Sophia Delgado
If you think you have a fungal nail infection, it is important to get it diagnosed and treated as it can spread if left untreated. The traditional method of testing nail samples involves sending clippings to a laboratory to test for the presence of fungi, which can take up to 3 to 6 weeks. However, new in-clinic tests, such as the Five Minute Fungal Nail Test, can deliver results within minutes and are highly accurate. These tests work by adding a nail sample to a solution that reacts with a chemical found in the type of infection that causes most fungal nail infections.
| Characteristics | Values |
|---|---|
| Test type | Fungal nail test |
| Sample collection | Nail clippings, nail scraping, nail biopsy |
| Sample preparation | No preparation needed, but abstain from antifungal medication for at least 2 weeks |
| Test methods | Microscopy, fungal culture, staining, sensitivity testing, 5-minute fungus test, immune-chromotography |
| Accuracy | 97% for 5-minute fungus test, 46%-54% for standard laboratory test, 67% for visual diagnosis by experts |
| Results time | 5 minutes for 5-minute fungus test, up to 3-6 weeks for standard laboratory test |
| Cost | £40 for the 5-minute fungus test, free for standard NHS laboratory test |
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What You'll Learn
The 5-minute test
The test works by identifying various dermatophyte types that commonly cause fungal nail infections. It is unaffected by anti-fungal treatments within nail samples, which is a problem with standard NHS testing. Only a small nail sample is required, and the test uses a process called immune-chromatography, similar to that used in a pregnancy test. When the infected nail sample is added to the solution, a chemical is released and picked up by the test. A pink line appears on the test strip to confirm that the test has worked, and a purple-brown line below it confirms the presence of fungus in the nail.
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Microscopy and staining
Microscopy Techniques
Microscopy techniques are used to visualise the microscopic features of nail clippings or specimens retrieved from the nail bed and underneath the nail plate. Direct microscopy, for example, involves examining nail fragments under low power. To obtain a suitable specimen, nails must be clipped and cleansed with an alcohol swab to remove bacteria and debris. Large pieces of the nail plate may need to be pulverised using a hammer or nail micronizer. In distal lateral subungual onychomycosis (DLSO), a specimen is obtained from the nail bed by curettage, and the sample is taken from a site most proximal to the cuticle, where the concentration of hyphae is greatest. Counterstains such as chlorazol black E or Parker blue-black ink can be used to accentuate the hyphae.
Staining Techniques
Staining techniques are often used in conjunction with microscopy to highlight the presence of fungi. The most commonly used stain is Periodic Acid-Schiff (PAS) stain, which is highly sensitive and rapid, providing results within approximately 14 days. Other stains that can be used include KOH, GMS, Calcofluor White, Evans Blue, Gram, Giemsa, and India ink. KOH testing, for example, involves dissolving the specimen in KOH to visualise the fungal septate hyphae. This technique is cost-effective and can determine the presence of fungal organisms within an hour, but it cannot specify the exact type of pathogenic organism.
Comparison of Techniques
Although fungal culture is considered the gold standard for evaluating nails for fungal organisms, it has several drawbacks, including delays in retrieving results (several weeks to months), high costs, and the need for a large sample size. In comparison, PAS staining with histopathology is faster, easier, less expensive, and more sensitive, detecting infections that were false negatives by culture. However, fungal culture can provide additional information on the type of fungal infection, which may be desired by the physician.
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Sensitivity testing
A fungal nail infection can cause nails to become discoloured, thick, fragile, or cracked. The nail may also become separated from the nail bed. Testing for a fungal nail infection typically involves taking a nail clipping or scraping and sending it to a laboratory for analysis. The traditional approach to testing for fungal nail infections involves sending nail clippings to a laboratory, which can take up to 4 to 6 weeks for results.
However, there are now more rapid and sensitive tests available, such as the Five Minute Fungal Nail Test, which offers 97% accuracy and delivers results within 5 minutes. This test is based on immune-chromatography, the same process used in pregnancy tests. It detects the presence of a chemical found in the dermatophyte infection that causes most fungal nail infections.
Another option is the ReliaHealth 3-in-1 Nail Fungus & Bacteria At-Home Test Kit, which provides results in 1-2 business days. This test detects more than 5 times more fungal organisms than other conventional tests and delivers 98% accurate and sensitive results. It also looks for bacteria, which is important since about 50% of nail infections are bacterial rather than fungal.
If you are experiencing symptoms of a fungal nail infection, your clinician may recommend a Fungal Culture and Sensitivity Test. This test helps to identify the presence of a fungal infection and determine its sensitivity to specific antifungal medications. The sensitivity part of the test involves exposing the identified fungus to different antifungal drugs to see which are most effective in inhibiting its growth. This test typically provides results within 7 working days.
Overall, there are now several rapid and sensitive options available for testing for fungal nail infections, offering improved accuracy and faster results compared to traditional laboratory methods.
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False negatives
Insufficient nail sample: Sometimes, the amount of nail sample sent for testing may not be sufficient to detect the fungus. This can happen when the doctor does not cut enough of the nail, or the nail sample does not contain a significant amount of fungus on the surface or ingrained in the nail.
Use of antifungal treatments: If an individual has been using antifungal creams, paints, or ointments before the test, these treatments may have killed the surface fungus or fresh fungal spores but not the entrenched fungus. As a result, the test may not detect the underlying fungal problem and return a false-negative result.
Storage and transportation of the sample: The storage and transportation conditions of the nail sample can also impact the accuracy of the test. For example, if the sample is placed in a plastic container and left in the sun or exposed to extreme temperatures during transportation, it can affect the viability of the fungus, leading to a false-negative result.
Visual misdiagnosis: Even experts, such as dermatologists and podiatrists, can have a relatively low accuracy rate when diagnosing fungal nail infections based solely on visual inspection. Studies have shown that visual diagnosis by experts can have an accuracy of around 67%, meaning they can misdiagnose one in three cases.
Type of fungal assay: The type of assay used for testing can also impact the accuracy of the results. For example, pan-fungal assays have shown a low sensitivity of 47% relative to culture methods due to the presence of multiple fungal species within both diseased and healthy nails.
To minimize the chances of false negatives, it is recommended to use a combination of clinical examination and mycological testing, such as fungal culture or molecular assays, for an accurate diagnosis. Additionally, new diagnostic tools like dermoscopy, reflectance confocal microscopy, and artificial intelligence can improve the detection of fungal nail infections.
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Treatment options
Over-the-Counter Antifungal Medicines
Pharmacists can recommend over-the-counter antifungal medicines that can be brushed onto the nail. These treatments need to be applied regularly for several months before any improvement is seen. It is important to continue using the treatment as directed until advised to stop by a healthcare professional. Discontinuing treatment early may result in the infection returning.
Antifungal Tablets
If over-the-counter treatments are ineffective, your GP may prescribe antifungal tablets. These tablets can help treat the infection, but they may also cause side effects. Additionally, they are not suitable for individuals with certain conditions, such as liver or kidney disease, or for those who are pregnant or breastfeeding. Before and during treatment with antifungal tablets, your GP may also perform blood tests to monitor the function of your liver.
Nail Removal
In severe cases, badly infected nails may need to be removed. This is typically done under local anaesthesia, and proper wound care is necessary after the procedure.
Laser and Light Treatments
Researchers are exploring the use of lasers and light treatments as a potential new option for clearing nail fungus. While this approach shows promise, more research is needed to determine its safety and effectiveness for a broad population.
Other Potential Treatments
Other potential treatments under investigation include patches, nail lacquers, and gels. These treatments aim to provide alternative methods to combat nail fungus and improve upon the limitations of existing options.
It is important to note that even with successful treatment, your nail may still appear unhealthy until the infected portion grows out completely. Fingernails typically require 4 to 6 months to grow out, while toenails can take 12 to 18 months.
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Frequently asked questions
Results can take up to 3 weeks to come back from a laboratory test. However, there is now a new test available that can provide results within 5 minutes.
The 5-minute fungal nail test, developed in Japan, is a highly accurate test that can provide immediate confirmation of dermatophyte presence, signifying a fungal nail infection in a small nail sample.
A nail sample is collected by clipping off a piece of the nail or scraping the nail near the infected area. This sample is then sent to a laboratory where it is placed in a special dish (culture) and monitored to see if bacteria, viruses, or fungi grow.
