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Fungal infection of the toenails or fingernails= is caused by a fungal microbe that invades the nail bed. Fungal nail infec= tion is also termed onychomycosis and tinea unguium. Fungal nail infection = causes fingernails or toenails to thicken, discolor, disfigure, and split. = At first, onychomycosis appears to be only a cosmetic concern. Without trea= tment, however, the toenails can become so thick that they press against th= e inside of the shoes, causing pressure, irritation, and pain. Fingernail i= nfection may cause psychological, social, or employment-related problems. H= alf of all nail disorders are caused by onychomycosis, and it is the most c= ommon nail disease in adults. Toenails are much more likely to be infected = than fingernails. The incidence of onychomycosis has been increasing and is= associated with diabetes, a suppressed immune system, and increasing age. = Adults, especially the elderly, are more likely to have onychomycosis than = children. Fungal nail infection is divided into subtypes. The main subtypes= of onychomycosis are as follows: Distal lateral subungual (the area under = the nail) onychomycosis (DLSO or DSO) White superficial onychomycosis (WSO)= Proximal subungual onychomycosis (PSO) Endonyx onychomycosis (EO)Candidal = onychomycosis

People with fungal nail infection may have a combinati= on of these subtypes. Total dystrophic onychomycosis is the term used to re= fer to the most advanced form of any subtype To have a better understanding= of how fungal nail infection affects the nail, a general knowledge of the = anatomy of the nail is helpful (see Figure 1). The nail, or nail unit, cons= ists of the following parts The nail matrix (where the nail starts) is wher= e nail cells multiply and keratinize (harden and form into nail material) b= efore being incorporated into the fingernail or toenail. Most of the matrix= is not visible. The matrix starts under the skin 5 mm below the nail fold = (the area of the cuticle where the finger or toe skin meets the nail) and c= overs the area called the lunula, or half moon (the white half moon-shaped = area at the bottom of the nail). The cuticle is a fold of modified skin whe= re the finger or toe meets the nail. The cuticle protects the matrix from i= nfection. The nail plate is the nail itself. The nail bed is the soft tissu= e underneath the nail, anchoring the nail plate. The nail plate protects th= e nail bed. Fungal nail infection is divided into clinical subtypes based o= n the cause and progress of the infection.

Distal lateral subungual = onychomycosis (DLSO) is the most common form of fungal nail infection. In D= LSO, the fungus generally spreads from the skin and invades the underside o= f the nail where the nail meets the nail bed. Inflammation in these areas o= f the nail causes the symptoms of DLSO. White superficial onychomycosis (WS= O) is a rare infection caused by the fungi directly invading the surface of= the nail plate and secondarily infecting the nail bed. In proximal subungu= al onychomycosis (PSO), the least common subtype, the fungi invade the cuti= cle (the skin around the nail) and the nail fold and then penetrate the nai= l plate (fingernail or toenail). Like DLSO, in endonyx onychomycosis (EO), = the fungi reach the nail via the skin. Instead of infecting the nail bed, h= owever, the fungi immediately invade the nail plate. Fungal nail infection = related to yeast (Candida) infection is a little different from fungal nail= infection related to other fungal infections. Candidal fungal nail infecti= on has several characteristics: Onycholysis describes the nail separating f= rom the nail bed. Chronic mucocutaneous disease (disease of mucous membrane= and regular skin) involves the nail plate (fingernail or toenail) and even= tually the nail fold (the skin fold behind the cuticle, where the nail meet= s the finger or toe). Total dystrophic onychomycosis is not a distinct subt= ype of fungal nail infection. Dystrophic onychomycosis is the term used to = describe the most advanced form of any of the above subtypes, and it involv= es the entire nail unit. Dystrophic onychomycosis may cause permanent scarr= ing of the nail matrix.

Fungal nail infection is caused by three mai= n classes of organisms: fungi that infect hair, skin, and nails and feed on= nail tissue (dermatophytes), yeasts, and non-dermatophyte molds. All three= classes cause the very similar early and chronic symptoms or appearances, = so the visual appearance of the infection may not reveal which class is res= ponsible for the infection. Dermatophytes (including Epidermophyton, Micros= porum, and Trichophyton species) are, by far, the most common causes of fun= gal nail infection worldwide. Yeasts cause 8 of infections, and non-dermato= phyte molds cause 2 of fungal nail infections. The dermatophyte Trichophyto= n rubrum is the most common fungus causing distal lateral subungual onychom= ycosis (DLSO) and proximal subungual onychomycosis (PSO). The dermatophyte = Trichophyton mentagrophytes commonly causes white superficial onychomycosis= (WSO), and more rarely, WSO can be caused by species of non-dermatophyte m= olds. The yeast Candida albicans is the most common cause of chronic mucocu= taneous candidiasis (disease of mucous membrane and regular skin) of the na= il. What Are Fungal Nail Infection Risk Factors? Risk factors for fungal na= il infection include family history, advancing age, poor health, trauma, li= ving in a warm climate, participation in fitness activities, immunosuppress= ion (can occur from HIV or certain drugs), bathing in communal showers (suc= h as at a gym), and wearing shoes that cover the toes completely and don't = let in any airflow. Fungal nail infections, especially toenail infections, = can be contagious person to person from direct and indirect contact with an= infected person or their clothing, such as wearing an infected person's sh= oes or socks. The incubation period for a fungal nail infection is about th= ree to six days.

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