Our feet move us through the world, and our toenails protect them. Unlike fingernails, toenails can be one of the most neglected parts of our bodies. It is important to remember that they too need some TLC. They can be subjected to a myriad of conditions and if picked up early, usually have good treatment outcomes.
Structure of the nail
Toenails are made up of the same material our skin and hair are made from; keratin. Keratin is a protective fibrous protein structure which is less prone to scratching or tearing than other types of cells within our bodies.
Our toenails are prone to a great deal of stress. Think of the number of times you’ve stubbed your toes, the rubbing inside your shoes, sweating inside your shoes or just how many visits to the nail salon you’ve had for a pedicure. In view of these factors there are many common and not so common toenails conditions that can present.
Lifted nail plate
Nail lifting, also known as onycholysis is usually a harmless condition that may affect one or many of the toenails. It is often seen as an outcome of trauma and care should be taken as the nail grows out. It is also important to keep your nails clean and dry to not allow any infections to present between the skin and lifted nail. Fungal nail infections may also cause lifting of the nail plate. It is important to observe for further structural changes.
Generally, there are three reasons a toenail may become thickened. Through the normal aging process, through trauma or a fungal nail infection. Thickened toenails are commonly seen in the elderly. If left untreated, thickened toenails can cause complications. Over time, they may grow thicker, become painful and more difficult to manage. They may cause discomfort when wearing shoes or injure the surrounding skin. If the nail has thickened due to a fungal infection, it is important to treat the fungal infection to slow down the progression of trauma occurred to the nail by the infection. Podiatrists can help with thick toenail treatments by cutting the nail and using a drill to reduce the bulk of a nail. This also allows for better penetration of nail ointments or solutions.
Nail ridging may be due to the natural aging process or signify an underlying condition. Skin conditions such as psoriasis can present on the nails. Psoriasis is an autoimmune condition causing red, scaly patches of skin. On the nails it may cause ridging, pitting or lifting of the nail from the nail bed.
Comparable to nail ridging, nail splitting may be due to the aging process or signify an underlying condition. It may present as horizontal or vertical splitting. It is common to see nail splitting in psoriatic nails, fungal or thickened nails, as a response to physical stress or a deficiency in nutrients. These factors can lead to a weakened nail structure. Treatment options to prevent nail splitting may include:
- Cutting toenails short
- Using moisturiser on your nails and cuticles
- Using nail hardening products
- Using vitamin supplements addressing your skin and nails
Deformed or brittle nails
It is important to identity the cause of why a nail may be deformed or brittle. Common causes include:
- Normal result of aging
- Fungal toenail infection
- Skin or systemic conditions that can affect the nails
Bacterial infection of the nail
Bacterial infections of the nail occur in the skin surrounding the nail. It may be caused secondary to an ingrown toenail or easily be mistaken for an ingrown toenail due to the location of the infection.
Inflammation of the skin alongside the nail – paronychia
Paronychia is the medical term given to bacterial infections surrounding the nail. It can cause redness and swelling around the toenail. It may also result in a pus formation or peeling of the skin.
You’re more likely to develop paronychia if you:
- Frequent nail salons
- Excessively trim the nails or cuticle
- Prone to ingrown toenails
- Wear tight fitting footwear
In the case of fungal nails, fungi use keratin as their source of food, hence they consume the nail structure which leads to nail deformations and thickening.
Fungal infections can occur on the skin or in a toenail. The fungi found in foot and nail infections is already found on the skin. Fungi like moist, warm and dark environments. When feet are subjected to this environment it increases their rate of formation. This can turn into a skin or nail infection.
The signs and symptoms of a fungal nail infection are:
- Toenails that change colour; this can be a yellow, brown or green
- A foul odour
- Lifting off the nail bed, splitting or crumbling
- A scaly or chalky appearance on top of the nail
Trauma to the nail
Trauma to the nail may occur from direct trauma or micro trauma. Direct trauma involves directly injuring your nail such as stubbing your toe or dropping something heavy on your nail. Microtrauma occurs gradually with time and may be caused from wearing tight fitting footwear or having a strenuous walking/ running routine. Changes that can occur to the nail include:
- Blood and bruising underneath the nail
- Toenail thickening
- Toenail loss
- A secondary fungal toenail infection if any part of the nail has become loose
Ingrown toenails occur when the edge of a toenail grows into the nail fold next to it. Usually, the nail component which causes the ingrown cannot be seen. As the nail continues to grow it can cause pain. It may also lead to an infection that may cause swelling, redness, warmth and a yellow discharge known as pus. Ingrown toenails may form as a result of:
- Nail trauma
- Improper fitting shoes
- A family history of ingrown toenails
- Fungal infections
- Abnormal toe/ toenail shape
- Increase in age
To treat ingrown toenails, you may need to take a closer look into the cause of the ingrown, this is the best way to decrease its occurrence.
Skin diseases and nails
Fungal infections on the skin have the potential of spreading to the toenails. If a fungal skin infection is present, it is important to treat the infection as early as possible to enable the best outcome. Once fungal infections penetrate the nails, it may take a long time to treat and potentially cause permanent changes to the toenails.
Unusual nail shape
Unusual nail shapes can have both normal or abnormal origins. As a rule of thumb, if a nail has not undergone change and has been stable it may be a be presenting with a benign or genetically predisposed condition. If a nail presents with pain, undergoes change or presents with an infection it is then advised to seek a medical opinion.
Alike tumours affecting the skin, tumours can also affect the toenails. Although rare, it is important to check your toenails for any changes or suspicious lesions. If you find a lesion is underneath your nail, does not resolve, or causes changes to your nail or skin, seek attention.
Splinter haemorrhages of the nail
A splinter haemorrhage is a tiny blood spot which appears underneath your nail. They occur when small blood vessels known as capillaries along the nail bed are damaged, leading to a small amount of blood to exude and become visible.
A splinter haemorrhage is usually painless and may not be initially noticed. The exception is when the splinter haemorrhage occurs as a result of injury such as stubbing a toe. Usually, splinter haemorrhages are not a cause for concern. They reside as the nail grows out. However, if recurring splinter haemorrhages are noted with no underlying cause noted, it is then important to seek attention to investigate the cause further
Diagnosis and treatment of nail problems
GP’s, podiatrists and dermatologists are all versed in treating toenail conditions. You may know why your nail is presenting in a particular way or you may require professional intervention. It is important to note, if a nail condition has arisen and has not settled, seek medical attention. In the treatment of nail conditions, usually prevention, followed with early intervention yields the best possible outcomes.
Strategies for healthy nails
1. Smooth It Out.
To begin, in order for the toenails to be healthy the skin surrounding your nails should be in optimum condition. A good way to start caring for your skin is to use a pumice stone or foot file on damp heels and any calluses. First, soak your feet in warm water for 10-15 minutes to soften the skin. Then, use a foot file or pumice stone to gently remove the thickened skin. If the skin is very dry and cracked, seek a podiatrist for a more intensive treatment.
Moisturising the feet, just like our hands and face is also very important in maintaining the health of the feet. Following on from a foot soak; after drying your feet use a rich foot balm to moisturise your skin. Then, apply moisturiser every night to maintain the soft skin. A top tip is to use a urea-based foot balm, urea based balms help soften the topmost layer of skin, this enables the top layer of skin to be easily released from the skin surface.
3. Fight Fungus.
The best method to treat toenail fungus is to prevent it. Giving your feet a break from dark, moist and warm environments is a good place to start. Wash and dry your feet thoroughly, especially between your toes. Change socks and hosiery daily. For sweaty feet, trial an alcohol based skin wipe or antiperspirant products.
If you do have a fungal infection on your toes, there are many forms of treatments that can be trialled. Non-medicated treatments include tea tree oil or apple cider vinegar soaks. These are natural fungicides. For medicated treatment, over the counter topical applications can be purchased from chemists or podiatrists. Non-medicated and medicated topical treatments are best suited for superficial fungal infections such as superficial onychomycosis or early distal subungual infections. If you believe you have a deeper infection, seek treatment from your podiatrist.
4. Wear Sunscreen.
When applying sunscreen, don’t forget your feet and the skin around your toenails. The skin on our feet can become extra dry during summer and are also prone to burning with more time spent in open shoes. Check your toenails and feet for any new moles, freckles or other skin changes regularly.
5. Get Support
If you’ve exhausted at home treatments or would like professional care for your toenails, remember to seek support through a podiatrist. Your podiatrist can give you tailored advice and care for your toenails.
In conclusion, if you’re experiencing any of the signs or symptoms mentioned or need help managing your toe nails, your podiatrist can help! The best intervention is early intervention.