Trimming thick painful toenails can be nearly impossible for older adults. Even the spouse of someone with thick toenails can find the task daunting. The last you thing you want to is hurt someone you love by cutting the nails too close. One San Francisco Bay Area podiatrist found that so many people needed the convenience of nail care at home, that he started a house call podiatry practice, just to fill the need. He now drives all over the Bay Area, Marin and the East Bay to provide podiatry services to private clients.
Almost everyone has seen “Digger the Dermatophyte” in the cartoon advertisements for Lamisil (the most commonly prescribed drug for toenail infections. In the ad, the nasty little creature lifts up the nail plate and climbs in, starting a fungal toenail infection (called “onychomycosis” by podiatrists). This is a relatively accurate depiction of how a fungal toenail infection starts. But not all thick, ugly, toenails are caused by foot fungus. Regardless of the cause, as a toenail becomes thicker, it changes the way light refracts through the keratin. This causes a yellow, white or grey tint to the nail plate. If the toenail has a rampant fungal infection, the fungus can cause crumbling, cracking and peeling away of the layers of the nail plate.For many people, particularly elderly people, they can be very difficult to trim or cut with regular toenail clippers. Those with rheumatoid arthritis also have a very hard time trimming these sorts of toenails.
The toenail grows out from the matrix, or root of the nail. The shape of the toenail matrix determines the shape if the nail plate itself. If the toenail gets repeatedly bumped against the inside of the shoe, the matrix tissue may get smashed and become deformed. If the matrix becomes thick, the toenail will then grow out thicker.Toenail Fungus can also cause the nail to become thicker. However it isn’t the only cause. One published study found that about half of all thick yellow toenails (that seemed to be fungal nails) actually had no clear evidence of a fungal infection. The thickness and discoloration was caused by something else. Sometimes it is activity related.
Onychomycosis (the medical term of toenail fungus) is usually caused by t. rubrum or t. mentagenophytes. Like other types of fungus, it thrives in an environment that is dark, warm and moist. Shoes are the perfect home for fungus. The inside of the shoe is dark (because it is enclosed), warm (because your feet are about 98 degrees) and moist (because your feet sweat and the shoes hold the moisture). If you wear the same pair if shoes to work every day, they may never dry out completely. They are almost like incubators for fungus.
Sports that require a lot of sudden stopping and turning (soccer, basketball, tennis, racquetball, etc.) can cause the toenail to slam against the inside of the shoe when stopping, turning or kicking the ball. Marathon runners and hikers also often develop this problem. After long runs (or long hikes) going up and down hills the toenail may turn black. This is really nothing more that bruising under the nail plate. But whether you hit the toenail once with hammer or bump it lightly on the inside of the shoe with a thousand strided, the result is the same. The trauma to the nail caused the capillaries to burst and bleed under the nail plate. Even f you didn’t feel it when it was happening, you have an obvious sign of injury.
Whether you hit the toenail with a hammer, drop a Thanksgiving turkey on it, or just bump it on the inside of your shoe again and again, trauma is a key ingredient for a fungal toenail infection. Any trauma or injury to the nail can cause the toenail to partially detach from the underlying tissue (called the nail bed). As soon as the nail plate starts to become separated from the nail bed, fungal spores can enter and set up a fungal infection.
Excess moisture in your shoes and socks is like fertilizer for the little critters that cause foot fungal infections and toenail fungus. It is no coincidence that people with excess sweating of the feet seem to develop more athletes foot. A fungal infection of the skin can make the skin too moist and more prone to the injury that starts an ingrown toenial. A fungal infection in the nail plate itself (known as a toenail fungus) causes the nail to become yellow, brittle and thick. The thicker nail places more pressure on the skin at the sides of the nail and can create an ingrown toenail.
Athlete’s foot and toenail fungus are caused by the same organism. If you suffer from chronic athlete’s foot infections, you are at higher risk of getting toenail fungus. During an athlete’s foot outbreak, the fungus is growing and repoducing in the skin. As the fungus grows, it pushed the outer layers of the kins apart. This results in the itchy peeling skin that you see. When the skin flakes off or peels away, fungal spores are shed. These fungal spores are deposited inside your shoes and socks. With all of those fungal spores sitting around, all you need is enough enjury to the nail plate to let the fungus in ans start a fungal infection of the toenail.
Diabetes is a chronic disease that affects many systems in the body. Diabetes also depresses your immune system. With impaired immune function, the diabetic’s body is less capable of fighting off a fungal infection. Toenail fungus is very common in diabetic feet. Unfortunately, fungal toenails can make the diabetic patient more prone to ingrown toenails as well. Ingrown toenails can quickly lead to a dangerous bacterial infection, and even a bone infection. Whenever a diabetic develops these sorts of infections, amputations can result.
HIV/AIDS produces severe loss of immune function. Anytime the immune system is decreased, it is easier for fungal infections to set it. Those with HIV are more prone to an unusual form of onychomycosis that grows on top if the nail plate. If you or someone you care about has HIV see a specialist who understands the condition. In addition to fungal infections, the antiretroviral medications used to treat HIV can lead to neuropathy in the feet. This can cause numbness that may make it hard to tell when an ingrown toenail is starting to develop.
Toenails that are infected with fungus are usually discolored (yellow, white, grey or brown). This is similar to those with only onychauxis (thickening due to repeated injury). However toenail with fungus usually have more cracking, and peeling. They are more friable. They also often smell bad. Lots of fungal debris (white or yellow crud) will collect under the end of the nail plate. It is often possible to examine this stuff under a microscope and see the fungal strands (called hyphae).The fungal toenails themselves are not necessarily painful. However, as they get progressively thicker, they can push down into the nail grooves beside the nail and cause painful ingrown toenails. The thick nails may also press inside the shoes and cause pain. In advanced cases (particularly with diabetes) ulcers (or open sores) can develop underneath the fungal nail. Any redness in the skin around the nail might mean a bacterial infection or inflammation is present.
In this study, your fungal toenail specialist will take a sample of toenail tissue. The sample is placed on a microscope slide with a drop of KOH (potassium hydroxide solution). The doctor then searches for little clear branching stands that sort of resemble bamboo. These are hyphae. If your podiatrist sees hyphae in the sample, you have a fungal infection. This test is fast, easy and cheap. The problem is that it is possible to get a sample of tissue that just doesn’t have any visible fungus. If that happens, your doctor might tell you that you don’t have onychomycosis, when actually you do. You are then less likely to get the treatment that will make the fungus go away.
In this study, your fungal toenail specialist will take a sample of toenail tissue. The sample is sent to a special podiatric dermatolgy laboratory. The dermatophatologist the applies a special chemical that will react with the fungus. When examined the normal then appears pink and the fungus appears green. The pathologist then takes a picture of the sample under the microscope and sends it back to your podiatrist to discuss with the patient. The little green strands of fungus can be seen boring right through the toenail. This test takes longer than a KOH exam, but is much more reliable.
In this study, your toenail fungus expert takes a sample of the nail that looks infected. The sample is placed in a special container with a gel that will allow the fungus to grow. If fungus is present it should grown when incubated at the proper temperature. If it does grown, it can be identified under a microscope to determine which organism it is that cause the fungal toenail. The benefit of a culture is that when it works you can be certain that fungus is present. You also get to learn which fungus is causing the toenail infection. This test takes much longer than the others, and is not very accurate.
Unfortunately many insurance companies “require” a positive fungal culture before they will pay for fungal toenail medicine. This of course save the insurance company money because almost half of all fungal cultures never grown anything. So the insurance companies can deny half of their patients the expensive medicine.
The goal of any initial treatment is to relieve the pain, and clear the infection or inflammation. If the toe isn’t infected, your foot doctor may be able to carefully trim the ingrown nail edge and fix the problem. An infected ingrown nail most often needs to have a portion of the nail removed. In severe cases, the entire nail may need to be removed. The portion of the nail that is removed will grow back. Local anesthetic can be used to numb the toe an lessen the pain. A bandage is usually placed on the toe by the podiatrist after treatment. Activities can usually be resumed the following day.
The best news about ingrown toenail treatment is that the relief is usually immediate. Most patients feel much better immediately after the painful portion of nail is removed. It also heals very quickly. When antibiotics are required, it s important to finish the entire prescription provided by your podiatrist.
Depending on the severity and thickness of the thickened toenail, a number of treatments might be recommended. For many elderly patients, just trimming the thick toenails every month or two to prevent them from becoming too thick and uncomfortable is enough. Tests can be performed to determine the nature of the fungal infection. If the concern is the unsightly nature of the nail, medications like Lamisil might be prescribed. There are also newer treatments that have some promise in helping to treat the toenail infection without oral medications.
If the thick fungal toenail has any drainage or redness at the border of the nail or end of the toe, an emergency appointment might be needed. This could be a sign of an ingrown or infected toenail. In some cases the infection can quickly spread and lead to amputations or other serious problems. Because they can be so painful, we offer 24/7 on-call availability of our foot doctor to treat this problem. We will even do housecalls, so you don’t have to try to wander around town with an infected painful toe. Housecall Podiatry appointments are available in San Francisco and the Greater Bay Area including Marin County, the East Bay and the peninsula.
Dr. Christopher Segler is a podiatrist and toenail specialist who believes that the best medical care requires personalized attention and great customer service. His podiatry practices serves San Francisco Bay Area people who are busy and still want the best care. He is an award-winning foot surgeon who provides the most convenient podiatry treatments possible in San Francisco. If you just have a simple question about whether or not your foot or ankle problem needs to be treated by a podiatrist, you can speak with him directly by calling Doc On the Run.