Persistent Nail Bed Fungal Infection: Treatment Challenges and Solutions

The fungal infection near the fingertips close to the nails has not improved even after more than two months of continuous treatment?

Symptoms and Treatment Process: The right side of the tip of the left thumb initially developed many small blisters (which do not easily burst, and the skin thickens).
Then, the right front began to peel, and the nail bed started to separate.
After applying clotrimazole, betamethasone, and gentamicin ointment (twice a day) for about a month, the medication was stopped.
A week after stopping the medication, the same symptoms recurred.
At first, I didn't pay much attention, but then the left front of the left thumb developed the same condition, leading to the separation of the entire nail bed (the transparent membrane at the front edge of the nail disappeared and continued to recede, causing the skin underneath the nail to darken before the blisters began to form irregularly from the outside in).
The color of the nail remained normal, similar to the other hand.
At this point, I started applying clotrimazole and urea ointment (twice a day) along with another butenafine ointment (also twice a day) because I was concerned that stopping the previous medication too early might lead to drug resistance.
I used both ointments every 4-6 hours apart, as new blisters continued to emerge from the edges of the treated area, causing the treatment area to expand.
To prevent the spread of the fungus, I enlarged the area of application (covering the entire finger) and tried to keep the skin in contact with the medication.
I reapplied the ointment whenever it was accidentally wiped off (sometimes I would experience itching if I didn't reapply).
By the second month of treatment, the right side of the right thumb developed blisters similar to those on the left thumb, and the corners of the left and right front of the right thumb nail bed began to separate (the skin color underneath the nail bed did not darken before separation).
Therefore, I started applying medication to the right thumb as well, but the area of application was not as extensive as on the left hand.
Currently, in the third month of treatment, although the blistering has not recurred (observed for two weeks), the transparent thin membrane at the front edge of the left thumb nail has regrown (except for the darkened skin at the right front corner).
I feel it is not completely healed, so I am hesitant to stop the medication.
However, due to severe skin peeling causing wounds and wrinkling, I have reduced the application area to only the front edge of the nail and stopped using the clotrimazole and urea ointment, now only applying butenafine ointment (twice a day).
On the fifth day of changing the application method, the right front of the left thumb began to thicken, and the skin color under the nail darkened and expanded to the left, suggesting that the nail bed separation was starting to recede irregularly.
The thick-walled blisters on the right side of the right thumb began to reappear, so I resumed using clotrimazole ointment (this time without urea) and expanded the area of application, and I am currently still observing the situation.
In my daily environment, except for bathing, my thumb rarely comes into contact with water.
I do not have athlete's foot or dandruff, and I clean and disinfect my nail clippers before each use.
I live with family, and I am the only one infected.
I would like to ask: 1.
How long will this treatment take to fully heal? After two months of treatment with improvement, why did it recur when I reduced the medication? 2.
What ingredients or reasons cause the skin to keep peeling? How can I treat it if it recurs without medication, and if medication causes the skin to wrinkle and peel? 3.
Is there a therapeutic effect from applying medication around the tight spaces between the nail and skin, even though I trim my nails and try to push the medication in as much as possible? Why does the right upper corner of my left hand seem to not improve? What is the best way to apply the treatment? 4.
Do I need to switch to ointments with different ingredients, or should I continue with the same treatment? 5.
The transparent thin membrane at the front edge of the left thumb nail has regrown, but the nail has become shorter.
How can I promote the nail bed to reattach and grow back to its original length?

Xiao Mei, 30~39 year old female. Ask Date: 2022/11/24

Dr. Wu Yuxin reply Dermatology

You should consider seeking medical attention or consulting the physician who prescribed your medication.
I cannot provide an answer without seeing your nails.

Reply Date: 2022/11/24

More Info

Persistent nail bed fungal infections can be quite challenging to treat, and your experience reflects the complexities often involved in managing such conditions. Let’s address your questions systematically, while also providing some insights into the nature of fungal infections and their treatment.

1. Duration of Treatment: Fungal infections, particularly those affecting the nail bed, can take a significant amount of time to resolve completely. The duration of treatment can vary widely depending on the severity of the infection, the specific fungus involved, and individual patient factors such as immune status and adherence to treatment. It is not uncommon for treatment to last several months, and even after visible improvement, it may be necessary to continue treatment to prevent recurrence. The fact that you experienced a resurgence of symptoms after reducing medication suggests that the fungal infection may not have been fully eradicated. It is crucial to follow the treatment plan as prescribed and consult your healthcare provider before making any changes.

2. Skin Peeling and Recurrence: The peeling of the skin you are experiencing could be due to several factors, including the irritation from the topical medications, the underlying fungal infection itself, or a combination of both. Fungal infections can cause inflammation, leading to skin changes such as peeling and thickening. If the skin is becoming too irritated or if you are experiencing excessive dryness, it may be beneficial to incorporate a gentle moisturizer to help alleviate these symptoms. However, be cautious to avoid applying it directly on the infected areas immediately after medication application, as this could dilute the effectiveness of the antifungal treatment.

3. Effectiveness of Application: When treating nail bed infections, it is essential to ensure that the antifungal medication penetrates adequately into the affected area. Applying the medication around the nail and into the cuticle area is important, as fungal infections can reside in these tight spaces. You may want to consider using a cotton swab or a small brush to apply the medication more precisely. Additionally, keeping the nails trimmed and clean can help facilitate better penetration of the medication.

4. Medication Considerations: If you find that the current treatment regimen is not yielding satisfactory results, it may be worth discussing alternative antifungal agents with your healthcare provider. There are various classes of antifungal medications, and sometimes a switch in medication can be beneficial if resistance is suspected or if the infection is not responding to the current treatment. Your healthcare provider may also consider a culture to identify the specific fungus involved, which can guide more targeted therapy.

5. Nail Growth and Recovery: The regrowth of the nail and the restoration of the nail bed can take time, especially if the nail has been significantly affected. Maintaining good nail hygiene, avoiding trauma to the nail, and continuing with the antifungal treatment as prescribed are key steps. If the nail is growing back but remains short or irregular, patience is essential, as nails grow slowly. In some cases, a dermatologist may recommend additional treatments or procedures to promote healthy nail growth.

In summary, managing a persistent nail bed fungal infection requires a comprehensive approach that includes consistent medication use, proper nail care, and possibly adjustments to treatment based on your response. It is advisable to maintain open communication with your healthcare provider, especially if you notice any changes in your symptoms or if you have concerns about your treatment plan. Regular follow-ups can help ensure that the infection is being adequately addressed and that any necessary modifications to your treatment can be made in a timely manner.

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