Toenail problems are the most common foot condition seen in the Podiatrist’s office. The human toenail is one of the fascinating structures of the human body. Its position on the toe, together with its being encased within the toe box of the shoe, exposes it to frequent micro trauma, which may affect the appearance and health of the nail. Many systemic diseases, such as diabetes, psoriasis, dietary deficiencies, and decreased circulation can manifest themselves early by changes in the appearance of the nails.
ONYCHIAL CHANGES ASSOCIATED WITH THE ELDERLY:
Disorders of the toenails are most common in the elderly. They may result from bacterial or fungus infections, repeated trauma, metabolic diseases such as diabetes, and vascular insufficiency. It is extremely important, especially in those people with compromised circulation to adequately diagnose the etiology of the deformed nail and treat it promptly. Any delay may lead to a disastrous outcome.
INGROWN NAILS (ONYCHOCRYPTOSIS):
An ingrown nail is a condition in which a portion on the nail presses into the flesh, causing pain, redness, and sometimes infection. They are most commonly associated with the inside or outside of the great toe but may occur in any toe. Contrary to popular belief, most ingrown nails are caused by a growth disturbance at the base or root of the nail, not by improper cutting. As the nail plate penetrates the adjacent tissue, it may cause irritation, inflammation, and eventually infection. A permanent cure is easily obtained by removing the irritating portion of the nail and chemically cauterizing the corresponding portion of matrix (root). There are no stitches involved, and the patient may leave the office in normal shoe gear.
ONYCHOGRYPHOSIS (CLUB NAIL, RAM’S HORN NAIL):
Trauma to the nail matrix (root) may cause the toenail to become enlarged, sometimes over a period of many years. The nail becomes hooked at its distal end and may eventually encroach on adjacent toes causing lacerations and infections. If neglected the nail may actually resemble a club or a ram’s horn. Treatment may involve periodic palliative reduction of the thick nails by the skilled use of nail nippers and podiatric burrs usually every 2 to 3 months. Permanent cure in healthy individuals may be obtained by avulsion of the nail and chemically cauterizing the entire root of the nail. This will lead to a non-painful and cosmetically acceptable result in most people.
ONYCHOMYCOSIS (FUNGUS OR YEAST INFECTION OF THE NAIL)
Besides bacterial infections (ex. Ingrown nails), the nail can commonly be invaded by a fungus or yeast.
Often, a minimal trauma to the end of the nail will allow for invasion of pathogen. Early involvement may manifest itself by colored spots or striations. These may be white, black, brown, black, or green depending on the invading organism. As the total nail and eventually the root become involved, it will become thickened, dry and extremely brittle. When treating a mycotic nail, it is important to identify the offending organism. This may be done by taking a scraping of the nail and placing it in a fungus culture. The results are obtainable in 10 – 14 days. Depending on the length of time and severity of the problem, treatment may involve a topical fungicide along with periodic palliative debridement of the nail or oral fungicides such as Sporanox, Lamisil, or Griseovulvin. Surgical avulsion of the involved nail plate is often necessary to expose the affected nail bed more advantageously to topical therapies.
ONYCHOPHEMIA (BLOOD UNDER THE NAIL)
This is usually caused by trauma and should be treated immediately to relieve pain and pressure. This can be easily achieved by drilling 1 or 2 small holes with a dental drill under local anesthesia. Usually if the trauma involves external bleeding (ex. a bloody sock or shoe), this is unnecessary, and the nail may simply be simply cut back to the point of attachment and allowed to grow back.
SUBUNGUAL EXOSTOSIS (BONE SPUR UNDERNEATH THE NAIL):
Trauma to the top of the nail may produce a reactive periostitis and cause bone or cartilage to grow underneath or to one side of the nail and elevate the nail plate itself. This most commonly occurs underneath the great toe or to the outside of the 5th toenail (often mistaken for an ingrown nail). Treatment usually consists of surgical filing of the spur, usually requiring one stitch.