows. The lesion involves the skin of the fingers, the lateral (often the back) surfaces of the feet. In areas of pressure and friction with poorly fitting shoes, much more often than at a young age, foci of hyperkeratosis with cracks appear (sometimes deep and painful, especially in the heel and Achilles tendon). With mycosis of the feet in the elderly, especially with rubrophytosis, multiple lesions of the nails are observed, most often occurring as a total dystrophy. This is due to the fact that 40% of patients with onychomycosis are people over 65% of years of age [4].
With rubrophytosis (causative agent - Tr. rubrum), the damage is not always limited to the feet.
Treatment of mycosis of the feet is often carried out in 2 stages. The purpose of the preparatory stage is regression of acute inflammation in intertriginous and dyshidrotic forms and removal of horny layers in squamous-hyperkeratotic forms. With extensive maceration, excessive weeping and continuous erosive surfaces, warm foot baths from a weak solution of potassium permanganate and a lotion from a 2% solution of boric acid are indicated. During the bath, you should carefully (preferably with your fingers) remove the macerated epidermis and crusts. Then, after drying the skin of the feet, a cream (but not ointment!) containing corticosteroid hormones and antibiotics is applied to the affected areas (exudative mycosis is rich in coccal flora). First of all, the creams “Triderm” (betamethasone dipropionate, clotrimazole, gentamicin), “Diprogent” (betamethasone dipropionate, gentamicin), “Celestoderm B with garamicin” (betamethasone valerate, gentamicin) are indicated. When acute inflammation subsides (rejection of macerated epidermis, cessation of oozing, epithelization of erosions), foot baths are stopped, and the creams listed above are replaced with ointments containing the same components and having the same trade names. For severe inflammation with extensive exudative manifestations, including diffuse swelling of the feet, corticosteroid hormones are prescribed orally [4]. This is especially advisable, in our opinion, in the presence of numerous and widespread dermatophytids. The most effective is diprospan, which has a prolonged effect (betamethasone dipropionate and betamethasone disodium phosphate; intramuscularly in a dose of 1 ml - 1 ampoule). If the patient weighs more than 80 kg, it is preferable to administer a double dose (2 ml). Usually the severity of inflammation can be controlled with 1-2 injections.
With moderate inflammation (scanty weeping, limited erosion), there is no need for foot baths; Treatment can begin with the use of creams and then ointments. In old and senile age, the preparatory stage is reduced to the removal of horny layers using various keratolytic agents. So, 5-15% salicylic petroleum jelly is applied to the soles 1-2 times a day (at night, under wax paper) until the horny masses are completely removed. Detachment according to Arievich is more effective (if necessary, repeated): an ointment containing salicylic acid (12.0), lactic acid (6 ,0) acid and petroleum jelly (82.0). A good effect is obtained by lactic-salicylic collodion (lactic and salicylic acid - 10.0 each, collodion - 80.0), which is used to lubricate the soles in the morning and evening for 6-8 days, then at night 5% salicylic petroleum jelly is applied under a compress, after what are soap and soda foot baths prescribed for; exfoliating epidermis is removed by scraping with pumice. Softening the thickened (especially with rubrophytosis) stratum corneum of the epidermis facilitates the penetration of external antifungal agents into the affected tissues.
At the main stage of treatment of mycosis of the feet, numerous topical antifungal drugs are used (clotrimazole, exoderil, mycospor, nizoral, batrafen, etc.), but the drug of choice is Lamisil ® . Its active ingredient (terbinafine) is most effective against the main pathogens of the disease - dermatophytes. Antifungal ointments (creams) are used 2 times a day (Lamisil - 1 time), lightly rubbing into the affected skin and surrounding areas. The use of local forms of Lamisil® once a day ensures more accurate patient compliance with the doctor’s recommendations. Local treatment is carried out with intact nail plates; if nails are involved in the process, treatment with systemic antimycotics is carried out.
Treatment of onychomycosis is associated with certain difficulties, especially in elderly and geriatric patients, often burdened with various diseases. From these positions, Lamisil® is primarily indicated, as it has very high activity against dermatophytes, good tolerability and minimal risk of side effects.
MAIN CHARACTERISTICS OF LAMISIL ®
The most common causative agents of mycosis of the feet are Trichophyton rubrum and Trichophyton mentagrophytes var interdigitale. Much less commonly, mycosis of the feet can be caused by Epidermophyton floccosum, as well as yeast and mold fungi. At the same time, cases of mixed lesions have increased significantly. The frequency of foot lesions caused by various dermatophytes varies widely: 70-95% of cases occur with Tr. rubrum, from 7 to 34% - on Tr. interdigitale and only 0.5-1.5% on E. floccosum.
Infection with mycosis of the feet usually occurs in showers, swimming pools, baths, and when using household items shared with a sick person (towels, sponges, shoes, socks, etc.). Predisposing factors are excessive sweating of the feet, flat feet, and wearing tight shoes.
The process can be asymptomatic for a long time or manifest itself with minor symptoms in the form of mild peeling, maceration of the epidermis in the interdigital folds, peeling on the arch of the feet, and occasional minor itching.
This condition can last for many months and years without causing any particular discomfort to the patient. The chronic course and unsystematic short-term, and therefore unsuccessful, attempts at treatment lead to the unjustified conclusion that the disease cannot be cured. At the same time, a long asymptomatic course creates the illusion that the disease is not dangerous and does not cause any problems. Both of these conclusions are completely incorrect, since the infection continues to spread to the nails and smooth skin. The patient is a source of infection, especially for family members and for those with whom they use showers and swimming pools. In addition, violations of the integrity of the skin can become an entry point for bacterial infection. For example, the clinical manifestations observed in the intertriginous form of mycosis of the feet are the result of the interaction of fungi and bacteria. Allergization of the body increases significantly. According to many authors, mycoses of the feet are one of the main causes of sensitization, the occurrence of contact dermatitis, as well as the transition of the latter to allergic dermatitis and eczema. The attached secondary microbial flora aggravates the course of the fungal disease, further reducing the body's defenses. In contact with fungi, such flora acquires increased resistance to antibacterial agents.
Under the influence of provoking factors, an exacerbation of the disease may occur: redness, cracks, maceration of the skin, blisters and blisters in the arch and lateral surfaces of the feet appear, and pain occurs, which intensifies when walking. Periods of exacerbation of fungal foot diseases are more often observed in the warm season. The natural result of the development of mycosis of the feet is fungal infection of the nails - onychomycosis.
Predisposing factors for the development of fungal infections of the feet, especially in the case of complications with eczematization and/or secondary infection, are also vascular diseases of the extremities, diabetes mellitus, repeated microtraumas, and disorders of the nervous, endocrine and immune systems. The disease often develops against the background of long-term use of drugs that suppress the body’s defenses (glucocorticoids, cytostatics, broad-spectrum antibiotics), and complicates the course of the diseases for which these drugs are prescribed.
Clinical manifestations of mycoses of the feet differ depending on the type of pathogen. T. rubrum affects the skin, toenails (less often the hands), as well as any part of the skin; sometimes vellus and long hair are involved in the process. T. interdigitale affects the skin and nail plates of the feet only.
With mycosis of the feet caused by T. rubrum , the disease begins with the interdigital folds, then the skin of the soles, lateral and dorsal surfaces of the feet, palms, as well as the nail plates are involved in the process. The skin becomes dry, thickened, with a pronounced pattern of skin furrows and flour-like or lamellar peeling. Rubromycosis is characterized by multiple lesions of the nails of the feet and hands according to the normotrophic, hypertrophic, atrophic type and the type of onycholysis. Leukonychia is sometimes observed - the appearance of spots and stripes of white color.
Damage to the skin of the feet with rubromycosis can be in the following clinical forms: squamous, intertriginous, dyshidrotic, squamous-hyperkeratotic with single or multiple lesions of the nails or without it. The disease in some patients is accompanied by itching. The squamous form is characterized by the presence of peeling on the skin of the interdigital folds, soles, and palms. With the intertriginous form, slight redness and peeling on the lateral contacting surfaces of the fingers, maceration, the presence of erosions, superficial or deep cracks in the folds are observed. This form can become dyshidrotic, in which vesicles or blisters form in the area of the arches, along the outer and inner edges of the feet and in the interdigital folds. Superficial bubbles open with the formation of erosions, which can merge, forming foci with clear boundaries. In the case of a bacterial infection, pustules, lymphadenitis and lymphangitis occur, and secondary allergic rashes may develop on the lateral and palmar surfaces of the fingers, palms, forearms, shins, and less often in other areas. In some cases, the disease becomes chronic with an exacerbation in spring and summer. In the squamous-hyperkeratotic form, the skin of the soles (palms) becomes reddish-bluish in color, and pityriasis-like peeling is noted in the skin grooves, which extends to the plantar and palmar surfaces of the fingers. There may be ring-shaped or plate-like peeling on the palms and soles. In some patients, it is insignificant due to frequent hand washing. Sometimes, along with peeling, areas of skin thickening such as callus are noted.
T. rubrum often affects large folds: inguinal-femoral, axillary, intergluteal, under the mammary glands. When the process generalizes, rashes can occur on any part of the skin. In rare cases, the skin of the scalp and face is affected. Sometimes the disease occurs as a suppurative trichophytosis.
On smooth skin, the lesions are irregularly shaped, with an intermittent ridge consisting of small fused pink nodules, scales and crusts, with a bluish tint and peeling; in the center the skin is bluish-pink. There may be nodular lesions. On the lower legs, these elements are located mainly on the extensor surface, sometimes adjacent to the hair follicles, grouped into open rings and garlands, and vellus hair is often affected.
Manifestations of rubromycosis on smooth skin can be varied and resemble eczema, psoriasis, lupus erythematosus and other skin diseases.
In children, lesions of smooth skin on the feet are characterized by fine-plate peeling on the inner surface of the terminal phalanges of the toes, most often in the 3rd and 4th interdigital folds or under the toes, hyperemia and maceration. On the soles, the skin may not be changed or the skin pattern may be enhanced; sometimes ring-shaped peeling is observed. The disease is accompanied by itching. In children, more often than in adults, exudative forms of lesions occur not only on the feet, but also on the hands.
With mycosis of the feet caused by T. interdigitale , damage to the 3rd and 4th interdigital folds, plantar surface, lateral surfaces of the foot and toes, and arch of the foot is more often observed. The clinical forms of the lesion are the same as for rubromycosis, but the disease often occurs with more pronounced inflammatory exudative phenomena, the development of allergic rashes on the skin of the upper and lower extremities, torso, and face.
Mycosis of the feet is characterized by damage to the nails, and more often it is multiple in rubromycosis and single (I and V toes) if the mycosis is caused by T. interdigitale. Damage to the nails can be distal (changes in the nail begin from the free edge), distal-lateral and proximal. There are several forms of nail damage:
- hypertrophic (in most cases) - thickening of the nail throughout its entire length due to subungual hyperkeratosis; nails become dull, dirty gray in color, loosened at the free edge;
- normotrophic - the normal configuration of the nails is maintained, but they become dull, with a yellowish tint at the free edge, with thickening in the corners of the plate due to the accumulation of horny masses;
- atrophic - the nails are significantly destroyed, as if eaten away at the free edge, the bed is partially exposed, covered with a layer of loose and dry crumbling masses;
- onycholysis type lesion - the nail plate is separated from the bed, sometimes dirty gray in color, at the base the normal color of the nail remains.
may occur .
With onychomycosis caused by T. interdigitale, the nail damage is more superficial than with rubromycosis. Clinical manifestations in children differ in that the configuration of the nail may not be changed, but the surface is rough or exfoliated, subungual hyperkeratosis is rarely observed, the color of the nails may not be changed, or there are stripes of yellow or brownish-yellow color, sometimes merging into spots.
Mycosis of the feet is characterized by a chronic course with frequent exacerbations. Exacerbations and exudative clinical manifestations are characteristic of young and mature patients, while a monotonous course of the “dry type” is characteristic of elderly and senile patients.
Mycosis of the feet in the elderly is usually a long-term mycotic process (a disease acquired in youth lasts a lifetime). The soles and interdigital folds are mainly affected; their skin is pinkish-bluish in color, dry, covered with small scales, especially along the furrows. The lesion involves the skin of the fingers, the lateral (often the back) surfaces of the feet. In areas of pressure and friction with poorly fitting shoes, much more often than at a young age, foci of hyperkeratosis with cracks appear (sometimes deep and painful, especially in the heel and Achilles tendon). With mycosis of the feet in the elderly, especially with rubrophytosis, multiple lesions of the nails are observed, most often occurring as a total dystrophy. This is due to the fact that 40% of patients with onychomycosis are people over 65% of years of age.
Diagnosis of mycosis of the feet is based on clinical manifestations and detection of the fungus during microscopic examination of pathological material. The type of pathogen can be identified by culture.
It is necessary to differentiate mycosis of the feet from dyshidrotic eczema, psoriasis, Andrews pustular bacterid, keratoderma; when lesions are localized on the legs - with nodular vasculitis, papulonecrotic tuberculosis, limited neurodermatitis; on the skin of the body - with psoriasis, superficial and chronic trichophytosis, infiltrative and infiltrative-suppurative forms of zooanthroponous trichophytosis, inguinal epidermophytosis; on the face - with lupus erythematosus.
Skin mycoses, even at the earliest stages of development, require mandatory treatment, the leading role in which belongs to antifungal drugs for external use, acting directly on the lesion.
External antifungal drugs must meet the following requirements:
- have sufficient antifungal activity, taking into account the frequent occurrence of mixed infections, as well as in some cases the impossibility of an in-depth examination to identify the type of pathogen, the spectrum of antifungal action should be wide (this means activity against the maximum number of pathogens of skin mycoses found in the region and mucous membrane);
- ensure a sufficiently high concentration of the antifungal substance in the surface layers of the skin;
- combine antifungal and antibacterial effects;
- do not have a local irritating effect;
- do not have an allergenic effect;
- be easy to use, and also have no color or odor, do not make the skin “greasy”, provide sufficient effect when applied no more than 1-2 times a day;
- have an affordable price;
— uninterrupted presence in the pharmacy network.
In this regard, an important role in the fight against mycoses is played by mycological, treatment and advisory scientific centers, which, having trained specialists and appropriate laboratory and clinical facilities, have the opportunity to provide effective assistance to patients, not only introducing the latest achievements, but also developing new drugs in relation to various clinical forms of fungal infection.
Derivatives of azoles, undecylenic acid, allylamines, morpholines, etc. are used as active ingredients in external dosage forms.
For squamous manifestations of mycosis, antifungal drugs are prescribed externally until the clinical manifestations resolve. In case of significant hyperkeratosis in foci of mycosis on the feet, the stratum corneum of the epidermis is first detached using keratolytic agents. In case of acute inflammatory phenomena (wetting, the presence of blisters) and severe itching, desensitizing and antihistamine drugs are used in combination with external agents that have an anti-inflammatory, antiseptic effect (in the form of lotions).
In case of ineffectiveness of external therapy, for common and often recurrent forms, systemic antifungal drugs are prescribed:
Terbinafine orally after meals 250 mg/day for 3-4 weeks or
Itraconazole orally after meals 200 mg/day daily for 7 days, then 100 mg/day for 1-2 weeks or
Fluconazole orally after meals 150 mg once a week for at least 3-4 weeks.
Systemic therapy is carried out taking into account compatibility with other drugs (especially when prescribing azoles) and possible contraindications (primarily liver pathology).
Various approaches to the treatment of onychomycosis have been described. The most obvious, but not always effective, is the removal of the affected nail plates followed by external use of antifungal drugs.
Systemic therapy , the most common method of treating onychomycosis today, ensures the penetration of antifungal drugs into the nails through the blood. Indicated in the late stages of the distal-lateral form of onychomycosis, with total damage to the nail, proximal forms of onychomycosis, involvement of more than 50% of the nail plate in the process, damage to many nails, the nail matrix, long duration of the disease. Additional arguments in favor of such therapy have been the results of recent studies, which have shown that with total onychomycosis, not only the nail plate can be affected, but also the underlying tissues: epidermis, connective tissue and even bone structures, in particular the medullary canal. These data, from the author’s point of view, make it necessary for total and proximal onychomycosis to take a rather long-term use of a systemic antifungal drug on a continuous basis, since modern keratophilic antimycotics, accumulating in the stratum corneum, where fungi are exposed to their action even during breaks in treatment, do not affect this period on fungi located in deeper structures, which may contribute to their survival.
Dwelling in detail on the pathogenesis of onychomycosis, A.Yu. Sergeev (2001) comes to the conclusion that the area of articulation of the nail plate and bed is the one that most fully satisfies the requirements for the fungal habitat. Here are the softer, ventral layer of the nail plate and the upper layers of the nail bed, away from the vasculature. Moreover, the articulation of the bed and the plate occurs due to their longitudinal strands, represented by coinciding grooves and ridges. The space between them is a potential location for a fungal colony. According to the author, the exceptional conditions for the reproduction and vital activity of fungi in this zone explain the high frequency of the subungual form of the disease.
The duration of therapy with systemic antifungal drugs is determined by the rate of nail growth. The mechanism of action of systemic antifungal drugs in accordance with this concept is reduced to suppressing fungal invasion during the growth of the nail plate. If the nail grows slowly, then a larger dose and duration of treatment are necessary.
Due to the fact that the “most convenient” localization described above is remote from the vascular network, access to it by systemic antifungal drugs is ensured only when they accumulate in the growing nail. At the same time, when using onycholytic agents and subsequent external use of antifungal drugs, the latter act as synergists, acting on the fungal mass in the opposite direction with systemic drugs.
Removing the affected nail plate , on the one hand, helps to destroy a significant part of the fungal cells, and on the other hand, it facilitates access of antifungal drugs used externally to the lesion. At the same time, the growth rate of the nail plate, i.e. “repressing” its affected part becomes less significant. In addition, the chances of providing an antifungal effect on subungual structures during breaks in taking systemic drugs according to an intermittent regimen increase.
The synergy between systemic and external treatment of onychomycosis is also due to the fact that the development of new systemic antifungal agents has moved towards obtaining highly active components with good bioavailability. The development of topical drugs focused on mechanisms for improving the delivery of the active substance through the nail plate.
Thus, from our point of view, it is legitimate to add to the proposed ways to increase the effectiveness of treatment of onychomycosis the removal of the affected part of the nail plate using an onycholytic method.
Combination therapy is especially indicated in elderly patients in whom the growth of the nail plate is slower, and therefore, to suppress the growth of the fungus with systemic drugs, higher doses and longer duration of treatment are required, which is associated with an increase in both the cost of treatment and the risk of possible side effects . It is necessary to take into account that in this category of patients, concomitant pathology is more common, which is a contraindication to the prescription of systemic antifungal drugs, as well as impaired peripheral circulation, which impairs the delivery of the latter to the lesion.
So, the following approaches to the treatment of onychomycosis can be distinguished:
1) local therapy:
a) with removal of the nail plate
- through the use of onycholytic agents;
b) without removing the nail plate (fungicidal varnishes);
2) systemic therapy:
— standard regimen (daily administration of an average therapeutic dose of the drug);
— a shortened regimen (usually with an increase in the daily dose);
- intermittent regimens (with an interval between courses comparable to the duration of treatment or longer);
3) combination therapy:
- combinations of certain systemic drugs;
- a combination of systemic drugs and local treatment, including with and without removal of the nail plates.
Some authors understand combination therapy as a combination of specific systemic treatment and pathogenetic methods of therapy, for example, agents that accelerate the growth of the nail plate. If necessary, any of the specific methods for treating onychomycosis should be used in combination with pathogenetic methods.
A combined treatment method, including terbinafine 250 mg/day + external use of antifungal drugs after removal of the affected part of the nail plate with an onycholytic agent, turned out to be the most effective. It exceeded the overall effectiveness of local therapy by 36.6%, systemic monotherapy by 8% and reduced the duration of treatment by an average of 8.6 weeks compared to local therapy and by 1.3 weeks compared to systemic therapy. Combination therapy made it possible to reduce the duration of taking a systemic antimycotic, which helped reduce the likelihood of developing possible side effects and, what is also very important, reduce the cost of treatment. This method of therapy turned out to be effective even in patients with the most severe manifestations of onychomycosis, which arose against the background of concomitant pathogenetically significant pathology.
Therefore, combination treatment is indicated for moderate lesions, although in this case systemic monotherapy can also be used. In severe cases, combination therapy has significant advantages over monotherapy. Moreover, achieving clinical remission is possible, as a rule, when using pathogenetic methods of treatment.
Combination therapy is especially effective in severe forms of onychomycosis, in elderly people due to the slow growth of nail plates; deterioration of peripheral circulation; the presence of concomitant pathology, making it necessary to reduce the course dose and duration of use of the systemic drug; in the presence of subungual hyperkeratosis or partial detachment of the nail plate, making it difficult for the systemic drug to penetrate into it; when the nail plates are affected only on the first fingers, since in this case it makes possible a significant reduction in the duration of use of the systemic drug.
Thus, today new methods and means of treating and preventing fungal diseases have appeared in the arsenal of dermatologists. They are available, safe, effective, i.e. meet all modern requirements. At the same time, timely consultation with a doctor, correct diagnosis and treatment adequate to the form and stage of the disease will save the patient from such a serious disease as fungal skin infection, or prevent its occurrence.
Prevention of mycosis of the feet comes down to personal (fighting foot sweating, etc.) and public (maintaining baths, showers in a hygienic condition) hygiene, sanitary and educational work.
Nail mycosis often becomes a rather unpleasant problem. If it is not there, then a person does not think about preventive measures, because few people know that after its appearance, treatment will be quite difficult. The fungus gets under the affected nail plate, multiplying and spreading to neighboring nails and the skin of the foot. Ultimately, this impact leads to complete destruction. To prevent such consequences, timely treatment of toenail fungus is required, which is quite a difficult task.
The causes of mycosis of the toenails are represented by the following factors:
When it gets under the nail, the fungus begins to slowly multiply, but this does not make the force of destruction disappear. The nail plate is gradually destroyed, the fungus is localized throughout the area, after which it radiates to nearby tissues.
Thus, the main reason for the appearance of nail mycosis is violation of hygiene rules and behavior in public places, as well as neglect of one’s own health when using common objects. Even simply trying on shoes without stockings can cause a fungal infection. In addition, the disease appears when wearing tight shoes, a reaction to an allergen, weakened immunity and complications of diseases.
Diagnosis of mycosis of the toenails should be carried out by a mycologist. In some cases, an external examination is sufficient to identify nail fungus. In complex cases, laboratory tests are used to accurately determine the type of mycosis, which helps in prescribing the most effective therapeutic measures.
With a decrease in the functions of general or local immune defense, lack of hygiene and contact with a carrier of infection, the fungus begins to develop. The lesion appears in the interphalangeal areas, which causes itching and redness of the skin. If there is no treatment at this stage, the nails may be damaged, from where it will be more difficult to remove the fungus, since the administration of therapeutic agents becomes more difficult, because the nail plate does not have a blood supply.
Fungal microorganisms gradually damage the nail plate, beginning to grow throughout all nearby tissues. With destructive changes, a change in color begins, the plate crumbles, becomes cloudy, thickening or thinning is observed, and destruction occurs. The disease will not go away on its own, but will only spread to other nails and even internal organs.
Onychomycosis of toenails has the following symptoms:
Treatment of onychomycosis of toenails consists of local and systemic therapy, as well as their joint treatment - combined treatment. Local treatment is used mainly in cases where there are signs of superficial mycosis of the nails and initial distal progression. In addition, local treatment is used if only one nail is affected. In other cases, systemic treatment is more effective.
Modern topical medications against onychomycosis have an effect against the fungus. The most commonly prescribed drug is Loceryl, which has a convenient regimen of use: it is enough to take it once a week. Treatment should be continued until complete recovery.
Systemic treatment includes terbinafine drugs. The most prominent representatives are Lamisil and Exifin in tablet form. Such medications are most effective against dermatophytes. The daily dosage will be prescribed by the doctor, therapy will continue for 6 weeks or more.
You will also need to take itraconazole (Orungal capsule) and fluconazole (Diflucan capsule). Orungal helps with any type of onychomycosis, and Diflucan copes with dermatophytes and Candida yeast fungus.
Orungal is taken as a course of pulse therapy for a week, then a three-week break is taken, after which the treatment must be repeated. It should be noted that in case of mycosis of the nails of the upper extremities, the course must be repeated 1 time, and in case of disease of the legs - at least 2 times.
Therapeutic measures with any medication will depend on the symptoms of the disease, its prevalence, and the degree of hyperkeratosis under the nail. In addition, the age category of the patient is also taken into account. To calculate the duration of treatment, a specialized KIOTOS index is used.
Combination treatment is prescribed in the absence of sufficient effectiveness of systemic therapy or its long duration. Combination treatment with high efficiency is achieved as follows: the drug Diflucan is combined with simultaneous or subsequent use of Loceryl varnish.
Onychomycosis of the feet can be eliminated with medications, but folk remedies should not be neglected. How to treat nail damage using grandma's remedies?
Lavender and olive oil are mixed and applied every evening to the nails and feet, and socks are put on top. Oils must be of high quality; only in this case will they have an antimicrobial effect, relieve irritation and, as a result, cure mycosis.
Apple cider vinegar for mycosis is used in baths for 15 minutes. Lemon juice can be used for the same purpose. Some people add Listerine mouthwash. If you can find Berezhnov's liquid, it can be used for lotions.
Nail fungus, especially on the lower extremities, often appears due to neglect of hygiene rules. However, when the disease appears, you should:
If you neglect such rules, then you will probably only prolong the treatment of the disease for a long period, and even infect others.
It is a proven fact that mycosis appears when the immune system is weakened. The risk group includes patients with diabetes, people with impaired metabolism, excess weight and problems with the thyroid gland and blood flow in the extremities.
Antifungal treatment must be supplemented with proper nutrition, vitamin complexes and, of course, a healthy lifestyle.
Adults are more susceptible to mycosis of the nails than children. In older people, the nail plate grows back slowly, which gives fungal microorganisms more time to multiply. In addition, people with varicose veins and heart failure are at risk of developing the disease. It should be noted that fungus often appears during nail extensions.
Prevention of the disease involves wiping your feet between your toes after each wash, changing your socks daily, and avoiding wearing tight, uncomfortable shoes.
Mycosis of the feet is a fairly common disease that occurs as a result of the penetration of the trichophyton fungus. It has two varieties: trichophyton red and interdigital fungus. Most often, the first type is diagnosed on the feet. Microorganisms can cause pathological processes on the upper layer of the epidermis of the feet and between the toes. Fungus also appears on the heels, resulting in cracking and peeling. Treatment is carried out with antifungal drugs.
The main feature of the disease is frequent relapses. The pathology negatively affects the quality of life of patients and is diagnosed in 20% of the population. Mycosis of the feet and nails is caused by the fungus Trichophyton, which lives on the surface of the skin. Pathological microorganisms are activated under the influence of various external factors. These include:
The infection reaches the surface of the skin when visiting public places where conditions are favorable for the development of the fungus. These could be saunas, showers or swimming pools. Infection also occurs in cases of wearing someone else's shoes, using a towel or washcloth. Failure to maintain foot hygiene, wearing low-quality shoes or dirty socks can intensify the activity of fungus on the feet.
As a result of increased sweating of the feet, microcracks form on the skin, through which pathogenic microorganisms penetrate.
In accordance with the international classification of diseases, mycosis of the feet is also called dermatomycosis or dermatophytosis. Lack of treatment can lead to the spread of the fungus to the nail plate. In medicine, mycosis is divided into the following types:
The disease may not show symptoms for a long time. Patients are most often not bothered by slight peeling on the sides of the feet or between the toes. It is for this reason that people do not seek help from specialists. Mycosis of the legs is diagnosed only in cases where the pathological process spreads to large areas and begins to cause inconvenience.
Depending on the duration of development of the disease, several forms of the fungus are distinguished in medicine. Each of them differs in certain clinical manifestations. These include:
The disease manifests itself after suppression of the immune system as a result of a cold, stress, hypothermia or the influence of negative external factors.
Mycosis of the foot does not show signs for a long time. There may be slight flaking and dryness. This is how the erased form is characterized. This condition lasts from several months to several years.
Mycosis of the skin of the feet is diagnosed based on patient complaints, external signs and laboratory test results to determine the type of fungus. To suppress the activity of pathogenic microorganisms, new generation antifungal drugs are prescribed. They help restore the skin and do not affect liver function.
Lamisil is particularly effective against fungus. The product contains terbinafine, which inhibits the activity of fungi and viruses. This component is also found in many drugs:
The products are available in the form of creams and ointments and are applied to the affected surface. Due to their composition, they form a protective film. It is recommended to use the drugs once or twice a day for up to 4 weeks. Patients may also be prescribed medications such as Travogen, Batrafen, Mycoseptin.
Before applying ointment or cream, the surface of the foot must be cleaned. To do this, do a wrap with salicylic acid or take soap and soda baths.
If vesicular mycosis is diagnosed, the injured areas are treated with iodine, boric acid or brilliant green. This is necessary to prevent pathogenic microorganisms from spreading to the nail plate. Nails are treated with a special medicinal varnish.
Mycosis of the foot in the photo is a dyshidrotic form and requires the use of corticosteroid drugs. These include:
I saw an advertisement for Triderma on TV and purchased it for my husband, since he suffered from mycosis for a long time. The symptoms could only be relieved for a while. After using the product, the fungus on the foot completely disappeared.
In cases of severe disease, antimycotic drugs may be prescribed. They are available in tablets or capsules. The most effective are Irunin, Sandoz, Terbinafine. The drugs should be used only as prescribed by the attending physician, since they all have a number of side effects and negatively affect the functioning of the liver. How and with what to treat the disease, only a doctor will tell you after an examination.
When diagnosing mycosis of the feet, traditional medicine recipes must be used in combination with medications. The most popular remedy when fungal diseases develop is foot baths. You can add various components to a basin of warm water:
The skin on my toes began to peel, itch, and itch. The doctor diagnosed it as mycosis. I made foot baths with celandine. After two days I already noticed an improvement.
Traditional medicine also recommends wiping the phalanges of the fingers with iodine and table vinegar every day. This remedy is alternated every two weeks. Treatment is carried out until a positive result appears.
Before going to bed, it is recommended to wash your feet with soap and dry them thoroughly, especially the area between the toes.
When using traditional medicine, it is important to take into account that a positive result is achieved only if all recommendations are followed, the proportions and duration of treatment are observed. Before using prescriptions, you should consult your doctor.
Symptoms and treatment for athlete's foot depend on the type of infection. That is why many different medications are used, and traditional medicine recipes do not always have a positive effect. Mycosis of the legs can be completely cured only with the help of an integrated approach to treatment. Traditional methods of treatment should be used together with medications.
Mycosis of the feet, like any disease, is easier to prevent than to carry out a course of therapy. To avoid the development of the disease, you should follow a number of simple rules:
Mycosis of the feet is a fairly common disease. The cause of development is pathogenic microorganisms that get onto the surface of the skin as a result of using someone else's washcloths, towels or wearing shoes. They enter the body through microcracks and wounds. Treatment of athlete's foot is complicated by the fact that in the early stages it does not show symptoms, and many patients do not notice minor peeling or redness. Lack of treatment for mycosis can cause itching, burning and other unpleasant sensations. That is why, when the first signs appear, you need to consult a doctor.