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Treatment of Nail Fungi Using Herbal Extracts / Dr. Amir Kitron

Background

Nail fungi (Onychomycosis) is a localised infection of the nail or nail bed caused by a pathogenic fungi. It is not life threatening, but may cause pain and discomfort. It is also a source for infection. (Mooney, 1993). In a study in the UK, the incidence of nail fungi increased with age. In the group aged 16-34 years, the prevalence rate was 1.3%. This increased to 2.4% in the grouped aged 35-50, and 4.7% in those aged 55 years and over (Mooney, 1993). Toenail infection is 6.8 times more common than fingernail infection (Mooney, 1993).Nail fungi can be divided into four different types as follows:– Distal and Lateral Nail Fungi, which is the most common. The usual clinical features are thickening and opacification of the nail plate along the distal or lateral borders. The discoloration ranges from white to brown. White patches may form following the development of air spaces within the nail plate. The edge of the area of affected nail is usually irregular. Subungual haemorrhages may also occur. In chronic cases the free edge of the nail may become severely eroded with partial or total loss of nail plate. (Hay, 1986).– Proximal Subungual Nail Fungi, which is not common. A white spot appears beneath the proximal nail fold and may extend distally to involve the deeper layers of the whole nail (Haneke, 1990). This condition is sometime accompanied by slight discomfort (Hay & Baran, 1984).– Superficial White Nail Fungi is also uncommon. The surface is the initial site of invasion. The causative organism produces small superficial white and powdery patches over the nail (Hay, 1986). The surface becomes roughened and the texture softer than normal. The affected nail plate disintegrates easily.– Total Dystrophic Nail Fungi represents the most advanced form of all the previous three types, especially the Distal and Lateral Nail Fungi. The nail matrix becomes permanently scarred by chronic infection. The nail is thickened, elevated, and more dense or opaque (Robbins, 1994). Preventive MeasuresFailure to maintain a good standard of foot hygiene, exposure of feet to floors in communal areas (showers, swimming pools), and failure to dry feet thoroughly are all factors which may increase risk of Nail Fungi. The risk rises with age.  Athlete’s Foot may sometimes deteriorate to Nail Fungi.Causing OrganismsThe micro-organisms which cause Nail Fungi include:-Dermatophytes: Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton interdigitale and Epidermophyton floccosum (Haneke, 1990).-Yeast: Candida albicans.  This occurs more often in the fingernails (Hay & Baran, 1984).-Mould: Scopulariopsis brevicaulis.  It is very rare (Hay & Baran, 1984).Diagnosis– Direct Microscopy, where the diagnosis of Nail Fungi due to dermatophytes can be confirmed by soaking full-thickness nail clippings in 20% potassium hydroxide. After between 15 and 90 minutes, the nail become soft and can be placed beneath a cover slip. The clear nail is examined microscopically. Dermatophyte hyphae should be easily visible ( Meisel, 1990).– Culture, where the micro-organisms are cultured.Differential Diagnosis.-Psoriasis affecting the nail, which may clinically be indistinguishable from Nail Fungi. However, Nail Fungi very rarely involves all ten toenails. Psoriatic nails are likely to be accompanied by psoriasis elsewhere (Rotstein, 1993).-Dermatitis involving the proximal nailfold may produce nail dystrophy, but the nails are friable and retain a normal lustre (Rotstein, 1993).-Paronychia (inflammation of the nail folds) may cause discoloration and dystrophy of the nail, but the primary change is in the nail fold (Rotstein, 1993).-Onychogryphosis, onychauxis, subungual hyperkeratosis, leuconychia (Neale & Adams, 1989)Current Pharmaceutical Treatments :To stop the growth, and perhaps ultimately eradicate a fungal infection of the nail requires continuing treatment over many (3-18) months.  In many forms of treatment plans, to maximise the full potential of the drug, the affected nail should be thinned as much as possible (Neale & Adams, 1989).  Existing topical treatments include:Daktarin (myconazole nitrate). It targets T rubrum, T mentagrophytes and yeast.Canesten, contains clotrimazole. Effective against T rubrum, T mentagrophytes and candida infections.Betadine (10% povidine iodine, effective against most fungi). 82% cure rate onsuperficial white Nailfungi study (Foxall & Richards, 1993).Egostatin (1% econazole nitrate, effective against dermatophytes, yeasts and moulds).The Ciclopirox nail lacquer was recently found to be effective for 86% of patients, and required 6 months of treatment (Seebacher et al, 2001).Existing oral treatments include:Systemic fungal treatment with griseofulvin (which had to be used for prolong period of time and reoccurrence was common) : this has been disappointing to date with side-effects such nausea, headache, photosensitivity and gastrointestinal intolerance, which has cause the patient to discontinue treatment after a short time (Rotstein, 1989). In a recent study (Arca et al, 2002), the efficiency of the most commonly prescribed systemic drugs for nail-fungi was compared.  The treatment was given for three months, then a follow-up check was made after 3 more months.  The cure rates found after the 6 months period were:  Itraconazole: 77.8%, Terabinafine (Lamisil): 81.3%, Fluconazole: 37.5%.  There were side effects among 25% of the patients.  Although the side effects were not severe, they included gastrointestinal disorders and central nervous system symptoms. Drawbacks of the above pharmaceutical treatments: The usage of synthetic anti-biotic and anti-fungal materials often requires monitoring of liver function, as it might be affected by the high levels of such materials used in the treatment.  Patients frequently give up treatment of Nail Fungi due to this risk.As described above, other side effects may include gastrointestinal disorders and central nervous system symptoms. The Proposed Herbal AlternativeWe have found that the topical use of a mixture of oils, including essential oils from various plants as described below, and using special plant species grown in specific Judean Desert climates, provides an effective solution.  The mixture is capable of penetrating the nail surface, and is capable of eliminating the fungi.  Such a mixture has the advantage of a combined activity of various compounds, rather than relying on a single molecule as in synthetic drugs.  The mixture has been tested both in vitro and on hundreds of volunteers, and was found to be highly effective. The Plant Thymus vulgaris and related species of the Judean DesertThe plant Thymus vulgaris is known for its anti-bacterial (Beuchat, 1976)  and anti-fungal (Herrmann & Kucera, 1967; Panizzli et al, 1993; El-Kady et al, 1993) activity.  The essential oil obtained from this plant is rich in Thymol, which possesses a strong anti-bacterial, anti-fungal and anti-inflammatory activity.  Also for inflammations surrounding the nail, Thymol provides an effective treatment.Other species related to it are grown in the Judean Desert and are rich in Thymol, Carvacrol and hundreds of other components possessing anti-fungal activity.  These include: Coridothymus capitatus, Thymbra spicata, Origamum syriacum.  Under Judean desert conditions, the levels of  various such components are particularly high, due to absenceof hydrolysis by rain, and the coolness during the night.The Plant Origanum vulgareThe plant Origanum vulgare is also known for its anti-bacterial and anti-fungal activity.  It was found effective against fungi of the  type Trichophyton rubrum (Adam et al, 1998).    The latter fungi has been found in one study to be responsible for 82% of nail fungi cases and to 45% of athlete’s foot cases (Perea et al, 2000).   This plant’s essential oil contains Thymol and also Caryophyllene oxide (Atsherypoor et al, 1997),  which also possesses an anti-fungal activity (Yang et al, 2000). The Plant Cinnamonum zeylanicumThe plant Cinnamonum zeylanicum also possesses an anti-fungal and anti-bacterial activity   (El-Kady et al, 1993).  Its essential oil contains 10% Caryophyllene oxide, which as described above possesses an anti-fungal activity.    The Usage of the Herbal Mixture:The oils mixture should be applied on the nail surface twice daily for ten days, then once daily for 10 more days.  Since some patients are sensitive to Thyme oil, the skin surrounding the treated nail should be protected with Vaseline , prior to each treatment.  Following a recess of two weeks, the above treatment cycle should be repeated.  The recess is intended to avoid the development of resistance by the fungi.In some cases, particularly if the fungal problem is not older than 2 years, two cycles may suffice to cure the nail.  In other cases, more cycles may be necessary.  Signs of progress during treatment include: coloration of the nail (the white powder created by the fungi becomes darker when the fungi begin to die); smoother nail growth in the proximal nail area.Side Effects: It must be emphasized that contact with the skin must be avoided.  If the skin shows some reddening, the treatment should be discontinued; otherwise, blisters may appear. In cases where the skin around the nail is affected by fungi, the skin should be treated for a week before starting the nail treatment.    ReferencesAdam, K., Sivropoulou, A., Kokkhini, S., Lanaras, T. & Arsenakis, M. (1998)  Antifungal activities of Origanum vulgare subsp. Hirtum, Mentha spicata, Lavandula angustifolia, and Salvia fruticosa essential oils against human pathogenic fungi.  Journal of Agriculture & Food Chemistry, 46 (5), 1739-1745. Arca, E. et al, “An open, randomized, comparative study of oral Fluconazole, Itraconazole, and Terabinafine therapy in onychomycosis,” J. Dermaolgical Treatment, 2002, 13(1), 3-95.Atsherypoor, S., Sajjadi, S. E., Erfan, M. M.  (1997)  Volatile constituents of Origanum vulgare from Iran.  Planta Medica, 63 (2), 179-180.Beuchat, L. R. (1976)  J.  Food Sci., 41, 899-902.El-Kady, I.A., El-Maraghy, S.S.M. & Mostafa, M.E.  (1993)  Antimicrobial and antidermatophytic activities of some essential oils from spices.  Qatar University Science Journal, 13 (1), 63-69.Haneke, E. (1990). Epidermiology and Pathology of Onychomycoses. In S. Nolting & H.C. Korting, Onychomycoses. Heidelberg: Springer-Verlag.Hay, R.J., Baran, R. (1984). Fungal (Onychomycosis) and Other Infections of the Nail Apparatus. In R. Baran & R.P.R. Dawber, Diseases of the Nails and their Management. Oxford: Blackwell Scientific Publishing.Hay, R.J. (1986). Infections affecting the Nails. In P.D. Samman & D.A. Fenton, The Nails in Disease. London: William Heinemann Medical Books.Herrmann, E.C. & Kucera, L. S. (1967)  Proc. Soc. Exp. Biol. Med., 124, 874-878.Mooney, J. (1993). A review of current treatments for toenail mycoses. Journal British Podiatric Medicine, pp 5-6.Neale, D., Adams, I.M. (1989). Common Foot Disorders (3rd ed.). Edinburgh: Churchill Livingstone.Panizzli, L., Flamini, G., Ciomi, P. L. & Morelli, I.  (1993)  Composition and antimicrobial properties of essential oils of four Mediterranean Lamiaceae.  Journal of Ethnopharmacology, 39 (3), 167-170.Perea, S., Ramos, M. J.  (2000)  Prevalence and risk factors of tinea unguium and tinea pedis in the general population in Spain.  Journal of Clinical Microbiology, 38 (9), 3226-3230.Robbins, J.M. (1994). Primary Podiatric Medicine. Philadelphia: W.B. Saunders.Rotstein, H. (1993). Principles and Practice of Dermatology (3rd ed.). London: Gower Medical Publishing.Seebacher, C. et al, “A multi-center, open-label study of the efficiency & safety of ciclopirox nail lacquer solution 8% for the treatment of onychomycosis in patients with diabetes,” Cutis 2001, Aug, 68(2), 17-22.Yang, D., Michel, L., Chaumont, J. P. & Millet, C. J.  (2000)  Mycopathologia, 148 (2), 79-82. 


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