Nail Problems

 

Introduction:

Many of you who read this post will find it absolutely disgusting. :)  However, this information is based on questions I am asked everyday by people truly curious and wanting to know what can be done for their issues.  Some nail pathology is purely cosmetic and some can be deadly.

Nail Anatomy:

The nail matrix is where the nail is actually created and protrudes from as it grows.  The nail bed also creates the bottom layer of the nail.  On occasion, the nail root and nail plate  will be destroyed and the nail bed will go into overdrive creating a nail like structure leading the patient to wonder if their doctor missed the root.  This happens from time to time and cannot be predicted.

 

Ingrowing Nails:

Probably the most common procedures performed in the average podiatrist's office are those concerning ingrown nails.   The photo below is a classic ingrown nail.  The nail is penetrating the skin along the edge allowing bacteria to enter tissue and start an infection.  Note the redness starting to appear around the nail border, this is early cellulitis and irritation.

Nails grow into the skin for a variety of reasons.  Some nails are shaped like the picture below, called "pincer nails".  You can see below by the way the nail edge pushes on the skin, that it wouldn't take much for the nail to penetrate the skin and become irritated or infected.  There are many nail shape types, the closer your nail gets to the shape below, the larger your chances of having issues.

Other patients have nails that grow more or less flat, but have excessive amounts of skin around the nail (seen below), also setting up the situation for the nail to penetrate the skin.  This may require removal of the excess skin to allow for normal and pain-free nail growth.

In the cases where the nail is clearly the problem, the edge of the nail is removed after a local block of lidocaine, marcaine or similar drug.  Once the offending portion of the nail is removed, the nail root/matrix is usually removed either surgically or with a chemical.  Quick applications of Phenol or Sodium Hydroxide are the most popular.  A bandage is placed and the patient is instructed on the follow-up care.  Commonly if chemicals are used, the patient will need to soak the foot in Epsom Salts or Iodine treated water 1-2 times per day for 15 minutes to allow the chemical burn to drain freely without creating an abscess.  If surgical resection is done, the bandage is usually left on for a number of days to allow the skin to heal in a sterile environment.  If done correctly, pain levels rarely exceed that controllable with ibuprofen or Tylenol.  In all cases, infection if very often associated with ingrowing nails and "bathroom surgery" is highly discouraged.  Also, don't wait too long.  The longer you wait, the more difficult the issues become to fix.

Skin Cancer:

Toenails and skin cancer aren't usually associated, but it does happen and often the results can be very scary.  Signs of concern are new dark-colored streaks in the nail itself.  Melanoma is a skin cancer that involves the pigment making cells in our skin.  People normally think of this kind of cancer occurring where sun damage has happened.  This is not true,  melanoma can appear anywhere in the body, even in places where "the sun don't shine".

Subungual melanoma (skin cancer under the nail) is a rare form that occurs under a nail and can affect the hands or the feet. It's more common in african americans and in other people with darker skin pigment. The first indication of a subungual melanoma is usually a brown or black discoloration that's often mistaken for a bruise (hematoma).  Long standing streaking is more likely not to be cancer, but, you should always get it checked out by a podiatrist or dermatologist.  My colleagues have reported to me cases where evaluation was delayed by the patient and by the time a diagnosis was made it was too late and the patient died from the spread of the cancer.  If caught early, recover rates are quite high.  A biopsy is the first line of treatment with the nail being removed or softened to allow for a segment of the skin to be removed and sent to a pathologist.

Fungus:

Nail fungus is a tough disease to treat successfully.  The older we get, the more likely we are to develop a toenail fungal infection.  The reason for this is unclear, but some studies have suggested that certain immune system deficiencies may set you up for an infection.  A very clear trend is that the older the patient, the more likely they are to contract this disease.  The likely reason for this trend is the wide spread exposure we have to the spores the fungus drops like seeds all around our environment.

 

The most succesful treatment options include oral antifungal pills.  Lamisil is the most common and the most effective, with a 50-60% success rate.  It is taken once daily for 3 months.  Concerns of liver damage from this pill have lessened considerably over the last few years with recent recommendations saying that liver tests only have to be done prior to taking the drug and not after, since a healthy liver is very unlikely to be damaged during its' use.  The nail does take upwards of a year to grow out, but the pill seems to persist within the tissues around the nail creating lasting effects.

Other treatment options include topical drugs such as Penlac that is applied daily for about a year.  My only issue with this one is ease of use.  It does require you to remove the film that builds up with a toenail polish remover at least once a week.  Another option is Formula 3 that is oil based and never needs to be removed (sold only in a Dr's office).  Formula 3 is usually only available through a doctors office such as ours.  None of these have reliable shown to be more than 30-40% effective.

For very thick nails, a power debrider sometimes is necessary along with nail nippers.

You may have also heard of Laser nail treatment options.  Please see this link for a more in-depth discussion on that aspect.  In short, lasers only appear to work on slight cases of fungal infection.

If you google "nail fungus treatment" you'll find an endless list of options.  This is always a bad sign in medicine, because if a silver bullet existed with few side effects we wouldn't be searching madly for the cure.

In conclusion, if a patient is truly concerned about their fungal infection and they have a healthy liver, I'll first help reduce the nail bulk in the office and then place them on the oral pill Lamisil and the topical medication Formula 3 to increase our chances of success.  We will take a simple liver blood test prior to starting Lamisil to verify the liver is functioning at a high enough level for safety.

Normally, this disease is not a threat to your overall health. There are a few exceptions including the fungus in the nail can be a source of fungal infection of the skin (athletes foot).  If you have little sensation in you feet like with some diabetics or back injury patients, the nail can become thick and rub in a shoe causing a wound under the nail that can become infected etc.  For most people, nail fungus is purely a cosmetic concern.

I could go on and on about the different disease states that can affect the nail, in short, if it concerns you have it checked out sooner than later by a podiatrist or a dermatologist.

As always, I welcome any questions or comments you may have.

Dan Preece, DPM

 

 

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 430 N. 400 W. Salt Lake City, UT 84103
 
                
     Foot & Ankle Specialists