Dermatophytes Breach the Nail Plate
Hyphae enter through small trauma sites at the nail edge.
- T. rubrum: Common pathogen (most frequent dermatophyte)
- Distal edge: Entry point (subungual space)
- ~10%: Global prevalence (adults affected)
- ~3 mm/mo: Nail growth rate (toenail baseline)
How invasion starts
Hyphae colonize keratin from the distal-lateral edge inward.
Discoloration and Thickening
Untreated infection spreads, causing visible nail damage.
- Yellow-brown: Color change (debris accumulation)
- 2-3x: Thickness increase (subungual hyperkeratosis)
- Months: Progression time (to full plate involvement)
- ~0%: Untreated cure (spontaneous resolution rare)
Structural damage
Nail becomes brittle, crumbly, and separated from the bed.
Systemic Oral Terbinafine Therapy
Pill delivers drug through blood to the growing nail bed.
- 12 weeks: Typical course (toenail regimen)
- ~63%: Cure rate (mycological cure)
- ~3 months: Onset (visible clear growth)
- ~20%: Recurrence (within 2 years)
Mechanism
Terbinafine accumulates in keratin via the nail bed circulation.
Topical Efinaconazole Application
Daily brush-on solution penetrates the nail plate directly.
- 48 weeks: Typical course (daily application)
- ~55%: Cure rate (complete/almost-complete)
- ~4 months: Onset (visible clear growth)
- ~30%: Recurrence (higher without systemic reach)
Mechanism
Low surface tension formula diffuses through the keratin matrix.
Laser-Based Antifungal Therapy
Focused laser heat aims to disrupt fungal cells in the nail bed.
- 3-4: Sessions (spaced over weeks)
- ~35%: Cure rate (variable evidence quality)
- ~2 months: Onset (fastest visible response)
- ~45%: Recurrence (highest among options)
Mechanism
Thermal energy targets fungal elements without systemic drug exposure.