Nail Problems
 

This page relates to three of the most common nail problems:

  • Ingrown nails
  • Fungal nails
  • Psoriatic nails.   

If you're interested in the structure of the nail and medical terms relating to the nail, visit our web page on nail anatomy and glossary of nail conditions.  We have another page that discusses some basic surgical nail procedures.  

 

Ingrown Toenail

An ingrown toenail is probably the most common abnormality involving the nail, and we see this problem in our office on a daily basis.  Simply put, an ingrown nail is a condition in which the nail is growing into the flesh.   

The condition may involve one border or both, and is accompanied by redness, warmth, swelling, and quite frequently, infection.  

The amount of pain the patient experiences varies, depending upon one's age, gender, circulation, and general medical condition.  As a rule, smokers will have more pain than non-smokers.  

While the problem is often dismissed as inconsequential (at least by those who have never experienced the problem), it should not be taken lightly.  Just a couple generations ago, in the era before antibiotics, an ingrown toenail that developed into an infection could kill people.  Even today, if the patient has compromised circulation or diabetes, the condition may frequently lead to loss of a limb. 

Ingrown toenail may be caused by:

  • Improperly trimmed nails (Trim then straight across, not longer than the tip of the toes. Do not cut down the corners.)
  • Heredity
  • Shoe pressure; crowding of toes in poorly-fitting shoes.
  • Repeated trauma to the feet from normal activities.

The most common treatment a patient attempts to perform for this condition is so-called "bathroom surgery".  This is where the patient attempts to remove a portion of nail, himself.  Unfortunately, this will often worsen the condition and can make proper treatment more difficult.  

We suggest that you may clean the foot in a warm (not hot) salt water soak, or a basin of soapy water, then apply an antiseptic and bandage the area.  You should then schedule an appointment with a podiatrist as soon as possible.  He or she can diagnose the problem, the prescribe medication or other appropriate treatment.  People with diabetes or circulatory disorders are especially sensitive to infections and serious problems and need to seek podiatric medical care as soon as possible.

Antibiotics will usually address the infection-portion of this complaint, but they do nothing for the actual problem of the nail digging into the flesh.  So most podiatrists will resect the ingrown portion of the nail and may prescribe a topical or oral medication to treat the infection as an adjunctive treatment.   

If ingrown nails are a chronic problem or severe enough, we can perform a simple procedure to permanently prevent ingrown nails. This procedure consists of removing the problematic nail border and killing or removing the root of the nail in some way so that it never regrows.  This is a very common procedure, one that we perform every day.  And the procedure very rarely hurts.  

For more information on some of the types of surgical procedures used for ingrown nails, please click on the following link for Permanent Nail Procedures.

Fungal Nails

Fungal infections of the nail, (also known as tinea unguium or onychomycosis), usually develop as a result of spread from a fungal infection of the skin (tinea pedis or athlete's foot).  

In contrast to athlete's foot, which is often itchy or even painful, fungal nails are frequently painless, and so are often ignored for years.   Early fungal disease is characterized by a slow but progressive change in a toenail's quality and color.   

While many patients believe the infection lies beneath the nail plate, it usually involves all layers of the nail--on top of the nail plate, beneath it, and within it.  

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As time progresses and becomes more advanced, the nail will often worsen, becoming more and more discoloured, thickened, and difficult to cut.  There is frequently a foul odour associated with the condition. 

The infection may also spread to other toenails, the skin, or even the finger nails.  

As the thickened nails deteriorate, they may become ingrown (discussed above) and painful.  

Pain may also develop because the thicker nails are difficult to trim and make walking and wearing shoes uncomfortable.  

Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are especially vulnerable around damp areas where people are likely to be walking barefoot, such as swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more susceptible to all types of infection, including fungal infection. The elderly and those who suffer from chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails. Other contributing factors may be a history of athlete's foot and excessive perspiration.

Prevention

  • Proper hygiene and regular inspection of the feet and toes are the first lines of defense against fungal nails.
  • Clean and dry feet resist disease.
  • Washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection.
  • Shower shoes should be worn when possible in public areas.
  • Shoes, socks, or hosiery should be changed more than once daily.
  • Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe.
  • Wear shoes that fit well and are made of materials that breathe.
  • Avoid wearing excessively tight hosiery, which promote moisture.
  • Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks.
  • Disinfect instruments used to cut nails.
  • Disinfect home pedicure tools.
  • Don't apply polish to nails suspected of infection—those that are red, discolored, or swollen, for example.

Treatment of Fungal Nails

Treatments may vary, depending on the nature and severity of the infection. A daily routine of cleansing over a period of many months may temporarily suppress mild infections. White markings that appear on the surface of the nail can be filed off, followed by the application of an over-the-counter liquid antifungal agent. However, even the best over-the-counter treatments may not prevent a fungal infection from coming back.

A podiatric physician can detect a fungal infection early, culture the nail, determine the cause, and form a suitable treatment plan, which may include prescribing topical or oral medication, and debridement (removal of diseased nail matter and debris) of an infected nail.

Newer oral antifungals, may be the most effective treatment. They offer a shorter treatment regimen of approximately three months and improved effectiveness. Podiatrists may also prescribe a topical treatment for onychomycosis, which can be an effective treatment modality for fungal nails.

In some cases, surgical treatment may be required. Temporary removal of the infected nail can be performed to permit direct application of a topical antifungal. Permanent removal of a chronically painful nail, which has not responded to any other treatment, permits the fungal infection to be cured, and prevents the return of a deformed nail.

Trying to solve the infection without the qualified help of a podiatric physician can lead to more problems. With new technical advances in combination with simple preventive measures, the treatment of this lightly regarded health problems can often be successful.

Psoriatic Nails

Psoriasis is a chronic skin disorder affecting about 2% of the population.  It is non-contagious and appears to have a genetic origin, though episodes may be triggered by stress and trauma.  

Psoriasis may be rather mild, involving occasional bouts of non-painful, silver-white scales on a small area of the skin with varying degrees of redness (inflammation) surrounding it (see diagram to the right), or it may be severe, involving uncomfortable blisters over large portions of skin throughout the body.    

While psoriasis may be found anywhere on the body, the classic areas of involvement are the elbows, knees, hands, feet, scalp, ears, and the genital region.

Some 50% of individuals with psoriasis may develop the condition in their nails.   This condition causes some combination of pitting in the nails (see diagram A below), yellow-white discoloration and dystrophy (degeneration) mimicking fungal involvement (see diagram B below), and onycholysis, where the nail slowly becomes detached and loose from the nail bed (see diagram C below).   The nails are usually painless, but may become painful in some cases.

Picture

A.  Pitting

B.  Discoloration & Dystrophy C.  Onycholysis

Patients with psoriatic nails may also develop psoriatic arthritis, a form of arthritis involving the nail in the finger or toe joint closest to the nail.

There is no cure for psoriasis, though there are a variety of topical medications and treatments that may be effective in controlling symptoms, such as sunlight and ultraviolet light, corticosteroids, calcipotriene (Dovonex), coal tars, anthralin, and tazarotene.

 

 

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The Achilles Foot Health Centre
S. A. Schumacher, D.P.M., F.A.C.F.A.S., F.A.C.F.A.O.M.  
Dr. S. A. Schumacher, Podiatric Corporation  

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