An Overview of Common Toenail Problems

Toenails are thickened extensions of the top layer of our skin and are made of the same tough protein, called keratin. The nail grows out from an area below the skin known as the matrix and is intimately connected to the blood vessel and nerve-rich nail bed beneath it.

Your toenails are subject to a great deal of stress, whether it's rubbing against shoes, a stubbed toe, or the constant presence of bacteria and fungi (picture the environment inside a shoe). In light of these conditions, there are three common toenail problems that we often see.

Toenail fungus, or onychomycosis, is a slow-growing infection of the nail and skin beneath it.

You may be surprised to learn that toenail fungal infections are usually caused by the same type of fungi that cause athlete's foot. In fact, people who are prone to athlete's foot may also be susceptible to toenail fungal infections.

Toenail fungus can affect anyone but becomes more prevalent with aging. Individuals with certain diseases, such as diabetes and conditions that affect limb circulation, are more susceptible to fungal nail infections, along with people who have suppressed immune systems. Other risk factors include:

• Hyperhidrosis, or a tendency toward sweaty feet
• Frequent fungal skin infections
• Trauma to the nail
• Shoe wear which provides a moist, dark, and warm environment for fungi to thrive

Fungal infections usually occur underneath the nail and begin at the end of the nail (where it gets trimmed). The most common changes that occur with toenail fungal infections include:

• Discoloration beneath the nail, usually brown, white, or yellow
• Thickening of the nail
• An increase in white debris beneath the nail which is keratin, a protein that gives form to skin and nails
• The infected part of the nail may become loose or separate from the nail bed
• The nail appears to "crumble" or break down

Less often, an infection can appear as a white, powdery discoloration on top of the nail. 

Treatment at a podiatrist's office will likely involve debridement, or trimming down and removing debris and the death nail. This will help decrease the thickness of the nail and relieve discomfort that may be occurring with shoe wear. Debridement may also increase the effectiveness of topical treatments.

Oral antifungal medications and/or prescription-strength topical treatments may also be prescribed. However, oral antifungal medicines are not always an option for many people due to potential side effects and cost.

Also, there are a number of over-the-counter topical medications for toenail fungus. However, since the fungus resides deep in the nail and underneath it, these medications have limited success in treating toenail fungus, especially if it has spread significantly throughout the nail. The good news is that other fungal nail treatments are available, including laser treatment that received FDA clearance.

An ingrown toenail occurs when the edge of the toenail, usually the big toe, grows into the skin next to it (called the lateral nail fold). 

Factors that increase a person's chance of developing an ingrown toenail include:

• Improperly fitting shoes or socks 
• Abnormal toe shape
• Nail trauma
• Toenails are clipped too short
• A family history of ingrown toenails
• Fungal infections
• Increasing age
• Health problems like poor leg circulation or lung disease

An ingrown toenail causes pain at the side of the toe along with swelling. It may become infected which can cause redness, increased swelling, and pain, warmth, and/or discharge. Note that the ingrown aspect of the nail is usually unseen because it is below the skin. 

Treatment for an ingrown toenail can be performed at home unless there is a suspicion of an infection or if you have a medical condition, such as diabetes, nerve damage, or poor circulation.

The first step for at-home care is to soak your foot in an Epsom’s salt solution using room-temperature water. Then, massage the side of your nail gently to decrease inflammation. Be sure to not cut your toenail and consider wearing open shoes like sandals until the problem resolves.

In addition, you may have to take a closer look at the fit and shape of your shoes and socks to analyze whether they are what is causing your ongoing problem. It might mean having to choose between cute shoes and cute toes. 

If your doctor suspects an infection, you may need to take an antibiotic. In addition, note that your doctor may need to remove part of or your complete toenail to ease the inflammation.

Trauma to the toenail can be chronic or occur as a result of an acute injury.

Toenail trauma may happen from repetitive rubbing against the shoe when walking or running. It may be that your new shoes are too tight or loose, which can lead to more friction against your toe as you work out. It can also be the result of a sudden injury, such as stubbing your toe or dropping an object on it.

Injury to the nail's growth center, or matrix, can result in a number of possible changes to the nail. Changes that can occur include blood and bruising beneath the toenail, toenail thickening, or toenail loss.

Toenail trauma can result in secondary bacterial or fungal infection if any part of the nail has come loose. This can lead to the dark discoloration of the toenail. Acute trauma may also result in a fracture of the bone beneath the nail, to which the nail is in close proximity.

Having a thick or otherwise damaged toenail removed surgically will probably not result in a healthier nail growing in its place. Once a nail's growth center (nail matrix) is damaged, it usually continues to produce a thickened or disfigured nail.

If you have a toenail problem, you may feel embarrassed by its appearance. Or you may be worried that whatever is wrong with your toenail is a window into an underlying health condition that has not yet been diagnosed.

Hopefully, though, this basic toenail knowledge will help ease your concerns a bit and get you prepared for your doctor's visit.