Can a purple foot soak cure my fungal nails?

Every week Dr Martin Scurr, a top GP, answers your questions

I HAVE a fungal nail infection and have been told it will take a threemonth course of pills to cure it, but there is a chance these could cause liver or kidney damage. I had the same treatment previously, but the fungus returned. As a stop-gap I have been soaking my feet in potassium permanganate. It does not cure it, but seems to hold it back. Is it worth trying the pills again? B. Jones, Colchester, Essex.

ThE technical term for fungal infections of the nails is onychomycosis. Typically, it affects the toenails, especially the big toe, and many patients will have athlete’s foot as well.

The infection can be caused by different types of fungus, and risk factors include swimming, and older age, diabetes and other factors that affect immunity. Living with someone who has the condition is another risk factor.

For patients, the main concern is cosmetic — the infection can make the nails thicken, with a yellowish or brownish appearance — but the nails can also become uncomfortable, even painful.

But a definitive diagnosis cannot be made just by appearance alone, as the skin condition psoriasis can also cause nails to change in this way, as can recurrent trauma to the nails — as seen in regular runners whose big toenail frequently strikes the end of their shoes.

A lab test on a fragment of the affected nail can help confirm the diagnosis, but a negative result does not mean there is no fungus. But if diagnosis is not simple, then neither is the treatment, which is not always effective.

Doctors may be reluctant to prescribe an oral antifungal drug (the most common is terbinafine) for a condition that does not threaten health or life, given such drugs are potentially toxic, particularly to the liver (though not the kidneys).

An initial course consists of one tablet a day f or three months. Even this is only 70 per cent effective and the improvements may occur slowly, sometimes over a year. One study f ound only 60 per cent of patients who took a four-month course of treatment were cured when examined at 72 weeks — hardly encouraging.

There are topical antifungal treatments, such as a lacquer

WHEN containing the drug amorolfine.

applied once or twice weekly for six months, there may be a 40 per cent cure rate, which is similar to the other available product, tioconazole nail solution, which is applied twice daily for six to 12 months. These preparations, which are prescription-only, don’t have the same risk of side-effects as the oral antifungal drugs.

There are two other possible treatments. The first is surgical removal of an affected nail, but recurrences are common.

The second is laser treatment, which is expensive and not available on the nhS. There is also limited published research on it.

Your strategy of potassium permanganate foot soaks interests me, though this highly caustic chemical can be harmful to tissue at too great a concentration.

When I was first practising, I routinely treated athlete’s foot with a one in 10,000 concentration of this as a 20-minute soak every night for two weeks. Back then the local chemist was happy to supply a concentrated solution for dilution in a footbath without a prescription (small packs are still available at some chemists).

For athlete’s foot it is highly effective, but we eventually gained effective antifungal creams and the process went out of fashion.

Whether this treatment — which stains the skin brown — will help with fungal nail infections is uncertain, though I would suggest it’s worth continuing for a longer period of regular soaks.

It is safer for you than opting for oral treatment again. FOR six years I have been getting more frequent chest infections, where my chest feels as if a band is being tightened, painfully, around it, with pain in my lower back. I have had my heart checked — it’s fine — as well as chest X-rays and CT and MRI scans. These found bilateral basal bronchiectasis, widened airways, rather than COPD, which had been suspected.

I have been discharged by the chest and pain clinic, who said bronchiectasis shouldn’t cause this level of pain. Now my chest tightens more frequently, such as after too much gardening. The ache starts mildly, but becomes more severe.

Name and address withheld. ThIS is a strange story, and I am far from convinced you have found a diagnosis that explains your chest pain. It is not usual for chest infections, or bronchiectasis, to present with this pattern of pain.

But first, a recap on bron- chiectasis and COPD, chronic obstructive pulmonary disease. Bronchiectasis is where the larger bronchi, the tubes along which air travels to reach the alveoli (the air sacs of the lungs) become widened. The condition is caused by chronic infection and inflammation. Symptoms include a cough that brings up purulent mucus. Some patients may have fever and breathlessness.

It is not uncommon to be diagnosed with areas of bronchiectasis — which has been present, silently — when having scans for a chest infection. Pain is not a common symptom.

CHRONIC obstructive pulmonary disease is where the airways become narrow, due to inflammatory responses to pollutants such as cigarette smoke. Over the years, symptoms such as a cough that produces mucus and breathlessness develop. Again, pain is not usually a symptom.

Your main complaint is a bandlike chest pain, worsened by physical activity. You have not described a fever, cough, sputum production or breathlessness, and I find it hard to accept those episodes of pain are related to bilateral basal bronchiectasis.

Your heart has been exonerated, the pain is not angina as it is not triggered by exertion and relieved by rest. rather, I suggest this is a pain of spinal origin, with some form of nerve entrapment.

I believe you should be reinvestigated by a spinal surgeon or pain clinic specialist. Discuss this with your GP as referral is essential.