So you noticed your toenail was looking a little funky…a year ago. Now, you are panicked because it didn’t resolve on its own, or maybe it’s event starting to hurt…oh! And you’ve got this vacation coming up and are embarrassed to wear those sandals! When a nail doesn’t look quite right, a lot of different conditions may be at play and nearly none of them are easy to treat.

Toenails are without a doubt the least predictable and most stubborn part of the foot that we, as podiatrists, treat. Toenails grow much slower than finger nails, which adds to the difficulty in treating. A toenail’s normal growth rate is approximately 1 millimeter per month.  When the nail looks different (especially thick or discolored), the condition at play is likely further slowing the process of nail growth down even more. 

So what causes nails to look not-so-pretty? The two most common causes are conditions called onychomycosis and onychodystrophy…a mouthful, I know.  How do you know which you have?  The best answer is to seek evaluation, advice and treatment from a podiatrist who understands both processes well.  Unlike decades ago, there is a great way to fully assess the nail to ensure (to a much greater percentage) which condition(s) is present. Yes, both can be causes of the changes to your nails.  Nail biopsies are an easy and quick procedure that can be performed in the office without any need for anesthesia.  Once a sample of the nail is taken, a lab that specializes in conditions of the skin and nails evaluates it and performs a series of stains to determine whether a fungus is present. They also look at the sample under a microscope to determine any difference cells are present. 

Onychomycosis (on-ee-co-my-co-sis) is the technical term for a fungal nail. Just as many people experience Athlete’s foot as a reflection of fungal infection in the skin, nails can suffer the same type of infection. However, with nails, the rate of growth is a challenge in successful resolution – especially in instances where it has been left to go without addressing for more than a few months. There are two types of fungus that most often cause a toenail fungal infection. In case you feel like learning to pronounce a couple new funny names for your friends, they are trichophyton rubrum and trichophyton mentagrophytes. Each fungus may look a little bit different. If you see that your nail has more of a white discoloration and is mostly on the top layer of the nail, it is more likely that T. Mentagrophytes is the culprit.  If the nail looks more yellow-brown and is very thick with some crumbly stuff underneath, it is more likely T. Rubrum.  Just like a bacterial infection, knowing what fungus (or in some cases molds) are in the nail can help to figure out what topical medication has a better chance of curing the toenail fungus.

Onychodystrophy (on-ee-co-dis-tro-fee) is a term used to describe (for lack of better term) a damaged nail. Damage to nails can occur very obviously from dropping a heavy object on the nail or stubbing the toe badly. However, some of the damage that occurs to nails can be from simply having a shoe that is a little too tight and pushes on the nail a little bit every day. I can be from a toe position that puts pressure at the tip of the toe as well.  When onychodystrophy is present and there is a clearly defined cause of injury, the nail will not likely recover normal appearance on its own. Using topicals to thin the nail and improve the color will help, but when you stop using these products it is common to have the nail appear thick again as it grows in. This is due to the fact that the growth cells which produce nail are damaged and these cells do not readily recover from injury – so we are left to treat the nail you have.  In many cases, our patients may have experienced onychodystrophy prior to infection with a fungus. Any damaged nail is more susceptible to a fungal infection creeping in. Just like a cut on the skin if not tended to can become infected. The normal bacteria on the skin can get into the cut where it should not be and cause infection.

So what to do? As stated earlier, it is important to know what you area working with before you will know the possibility of improvement and how to get that improvement. Nails that are damaged and without fungal infection can improve in appearance with a topical thinning agent. This product has an active ingredient that decreases excessive keratin development (nails are made of keratin). This is in a liquid formulation that is applied with a brush. Again, this treatment will improve the nail thickness and often its appearance as well, but only works when used consistently and the time until improvement is noticed depends on how much ‘bad nail’ needs to grow out. In more rare cases of nail dystrophy, there may be a bone spur under the nail and this can be removed to reduce pressure and has the potential to help the nail grow more normally.

When you find out you have onychomycosis, but the nail is not markedly thick or lifted from the nail bed, topical antifungal medicines have great potential to improve the condition.  If the infection is affecting the entire nail to the level of the cuticle, topical medicines may help, but some patients may require short term use of an oral medication. In cases where topicals and oral medication work (or if the nail is so badly damaged that it is not likely to improve) the affected nail can be removed. In some cases it may grow back with an improved appearance, but if it does not there are even more rare instances where our patients want the nail permanently removed.

As you can see, there is a range of options available and to know which is right for you, a consultation and biopsy are a must. The biopsy is most often covered with your insurance plan. If you are worried about a nail – whether you noticed a change one week or one month or one year ago, get in as soon as you can. The longer you wait, the less desirable the outcome and to this date there is no option of toenail replacement.