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Toe Nail Disorders

Zeehan S. Husain, DPM

Charles G. Kissel, DPM

Michael S. Schey, DPM

Angela Stoutenburg, DPM

Board certified by the 
American Board of 
Podiatric Surgery.


Toe Nail Disorders

Toenail Disorders and Treatments

Early Care is Best for Nail Health

In their protective role, nails bear the brunt of daily activities. Walking, running, wearing shoes or participating in sports are just a few of the stresses and strains the feet must endure.  All or a portion of the nail plate can be damaged when the feet are injured or abused.  Nail problems are commonly caused by improper trimming, minor injuries, or repeated trauma. Some nail disorders can also be congenital.  Proper trimming (along the contour) on a regular basis can help keep the toenails in the pink, as can wearing well-fitted, low to moderately heeled shoes.

Subtopics

1.     Ingrown Nail

2.     Nail Dystrophy (Thickened Toenails)

3.     Fungal Toenails  

1. Ingrown Toenail

When a toenail is ingrown, the nail is curved downward and grows into the skin, usually at the nail borders (the sides of the nail).  This “digging in” of the nail irritates the skin, often creating pain, redness, swelling, drainage, and warmth in the toe.  If an ingrown nail causes a break in the skin, bacteria may enter and cause an infection in the area, which is often marked by drainage and a foul odor.  However, even if your toe is not painful, red, swollen, or warm, a nail that curves downward into the skin can progress to an infection.

http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/common_foot_problems/PRinc_rm_photo_of_ingrowing_toenail.jpg

What Causes an Ingrown Toenail?

Ingrown toenails can develop for various reasons.  In many people, the tendency to have this common disorder is inherited.  In other cases, an ingrown toenail is the result of trauma, such as stubbing your toe, having an object fall on your toe, or engaging in activities that involve repeated pressure on the toes, such as kicking or running.  The most common cause of ingrown toenails is improper trimming.  Cutting your nails too short encourages the skin next to the nail to fold over the nail.  Another cause of ingrown toenails is wearing shoes that are tight or short.  Bunion [link] deformities can also lead to excessive pressure on the side of the toe pinching the skin between the ground and the nail margin.  Overlapping hammertoe [link] contractures of the second toe on top of the great toe can also cause a similar problem.  Certain nail conditions are often associated with ingrown toenails.  For example, if you have had a toenail fungal infection or if you have lost a nail through trauma, you are at greater risk for developing an ingrown toenail.

Treatment

Sometimes initial treatment for ingrown toenails can be safely performed at home.  However, home treatment is strongly discouraged if you suspect you have an infection, or if you have a medical condition that puts your feet at high risk such as, diabetes, nerve damage in the foot, or poor circulation.

Home Care

If you do not have an infection or any of the above conditions, you can soak your foot in room-temperature water (add Epsom salt or dish detergent if you wish), and gently massage the side of the nail fold to help reduce the inflammation.  Avoid attempting bathroom surgery. Repeated cutting of the nail can cause the condition to worsen over time and result in additional nail damage.  If your symptoms fail to improve, then it is time to see a foot and ankle surgeon.

Physician Care

The foot and ankle surgeon will examine your toe and select the treatment best suited for you.  These treatments are commonly performed in the office after numbing the toe.  Treatment may include:

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Oral antibiotics— If an infection is present, an oral antibiotic may be prescribed.

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Surgery— A simple procedure, often performed in the office, is commonly needed to ease the pain and remove the offending nail margin.  Surgery may involve numbing the toe and removing a corner of the nail, a larger portion of the nail, or the entire nail.

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Permanent removal— Various techniques may be used to destroy or remove the nail root.  This treatment prevents the recurrence of an ingrown toenail.  Recurrent conditions typically are recommended to have the permanent procedure.  Your surgeon will determine the most appropriate procedure for you.

Following the nail procedure, a light bandage will be applied.  Most people experience very little pain after the procedure and may resume normal activity the next day.  If your surgeon has prescribed an oral antibiotic, be sure to take all the medication even if your symptoms have improved.  The toenail should look relatively the same except for the offending ingrown nail margin.  In permanent nail procedures, the skin edge moves over and the nail cosmetically should look normal.  When the nail is not permanent removed, the nail will grow out over a year.

Preventing Ingrown Toenails

Many cases of ingrown toenails may be prevented by following these two important tips:

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Trim your nails properly— Cut your toenails in a fairly straight line, and do not cut them too short.  You should be able to get your fingernail under the sides and end of the nail.

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Avoid poorly-fitting shoes— Do not wear shoes that are short or tight in the toe box.  Also avoid shoes that are loose, because they too cause pressure on the toes, especially when you run or walk briskly.

Home Treatment Myths

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Cutting a notch (“V”) in the nail will reduce the tendency for the nail to curve downward— This does not affect the toenail growth or shape.  The nail shape is fixed.  Repeated disturbance to the nail bed will cause additional damage and worsen the curvature.

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Repeated trimming of the nail borders is a good way to treat ingrown nails— Repeated nail trimming fails to correct future nail growth and can make the condition worse.

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Cotton placed under the nail will relieve the pain— Cotton placed under the nail can be harmful.  It can easily harbor bacteria and encourage infection.

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You may buy effective ingrown nail treatments at the drugstore— Over-the-counter products may mask the symptoms, but fail to address the root cause of the problem.  Typically, only temporary relief is achieved.

2. Nail Dystrophy (Thickened Toenails) (top)

Not all toenails that are thick and discolored are infected with fungus.  Repetitive nail trauma from direct injury, stubbing the toe, pressure from tight-fitting shoes, or microtrauma from running can result in permanent damage to the nailbed and nail root.  Typically, once this damage is done, the physical characteristics of the toenail have been changed.

The cause of the nail appearance can only be confirmed with a simple nail biopsy that can be done in the office painlessly.  Unfortunately, damaged toenails rarely can be reversed.  Some topical agents can be used to soften the toenails.  In severe cases that cause chronic pain, the nail can be permanently removed to avoid continued problems.  In true fungal infections of the nail, your podiatric physician can discuss appropriate treatment options.

3. Fungal Toenails (top)

Various types of fungi are present everywhere in the environment.  The dark, moist surroundings created by shoes and stockings make the feet especially susceptible to fungal infection.  Most fungi are harmless until they penetrate the skin.  A fungus can invade through minor cuts or after injury or repeated irritation to the toes.  The fungal growth builds under the nail and can separate the toenail from the nailbed.  Fungal infections of the nail plate and nail matrix are quite common.

Symptoms: Fungus may cause the nail to thicken and become yellow or brownish.  As the fungus grows, foul-smelling, moist debris can be seen.  Pressure from a thickened nail or the build-up of debris may make the toe painful.

Treatments for Fungal Infections

Treatment is best begun at the early stages of infection.  The accumulation of debris under the nail plate can lead to an ingrown nail or to a more serious bacterial infection that can spread beyond the foot.  To reduce pain associated with a thickened, infected nail, your podiatrist may reduce its thickness by filing the nail plate down with a surgical burr.  Periodic nail debridement with proper use of antifungal medication is the key to successful outcomes.

Oral and topical antifungal medications can effectively eliminate the fungal infection.  However, please know that the appearance of the nail may or may not improve.  The goal of the medication is to eradicate the fungal infection and not to make the nail look normal.  Any permanent nail damage already caused by the infection may still remain.  It is possible to have recurrence of the fungal infection at a later time.

Oral Antifungals

Oral medication is typically only taken for three months and requires some blood work to check the liver function.  Despite the potential risk of side effects, the oral medications are safe and rarely cause problems provided the patient is being monitored closely by their podiatrist.

Topical Antifungals

Topical medications are used almost daily for nine to twelve months or until the effected portion of the nail has grown out.  Nail polish cannot be used at the same time.

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Rochester Center For Foot & Ankle Surgery
248-651-0162
Crittenton Medical Building
1135 West University Drive, Suite 235
Rochester, Michigan 48307

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