Toenail Problems

Toenail plate anatomy:

1-       Toenail plate                                

2-       Side nail lips

3-       Tip of the nail

4-       Base of the nail

5-       Cuticle area

6-       Matrix cell layer

7-       Toenail bed

8-       Bone supporting the nail plate.

   

Toenail plate problems etiology (Reason):

  
 

Medical Problems:

  
  Fungal Infections:      
    - The toenail plate is made out of a protein called Keratin. It is almost the same as the protein in skin and in the hair.
  Psoriatic nail diseases:      
    - Psoriasis afflicts mostly the skin at stress points in the body like the elbows and knees, as well as the toenail plate and makes the nails become thicker and mottled..
  Bacterial infections. example: ingrown toenails.      
    - Bacteria lives on the skin and bacterial infection may set in a wounded toenail
  Vitamins insufficiency.      
         
  Oral and other medications.      
         
    - Athlete’s foot may cause toenail fungus to start, and the nail can have the fungal elements in it, which can cause future athlete’s foot conditions. It is a center for future infections.
         
  Traumatic Problems:      
  Nail trauma:      
    - Long toenails transfer force from the shoes to the anchoring cells that produce the nail and may cause nail plate thickening.
    - Nail trauma (something being dropped on the toenail) or having had previous surgeries.
         
  Cuticle Damage:      
    - Some patients think that it is best to remove the cuticle from the nail plate. That is not the case and removing that tissue that is a kind of a sealant to the base of the nail is counter productive, from two aspect, one infection and another is trauma.
         
   Abnormal anatomy:      
    - Toenail plate growth problems.
    - Bone spurs under the nail plate, forcing the plate to be “humped” in nature.
    - Cuticle not separating from the toenail plate and adhering to it to the mid or end of the toenail plate, especially on the smaller toes.
    - Ingrown skin, where the skin on the bottom of the tip of the toe, grows underneath the toenail plate and continues to grow on the underneath side of the plate as it grows forward. This can cause patient to trim their long nails and also trim part of their skin with it.
    - The side nail lips can be enlarged and can cause the nail plate to look ingrown, but enlarged and attention should be directed to that aspect not the nail plate.
    - There are abnormal growths that can grow on the nail bed that can affect the toenail plate, ex:  fatty tumors, or others.
    - There are viral infections that can affect the toenail plate or the nail bed, ex: viral or plantar warts.
Toenail plate problems treatment:      
  Medical treatment:      
  Oral medication:      
    Lamisil tabs    
      - Effectiveness about 50 % over 2 year period of time.
      - Can cause headaches 10 % of the same.  
      - Can cause liver damage more than 3 % and less than 4 % of the time
      - Can cause blood problems (1/1000 that could be irreversible).
      - Can cause other problems, ex: vision color changes etc.
       - Possible return of fungal nail plate after cessation of the medication.
      - Oral medication may be out of the system, but can remain in the toenail plate for one year.
      - Need to take one pill a day for three months and then stop for two years.
      - Liver function and blood count is required before, during and after therapy.
         
      - First test before the medication is started, then one month into the medication regiment,  monthly thereafter until the medication is stopped, then again after the medication has been stopped for a month.
    Sporonox Tabs    
      - Medication interactions.  
      - Need to take one week- stop for three times three months.
      - Fell out of use because of potential problems and warnings.
    Grispeg Tabs    
      - Not used for toenail infection, but other severe fungal infections.
  Topical Medications:      
    Penlac 8 %    
      - Effectiveness is 20 % over 2 year period of time  
      - Only medication that is approved by the FDA for Nail Fungus.
      - Minor irritation to the skin surrounding toenail plate.
      - Need to apply once a day and remove it once a week with alcohol or toenail polish remover.
    OTC medications:    
      - There are a lot of medications advertised over the counter that may or may not help with toenail fungal infection.
      - No proof of effectiveness established.  
    Hear say medical treatments:    
      - Vicks Vapor Rub into the toenail plate.  
      - Head and Shoulder application into the toenail plate.
      - Brush the Toenails with above.  
      - Clean socks with boiling water.  
      - Keep the shoes in the sun where the UV light can get to them and kill the fungus.
  Combination treatment:      
    Penlac & Lamisil at the same time:  
      - Results are encouraging at this time.  
      - Can be a do-able combination.  
  Surgical treatment:      
 

Remove the toenail plate & allow it to re-grow:

    
    -  Procedure involves removal of the toenail plate fully or partially and keeps the growth plate cells and allows the toenail plate to re-grow.
    - As the toenail plate is re-growing, the plate is exposed to topical medications.
         
  Remove the toenail plate and DO NOT allow re-growth:    
    - This procedure involves removal of the toenail plate, fully or partially, and do not allow re-growth
    - The previous statement is only true 80 % of the time. 20 % of the time the toenail plate will come back after which the procedure is redone and then it is 95 % effective and 5 % return possibility.
    - This procedure leaves the area with only skin.
    - Scab formation is a possibility.  
     - Possible hypersensitivity to the area of the removal, resolving in a couple of years.
     - No more toenail plate = no more food for the fungus to grow on.