Disorders and Treatments
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.
And Their Care
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.
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.
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").
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.
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
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
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
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
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.
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.
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.
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
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.
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.
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.
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
© 1995. The American College of Foot and Ankle Surgeons