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Nail
Disorders and Treatments
- American
College of Foot and Ankle Surgeons©
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.
Nail Problems And
Their Care
Ingrown Nail
Painful ingrown nails may be congenital, caused by an overcurvature of the nail,
or an imbalance between the width of the nail plate and the nail bed. Toe
injuries that change the nail's contour also can lead to an ingrown toenail. Toe
deformities (such as a bunion that forces the big toe to lean toward the second
toe), high-heeled or narrow, pointed shoes can put pressure between the nail and
soft tissues, eventually forcing the nail to grow into the skin.
- Symptoms
Redness, swelling and infection make the toe very painful. Ingrown nails can
be accompanied by other toe disorders, such as excess surrounding tissue or an
outgrowth of bone beneath the nail.
- Treatments
Surgery is often necessary to ease the pain and remove the offending nail.
Only a portion of the nail may be removed. If the entire nail is affected or
there is a severe nail deformity, the nail plate and matrix (the cells that
grow the nail) may be completely removed (see "Surgical Treatments for Nail
Disorders").
Fungal Infections
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 have caused the nail to separate from the bed. 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
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, the surgeon may reduce its thickness by filing
the nail plate down with a surgical burr. Filing will not, however, prevent the
infection from spreading. Oral and topical medications may be prescribed when:
· Only a small portion of one nail is infected
· Several nails are affected
· Keeping the nail is desired
Medication may or may not
completely eliminate the fungus. Often, after medication is discontinued, the
fungus recurs. Your podiatric surgeon will monitor the results of oral
prescriptions carefully, and will explain any possible side effects.
While topical ointments
usually do not eliminate the fungus, they may be effective when used directly on
the nail bed, after the nail plate has been removed. Eliminating the infection,
in some cases, can only be achieved by permanent removal of the nail plate (see
"Surgical Treatments for Nail Disorders ").
Blood Beneath The Nail
A very common result of
active lifestyles is blood, or a hematoma, beneath the toenail. Hematomas are
especially common among people who jog or play tennis, caused by the toes
repeatedly rubbing against the shoe.
A hematoma might indicate
a fractured bone, especially after an injury (such as dropping a heavy object on
the end of the toe). The toe should be examined by the podiatric surgeon, who
may take an X-ray to determine the most appropriate treatment.
Hematoma Treatments
If the hematoma is
treated within the first few hours of forming, the podiatric surgeon will create
a tiny hole in the nail plate using a fine-point drill or scalpel. This releases
the blood and relieves pain. If several days have passed and the blood clot
becomes painful, the nail plate may require removal so that the nail bed can be
cleaned. Some podiatric surgeons prefer to remove the nail plate whenever blood
forms beneath it, because the blood can attract fungi and lead to infection. The
nail may also be removed to treat a bone fracture beneath the hematoma. If the
bone has fractured but has not moved out of its normal position, a splint may be
used to keep the toe aligned during healing.
Nail plates that have
been removed will grow again within three to six months.
Surgical Treatments
For Nail Disorders
If the problem is severe or chronic, surgery to remove all or a portion of the
nail may be recommended. Most surgeries are performed very comfortably under
local anesthesia, and require less than one hour at the podiatric surgeon's
office. Laser surgery, because it requires special equipment, may be performed
at a hospital.
Partial Nail Removal
For some cases of ingrown nails, only the portion of nail that is growing into
the skin is removed. If both sides of the nail are ingrown, they may be removed
during one procedure. After the affected portion of nail (one-eighth to
one-quarter inch) is taken, the nail bed is removed along with any enlarged
tissue adjacent to the nail plate. The nail root and matrix are then destroyed
by phenol, surgical removal or laser heat (see "Permanent Nail Removal").
Finally, the skin may be remodeled around the nail.
Permanent Nail Removal
Complete removal of the
nail plate is a common remedy for fungal infections and ingrown nails. During
this procedure, the nail plate is removed and the nail matrix is destroyed by
one of three methods:
· Phenol - An acidic chemical called phenol is applied only to the nail matrix.
This destroys the growth cells of the nail.
· Surgical removal - The nail matrix and bed is cut away. Stitches are only
occasionally necessary.
· Laser - A form of burning in which laser heat is focused on the matrix cells.
Removal of Bone
Overgrowth
Bone directly beneath the
nail plate may become enlarged, developing a spur or outgrowth that can deform
the nail plate or lead to an ingrown nail.
Removal of excess bone may be performed concurrently with surgery to partially
or permanently remove the nail plate.
Care After Surgery
Most people experience very little pain immediately following nail surgery, and
during the healing process, which lasts approximately two to three weeks. If
bone has been removed during surgery, a longer healing process should be
anticipated.
- Total Nail
Removal/Partial Nail Removal
The podiatric surgeon may prescribe medication for pain, and may, but not
always, advise that the toe be soaked two or three times daily for one week.
Some amount of drainage is normal when the nail has been removed chemically or
by laser. If the nail has been partially removed and stitches were used to
form a new nail fold, they are removed in approximately 10 days.
- Ingrown Nail
Daily soaking in a saline solution may be recommended. If the toe is inflamed
or infected, a topical antibiotic is applied for three to seven days; if the
infection is severe, an oral antibiotic may be prescribed. In very few cases,
the infection may invade the bone beneath the nail, requiring hospitalization
and further treatment. The healing process generally does not interfere with
daily activities.
- Hematoma
Following simple drainage of a hematoma, the podiatric surgeon may advise that
the toe be soaked and treated with topical antibiotics.
How Will The Toe Look
After Surgery?
After surgery to permanently remove the nail plate, the body generates a
hardened skin covering over the sensitive nail bed. When this covering has
developed, normal activities can be resumed. Women can also use nail polish on
this area.
Will The Nail Regrow
After Removal?
Partial growth of the nail plate after permanent removal is rare, but possible.
Because the nail matrix has been destroyed, the nail should not grow again.
While these are some of the most commonly prescribed treatments for nail
disorders, others may be used. The podiatric surgeon will determine which
treatment is likely to be the most successful in each case.
© 1995. The American College of Foot and Ankle Surgeons
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