Keratin is the main protein that makes up our skin, hair and nails. As part of the dermatological system, it is important in protection of the body. This type of protein is less likely to tear or break than other cells in our body. Our skin serves to block out pollutants and germs. What is the purpose of toenails though? If you look it up, you’ll find that toenails and fingernails are essentially ‘evolutionary remnants.’ That means that while nails used to be helpful for us, they no longer serve the same purpose given our evolutionary advancements. Nails used to help us to pick things up and climb – think of them as our equivalent of hooves or claws. Now that we have advanced, we don’t tend to climb trees or grab fish out of a river to sustain. In some instances, toenails can protect our toes from scrapes and injuries and lessen the severity of an injury.

Nowadays, nails are often a nuisance – especially when something goes wrong. Have you ever had an issue with your toenails? At a podiatry office, you can imagine that we see a variety of issues with toenails. We see nails that are ingrown, infected, fungal and damaged. Sometimes the cause of the issue is known and sometimes we’re all stumped about why a nail looks or feels a certain way. I’ll break down the common issues with see with toenails below.

  • Dystrophic nails
    • When broken down, the word dystrophic simply means ‘of bad nourishment.’ We also refer to this as a ‘damaged’ nail. A dystrophic nail can be due to a variety of causes, so we will find sometimes that there are other underlying conditions of the nail present. If a nail is dystrophic and all other causes of changes to the nail have been ruled out (ie. No fungus is present in the nail), most often the reason for the changes seen and felt are due to microtrauma or trauma. As you can imagine, trauma to the nail happens in the form of badly stubbing the toe or dropping a heavy object on the end of the toe and the toenail. Microtrauma describes the scenario whereby a toenail suffers repetitive injury in the form of pressure from shoes or even tapping of the tips of the toes on the ground or insole. Running in shoes that are too small are a perfect example of this. Pressure to the tips of toes can be caused by deformity of the toes themselves – have you heard of hammertoes? The toes are curled under which means that when walking there is more pressure at the tip of the toe and especially if nails are longer they can jam into the cuticle area enough to damage the growth cells which are responsible for nail growth.
    • A nail that is dystrophic is also more predisposed to suffer fungal or bacterial infection, as the damage compromises its protective abilities.

  • Subungual hematoma
    • As a continuation of our discussion on nail trauma, a subungual hematoma is a condition that arises as the result of traumatic injury to a nail. This can also happen in instances of microtrauma. If you know any runners, they may mention that they have lost their toenail(s) many times after long races or runs. By definition, a subungual hematoma is a collection of blood underneath the nail. If there is a traumatic injury to the nail, this bleeding may be due to an actual laceration of the skin under the nail (nailbed). When this happens, the recommended treatment is to remove the nail (if it hasn’t already lifted off) in order to fully assess the injury to the skin underneath. If a fracture has occurred concurrently AND there is an open wound under the nail, this is considered an open fracture and requires the use of antibiotics to reduce the likelihood of infection of the bone underlying the nail.
    • Smaller subungual hematomas or those without corresponding fracture may be treated by drilling a small hole into the nail to release the fluid and pressure from underneath. This may sound painful, but in instances where the pressure is this high under the nail it is a great relief of pain once drained. For subungual hematomas of the smaller toenails, they may not become particularly painful and the hematoma may actually dry up and the nail then grows out. In some cases, the nail may grow out and fall off later.

  • Fungal toenails
    • Fungal toenails are more common than they may be thought to be. The type of fungus affecting the nail typically dictates which types of changes to the nail are seen. The two main microbes causing fungal infections of the nails are Tinea Mentagrophytes and Tinea Rubrum. A nail affected by T. Rubrum will often appear yellow-brown discolored, thickened and crumbly underneath the nail. T. Mentagrophytes infection is more superficial and appears with a white chalky discoloration and is less often associated with thickening of the nail. Some mistake the finding of a T. Mentagrophytes infection with changes from leaving nail polish on too long and ‘not getting enough air’ to the nail.
    • People always wonder where they ‘picked up’ a fungal infection in the nails. Typically people feel that swimming at a pool or sharing a common shower – at an athletic club for instance – are the only places where this fungus lives. However, this fungus is all over in our environment. We can even contract these fungi from our pets, especially because they are out in the environment without shoes, etc.
    • What tends to happen is that the host (person) becomes compromised and when the immune system and protective measures are evaded, the fungus moves in. Compromised immune systems are typically the result of chronic disease such as diabetes or malnourishment. If a nail is already damaged, its mechanical protective mechanisms are compromised, making it more susceptible to infection. The same fungi discussed above are causes of tinea pedis (athlete’s foot) and if the shoes and skin continue to be a good environment for the fungus, it will eventually affect the nails.

  • Ingrown toenails
    • It is first important to define this term. An ingrown toenail is not always infected. It does not always bleed, drain pus, get red. An ingrown nail alone causes pain due to the shape of the nail border and the pressure it places on the adjacent skin. For some, an ingrown nail is due to the shape their nail inherently grows and can even be genetic. For others, ingrown toenails may result due to a nail being trimmed incorrectly or due to wearing inappropriate shoes that result in pressure to the nail border that otherwise would not be there. There are some instances of people recalling an injury to a nail in the past, and this can cause the nail to grow with a different shape than previously – curving into the skin when it may never have done so before.
    • An infected ingrown toenail is when the incurvated border of a nail pierces the skin slightly and allows bacteria from our normal flora to get where it shouldn’t be. When the body responds to fight this bacteria off, the result is redness and sometimes pus drainage. Infected ingrown nails do not typically resolve with antibiotics alone. If the border of nail that has caused damage to the skin is still present, the infection can re-start once the antibiotics are complete. Often these nails require some trimming and often a procedure to remove the portion of nail causing the infection as well as any infected tissue.

Having ingrown toenails treated is not always pleasant in the short term, due to the need for nail trimming and possible injections. However, once the issue is resolved, it is typically clear how to avoid future pain and problems. The same is true for acutely treating a subungual hematoma. What is more challenging is treating the dystrophic or fungal nail. All too often, a fungal nail is not evaluated or addressed until either the entire nail or multiple nails are affected. In these instances, the nail is usually so damaged that the best improvement is still unlikely to result in a completely normal looking nail. Early treatment is the key to success. Regarding dystrophic nails, as they are a result of damage to the growth cells producing the nails, they do not tend to recover and grow normally again. Rather, in these cases, treatment is focused on trying to manage the thickness of the nail and if the treatment is discontinued, the results will stall and the condition can return to its original state.

Don’t wait if you are noticing changes to the color or thickness of your nail. The longer the condition continues, the less likely treatment is to be successful – and it always requires diligence.