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Nail Fungus and Other Nail Abnormalities

Pain in the toenail area can be caused by thickening of the nail plate or incurvation of the nail border. A thick nail plate can cause pressure on the nail bed, especially when wearing shoes, which causes pain and sometimes ulceration of the nail bed. An incurvated nail border causes pressure on the skin adjacent to the are (the ungualabia) and may erode into the tissue, causing a local inflammation or infection commonly known as paronychia.

Thickening of the nail plate most commonly is caused by a fungal infection (onyuchomycosis) or traumatic injury to the nail matrix. Less commonly the nail matrix is damaged by chronic dermatoses such as psoriasis or eczema.

Treatment of the thickened nail is aimed at mechanically reducing the tissue and possibly treating the fungal infection, which is virtually impossibly using topical agents unless the infection involves only the distal end ofthe nail, which can be debrided easily. Most elderly patients are happy with routine debridement of the nail once every 2 to 6 months.

Topical antifungal agents useful in the treatment of onychomycosis are effective only if the affected portion of the nail place can be debrided thoroughly and the distal potion of the nail plate is involved. Clotrimazole solution, cicloprioxamine, and topical terbirnafine gel or cream are effective in this instance. Oral antifungal agents traditionally used in the past were griseofulvin.

Another form of onychomycosis is being observed in patients with AIDS. Rather than infecting the nail distally and progressing proximal, the infection starts at the base of the nail and progresses distally. It is also differentbecause it is white in color and rarely cause much thickening of the nail plate. This infection is termed proximal white subungual onychomycosisand if treated, oral antifungal agents usually are used.

Incurvation of the nail border, termed onychocryptosis,can be congential or acquired. The acquired form usually is caused by chronic pressure from footwear, the adjacent toe, or ground reactive forces on a deformed digit. The patient may complain of pain, swelling, redness, and possibly drainage. The patient often attempts to remove the offending wedge of nail and cause a sharp nail spicule or a laceration of the ungualabia that goes on to infection a few days later.

Treatment of this condition usually requires removal of the offending nail border for resolution of the pain or infection. Oral antibiotics may be temporarily effective, as are foot soaks, but they usually do not eradicatethe problem. Local anesthesia usually is required for this procedure in the form.

If this is the first occurrence, a partial nail avulsion is performed and the nail border is allowed to grow out. If the problem recurs or becomes chronic, a partial matrisectomy procedure or permanent removal of the offending border of the nail.