Your body hosts millions of microscopic organisms, some harmful, some hurtful. Fungi are one type of tiny, plant-like organism that lives on your body or inside it. Unlike plants, they have no chlorophyll, a chemical which turns sunlight into food. To survive, fungi absorb nutrients from other living or dead things. They thrive in warm, moist places, like underneath your toenails.
It is estimated that around 36 million people in the , United
States, have onychomycosis
,
a fungal nail infection. Fungal nail infections are more common in toenails,
but they also occur in fingernails. They are more likely in adults and often
follow a fungal foot infection, like athlete's foot.
When the nail is infected with fungi, it becomes yellowish, dry and brittle. The nail also becomes thicker, as layers of fungi grow and bloom. The nail may even separate from the skin, slightly rising off the toe.
Locker rooms, public pools and gym showers can all be sources of fungal infections. Fungi love these hot, damp environments. Nail salons can also be a source of fingernail fungal infection. If the foot tub is not properly cleaned after a pedicure, fungi can live there, infecting the next person that puts their feet in tub.
Perhaps the best way to prevent a fungal toenail infection is not to go barefoot at public pools or locker rooms. When you go to the nail salon, be sure the equipment is properly cleaned.
Although they may not hurt, it is best to treat fingernail fungal infections early. Untreated fingernail fungal infections can become very painful, making it difficult to walk and uncomfortable to wear shoes.
Doctors prescribe topical ointments or oral medication depending on how much
the fungus has grown. Fungal nail infections are not life threatening. It can
take years before the infection becomes large enough to cause pain or
difficulty walking.
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.
fingernail fungal infections of the nail, (also known as
tinea
unguium
or onychomycosis
), usually develop as a result of spread from
a fingernail 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.
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 fingernail 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 fingernail fungal infection from coming
back.
A podiatric physician can detect a fingernail 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 fingernail 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.
When an
ingrown
nail, fungal nail, psoriatic nail, or other uncomfortable
nail pathology does not respond to conservative care, an attempt may be made at
a permanent correction of the problem through surgical means.
Surgical nail procedures have improved greatly
over the years, and they may be designed to temporarily or permanently correct
ingrown nail conditions.
Listed below
are some of the most common procedures.
Temporary Nail Procedures.
At first glance, it may seem nonsensical to attempt a
temporary nail procedure.
After all, why
would anyone wish to temporarily fix a nail condition when you could do it
permanently?
Well, there are a couple reasons it may make sense to try
this sort of procedure.
First, if there
is nothing really wrong with the nail, but the ingrown nail was caused by a
one-time trauma, by cutting the nail improperly or by some other one-time
event, it may be quite reasonable to address the acute problem temporarily in
such a way that once the tissues heal, the problem may not be likely to return.
A couple examples of procedures that fall into this category
are listed below:
Wedge Resection
This
procedure simply aims to remove the offending portion of the ingrown nail
without touching the remainder non-problematic nail.
Depending upon the severity of the problem,
this procedure may be performed with or without anesthesia.
Granuloma
Excision
This
procedure aims at removing the
portion of skin that often grows up and over the nail plate when ingrown nails
are present.
This abnormal growth of
skin is known as a Granuloma
or Proudflesh
, and usually appears red, angry-looking (though they may be painless) and very
bloody.
While a granuloma
excision may performed
as an isolated procedure, it is
frequently performed along with a permanent nail procedure.
Skin Plasties
Skin
plasties
are techniques that primarily address an abnormal
component of skin that may be the cause of the problem.
For example, a portion of skin may be
excessively large and the nail may continually grow into the skin.
Again, this may be performed as an isolated
procedure or in conjunction with a permanent nail procedure.
Permanent Nail
Procedures.
There are three families of procedures that permanently
address nail conditions--"sharp" procedures, chemical procedures, and
miscellaneous procedures.
procedures
are known by that name
because they all have in common the use of a scalpel to excise a portion of the
nail root.
Because the nail root is
being cut out, or "excised", this family of procedures is properly
known as known as matrixectomy
procedures, with the
suffix "- ectomy
" meaning
"excision".
A matrixectomy
may either be a partial matrixectomy
,
when only a portion of the nail root is removed, or a total or complete matrixectomy
,
when the entire nail root is removed.
Compared to chemical procedures, sharp procedures have the
advantage of looking better immediately after the procedure, and they typically
have less drainage.
While sharp procedures are still performed frequently by
other medical professionals, it's probably safe to say that In the podiatric
profession they are performed much more infrequently today than in years past
because of their down side.
First,
there is cutting involved, so they may create more scar tissue than other types
of procedures, they may have a more noticeable post-operative appearance, they
may hurt more and they physically remove the nail root from the bone,
potentially increasing the odds of a bone infection.
Suppan
This
procedure
involves freeing the skin behind the nail and removing the nail, then peeling
away the root of the nail.
Zadik
Procedure
This
procedure involves an incision
that is angled at about 45 degrees from the nail border, and excising just the
nail root.
Frost Procedure
One
of the older "sharp"
procedures, the Frost involves making an "L"-shaped incision behind
the nail plate, peeling back the soft tissues to expose and excise the nail
root and any abnormal soft tissue associated with it.
Winograd
The
Winograd
procedure involves a "D"-shaped excision
of the nail root and overlying soft tissues.
Not so
aggressive as the Kaplan procedure, the
Winograd
may be a good choice when sharp procedures are
considered.
Kaplan
The
Kaplan procedure may be the most well documented nail
procedure in the literature.
It involves
an "H"-shaped incision and requires the excision of both the nail
root and the nail bed (the soft tissue upon which then nail rests).
This procedure may still be indicated in
cases where the bone underlying the nail is involved, but this procedure is
more aggressive then necessary for the vast majority of ingrown nails.
Terminal Syme
The
Terminal Syme
procedure is basically an amputation of the tip of the
toe.
I'd like to say this procedure is
rarely done any longer for routine ingrown nails, but from time to time, I
still see people who have had this done.
There are very few indications for this procedure to be performed.
Chemical Procedures.
Simply put, chemical procedures attempt to permanently
resolve an ingrown nail by chauterizing
the nail root through the application of a strong chemical.
Because the root of the nail is not actually removed, chemical procedures are not really matrixectomies
, though they
are often referred to as being so.
In theory, any chemical strong enough to chauterize
the root of the nail without adversely affecting the patient could be used, but
the most common chemical techniques are listed below.
The advantage of chemical procedures are that they are known
for being relatively painless; there is typically no scalpel used in these
procedures, so there is little scarring, and so they also tend to look very
nice after they are completely healed; and chemical procedures don't denude the
covering from the underlying bone, which diminishes the odds of a
post-operative bone infection.
The downside to these procedures is that they create a minor
chemical burn in the area, so they tend to drain.
Soaking and bandage changes are usually prescribed.
The most common names you might hear?
Phenol
The
phenol procedure involves applying an acidic chemical known
as phenol to the root of the nail.
(See
diagram to the right for an image of phenol's chemical structure.)
This is probably the most common chemical procedure used today.
P& A
The
P&A procedure is short for "Phenol and
Alcohol", because alcohol is commonly used at the end of the phenol
procedure to wash away any remaining phenol.
So a P& A is the same as a phenol procedure.
Phenol.
Sodium Hydroxide
The
second most common chemical method
involves using the base known as Sodium Hydroxide.
Some practitioners believe it creates less
drainage than phenol procedures.
NaOH
Those
of you who
have studied chemistry may recall that NaOH
is the
chemical abbreviation for
sodium
hydroxide, so the NaOH
procedure is the same as the
Sodium Hydroxide procedure.
Miscellaneous Procedures
In addition to sharp procedures and chemical procedures,
other techniques exist to address ingrown nails.
The two most common are listed below:
Radiosurgery
Radiosurgical
techniques can also be used to permanently resolve nail problems.
Much less expensive than lasers,