What you need to know about fungal infections Some fungi occur naturally in the body, and they can be helpful or harmful. An infection occurs when an invasive fungus becomes too much for the immune system to handle. We describe the most common types, including yeast infection, jock itch, and ringworm. Here, learn about risk factors and the range of treatments. Read now
White superficial onychomycosis (WSO) is caused by fungal invasion of the superficial layers of the nail plate to form "white islands" on the plate. It accounts for around 10 percent of onychomycosis cases. In some cases, WSO is a misdiagnosis of "keratin granulations" which are not a fungus, but a reaction to nail polish that can cause the nails to have a chalky white appearance. A laboratory test should be performed to confirm.[15]
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In some cases of suspected nail fungus there is actually no fungal infection, but only nail deformity. A 2003 source gives a figure of 50%[17] whereas a more recent source claims that fungus is present in 65 to 95 percent of cases.[18] Avoiding use of oral antifungal therapy (e.g. terbinafine) in persons without a confirmed infection is a particular concern because of the possible side effects of that treatment.[17] However, according to a 2015 study, the cost in the United States of testing with the periodic acid–Schiff stain (PAS) was about $148. Even if the cheaper KOH test is used first and the PAS test is used only if the KOH test is negative, there is a good chance that the PAS will be done (because of either a true or a false negative with the KOH test). But the terbinafine treatment only cost $10 (plus an additional $43 for liver function tests). In conclusion the authors say that terbinafine has a relatively benign adverse effect profile, with liver damage very rare, so it makes more sense cost-wise for the dermatologist to prescribe the treatment without doing the PAS test. (Another option would be to prescribe the treatment only if the potassium hydroxide test is positive, but it gives a false negative in about 20% of cases of fungal infection.) On the other hand, as of 2015 the price of topical (non-oral) treatment with efinaconazole was $2307 per nail, so testing is recommended before prescribing it.[18]

Dermatophytes — fungus that grows on the skin, hair and nails but don’t penetrate tissues of the body. Athlete’s foot or Trichophyton rubrum is the most common dermatophyte and can actually infect the toenails. Infection can also begin by touching objects that have dermatophytes on them, such as nail clippers, nail files, socks, shoes, shower floors, etc. Dermatophytes are the cause of most fungal toenail infections.
If you have diabetes or a weakened immune system, treatment is especially important. After getting a fungal nail infection, people who have diabetes have an increased risk of developing sores that do not heal. Sores that do not heal can lead to a serious health problem. It’s important to see a dermatologist (or other doctor) at the first sign of a nail problem. A dermatologist can tell you whether you have a nail infection or something else.
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