Have you ever taken the polish off your nails, only to find that something doesn’t look quite right? Don’t remember the color looking like that? Are there cracks in the nail? Spots on the nail? Is the top of the nail rough or seem ridged now? Changes in the appearance of fingernails and toenails can mean a number of things. Many people worry that any change must be from nail fungus, but it is not always the case. In some cases, the changes are from an injury you may recall. Let’s say, you dropped something on your toe or stubbed it. Some changes are from what we define as microtrauma, meaning pressure that has affected the nail over a longer period of time. This would be if you wear shoes that are too tight or too small, or if you run and your shoe contacts the top of the toenail with every stride. There are also underlying systemic conditions that can affect the appearance of nails.

Well then, how in the world are you supposed to know what is causing these changes? We typically have a number of ways to rule out (or determine what is NOT) the cause of changes until we are left with the answer as to what IS the reason. A simple in office test is performed in some cases which can help check specifically for nail fungus. In discussion with our patients, we often find out that there is something in their medical history that may be contributing to the changes in the nail that you see. The bottom line is, if you have concerns about a change in your nail, seeing a specialist is key in finding out what the cause is.

For nails that are discolored, the color of the nail provides some clues. If a nail appears black/dark red/brown and is something that was noticed seemingly overnight, it may be dried blood under the nail. This is a condition called a subungual hematoma. It is caused typically by acute injury or after a prolonged run. There is disruption in the nail where it attaches to the underlying skin and bleeding occurs under the nail which then dries. In cases of injury, our patients notice the color change AFTER noticing some amount of pain after an injury. For some of these people, the nail may need to be removed to fully evaluate the injury and to evacuate (or get rid of) the blood collection underneath as this is typically painful and can lead to infection under the nail. If this is due to repetitive pressure on the nail, these nails may not be painful, but if the subungual hematoma is extensive enough, the nail is likely to fall off at some point.

A white, patchy or spotty discoloration on the surface of the nail can be either that the nail is damaged from use of polishes, etc. which cause excessive drying of the nail. However, this can also be a fungus called T. Mentagrophytes. It is one of the two most common micro-organisms to cause nail fungus. If caught soon enough, this type of nail fungus responds more predictably to topical treatment than the other type of nail fungus.

T Rubrum is the other type of microorganism that is responsible for fungal nail infections. This type of fungus, when present, causes a yellow-brown discoloration that is moreso UNDERNEATH the toenail. In many cases it leads to a disruption in the connection between the nail and the underlying skin – therefore lifting the nail. We often see damaged nail that crumbles from underneath the nail and the nails affected by T Rubrum are often very thick.

If a nail has a brown appearance (even sometime similar to black/dark red), another possible condition is skin cancer, mostly malignant melanoma. Obviously there is a huge difference in treatment if this condition is present. Therefore, if you have dark color changes under the nail, we need to know how long it has been present, whether the location has moved or stayed the same and whether any pigments are noted in the adjacent skin. If there is a family history of skin cancers, a biopsy is necessary to fully evaluate for underlying cancer in a nail that has pigment changes.

If the color of the nail is generally normal, but the nail is brittle, this is often due to a lack of nutrients and/or water (hydration) that causes the nail to be weakened. If a nail has ridges present from one side to the other, these may be growth arrest lines. These occur when there are intermittent changes in health that damage nail here and there. This can occur in patients who have had chemotherapy, though there are many instances where we cannot determine the cause of intermittent disruption in nail growth.

Nail that have ridging from base to the tip of the toenail can be due to similar reasons as just mentioned. However, in some cases, this ridging (especially if deep or cracking through nail occurs) can be due to an underlying mass on the skin or bone under the nail. These masses can push up on the bottom of the nail and essentially cut through the nail as it grows forward. Removal of the nail help rule out soft tissue masses under the nail, while a simple x-ray or advanced imaging can help fully evaluate for bone spur that can be causing this.

If you have concerns about an altered appearance in your toenail, make an appointment today! A simple evaluation gives us a lot of information and we can then determine what the next steps in diagnosis and treatment will be!

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