titles for more details.
Ingrown Toe Nail
Most ingrown nail infections
can be described as a simple foreign body reaction. The nail grows into
the skin and acts as a foreign body, just like a splinter or a piece of glass.
Continued pressure by the nail against the skin causes inflammation and a soft
The most common reason we develop ingrown
nails is due to improper trimming of the nail. The nail is very weak when
twisted (torsion). If the nail is trimmed so that a small spur, called a spicule, is left on the border of the nail, the nail
will continue to grow forcing the spicule into the skin. As the skin
responds to this 'foreign object' it becomes inflamed and sore. The area
adjacent to the nail will become increasingly more difficult to trim, and so
begins the vicious cycle that we call an ingrown nail.
The majority of ingrown nails are on the hallux
(big toe). Pain is usually tolerable until the nail is bumped or stepped
on. Ingrown nails are extremely common in adolescent boys and in women 2-3 months
postpartum. Why? Young boys seem to have little regard for regular hygiene and
pregnant women have a difficult time reaching their feet during the last several
months of their pregnancy, not to mention the additional burden of their feet
The shape of the nail can also be a contributing
factor for ingrown nails. Pincer nails( as shown to
the left), a term used for nails that have a
pinched appearance, put pressure on the periungual folds. As
shoe pressure is exerted on the nail, the edges of the nail push into the skin
just as the weight of something put on a table pushes through the legs of the
table to the floor.
Other contributing factors that may cause ingrown
nails include trauma to the nail, pressure from adjacent
toes and the shape or profile of the forefoot in relationship to the shape of
the toe box of the shoe. Medical conditions, such as fungal infections or
psoriasis, can change the shape of the nail and contribute to ingrown nails.
Treatment for ingrown nails
Ingrown toenails are treated much the same as a splinter.
Antibiotics and soaking can help to reduce the inflammation associated with the
ingrown nail, but until the foreign object (ingrown nail) is removed, the stale
mate between the nail and adjacent skin will continue. Removal of the
offending border of nail is necessary in most cases of ingrown nails.
Many have suggested the 'proper' way to trim the
nail, but in actuality, every nail is a bit different from the next nail.
Therefore, it's most important to trim the nail with
quality nail trimmers in a way that it is not going to
irritate the periungual fold. Trimming the nail straight across may work
for some but is ineffective for others. Some advocate cutting a groove or
V in the distal tip of the nail. This is also ineffective. Cotton under
the edge of the nail has been tried, even metallic clips that 'lift' the nail,
but each of these will fail in time unless the offending border of the nail is
removed. NailEase may
help to lift the edges of the nail in a limited number of cases. Many pregnant
women develop ingrown nails due to their inability to reach their feet. NailEase
is a great product for them since they are poor surgical candidates until they
The technique used most commonly today to treat
infected ingrown nails is called a phenol-alcohol procedure (P&A procedure). This
procedure is performed in the office under a local anesthetic on
an out-patient basis. After the toe is numbed and cleaned with a
disinfecting agent, a thin margin of nail is removed. Phenol, which is 77%
carboxylic acid, is applied to the nail matrix to kill the cells that produce
that small margin of nail only. The phenol is then flushed out with
alcohol. Patients can return to a Band-Aid and regular shoes the next day.
The interesting thing about the phenol-alcohol
procedure is the lack of pain experienced by patients following their
surgery. This is due to the fact that phenol has a topical anesthetic
property that last for 2-3 weeks. Although the procedure will drain for
several days, the benefit of using phenol is significant. Phenol is best
know as the active ingredient in Chloroseptic Mouthwash Spray. In
Chloroseptic, phenol is used in a more dilute concentration but has the same
effect in that it inhibits sore throat pain.
Other surgical procedures may be used with or
without phenol and include the use of a CO2 laser or other chemicals to destroy
the matrix cells. The decision to remove one border, both borders or the
entire nail should be discussed with your doctor.
The following images show the steps involved in correcting an
ingrown nail with a P&A or phenol alcohol procedure. Image 1 shows
administration of local anesthesia. Once the nail has been anesthetised,
the foot is prepped with a Betadine or comparable solution. Image 2
shows a small tourniquet (Penrose drain) around the toe to inhibit bleeding (hemostasis).
A nail splitter is being used to create a clean split to remove just the borders
of the nail. Image 3 shows a hemostat being used to remove the nail.
The nail bed is then scraped with a small curette to physically destroy the nail
matrix. In image 4 we see the application of phenol. Phenol
application is normally done 3 times for 5-10 seconds each application.
And image 5 shows the final bandage. This procedure is completed in 10
minutes and is performed in an office setting. Post-op care varies, but
steps are taken to promote drainage of the nail and may include Epsom Salt soaks
or application of steroid/antibiotic drops. Patients return to a normal
shoe the day after surgery wearing just a 1 inch Band-Aid. Healing takes
| ingrown nail |
Onychomycosis refers to a fungal infection of the toe or
finger nail. Onycho refers to the nail and mycosis refers to a fungal
condition. Onychomycosis is very common in the toe nail and is seen to a much
lesser degree in the finger nail. It is estimated that 50 million
Americans suffer from onychomycosis. The organisms that cause
onychomycosis are usually fungus (90% of cases) or yeast (7% of
If you have a fungal infection in the nail, is it your fault? No,
not at all. Onychomycosis has nothing to do with hygiene. But unknowingly, we
can contribute to the growth of onychomycosis. The environment inside the
shoe is dark, damp and warm. This environment is wonderfully conducive to
the growth of onychomycosis.
It is safe to say that 50% of folks over the age of 50 have
some degree of onychomycosis. But this doesn't necessarily
mean that onychomycosis is due to 'old age'. But we can imply that over the
course of our lifetimes we would have more opportunities to acquire a fungal
infection of the nail. The reason that onychomycosis becomes more prevalent
with age is due to accumulated trauma to the nail over time. Trauma makes the nail much more susceptible to
onychomycosis. It's also reasonable to assume that folks in
professions or social activities where they may abuse their feet would tend to have a higher rate of
onychomycosis. An example of activities that may abuse the feet and nails would
included a mechanic dropping tools on their feet, horses or cattle stepping on
the toes or runners who constantly injure their nails. An injury to the nail is a common precursor to
onychomycosis. Trauma may be something abrupt or something as benign as a pair of
ill-fitting shoes constantly rubbing on the nail.
The appearance of onychomycosis can vary but most cases begin
at the distal tip of the nail and slowly progress into the nail over a period of
months to years. The nail will thicken as the fungus continues to
grow. The filaments of fungus take up space in the nail causing it to
swell. The nail can be yellow, white or even green to black. The
nail also begins to be chalky and flakey.
Treatment of toe nail fungus and onychomycosis
The single most important thing that you can do to
protect the nail from onychomycosis is to protect the nail from injuries.
A healthy nail acts as a protective barrier to fungal infections.
Once the nail is injured, the door of susceptibility swings open, allowing entry
of the fungus. Also, keep
the feet dry. Keeping the feet dry
will inhibit the ability of the fungus to thrive. Frequent changes of socks, the use of powder, such as baby
powder and rotating shoes so that they are worn only every other day, can help
Medications used to treat onychomycosis fall into two categories;
topical and oral. There are any number of effective topical medications
available over the counter. Topical medications are most helpful in
treating early, small infections and for maintaining clear nails. Topical
medications do have a limited ability to penetrate the nail to reach all of the
fungal elements. Topical medication inhibit the growth of onychomycosis
allowing for faster growth of the nail. Remember, fungus doesn't take a day off. Compliance is a big issue when using
topical antifungals. A number of effective over the counter (OTC) antifungal medications
are available including
Elon Dual Defense
Antifungal and Tineacide.
Onychomycosis can reoccur if your shoes are not properly
treated, therefore an
spray. Keeping the feet clean and dry is another important part of
treating fungal infections of the skin and nail. The daily use of a
will significantly decrease the ability of a fungal infection to thrive.
The newer generation of oral antifungals, including Sporanox and Lamisil
have been received very well by the medical community. Patients with a history
of liver disease should avoid the use of these medications due to their
hepatotoxicity. The older generations of oral Rx antifungal medications, Fulvicin or Griseofulvin,
have been used successfully for years and are making a comeback due to their
It's important to recognize that the use of a topical or oral
antifungal may temporarily treat onychomycosis, but the literature does show
that most cases of onychomycosis will recur without the use of a topical
antifungal. Topical antifungals are commonly used on a prophylactic basis
to inhibit the recurrence of onychomycosis.
Patients who use a topical or oral antifungal medication should
realize that the medications may treat onychomycosis, but these medications
cannot restore the normal shape of the nail. In long standing cases of
onychomycosis, nails change in shape becoming thick. Nails also separate
from the underlying nail bed. Oral and topical antifungals cannot restore
the shape of the nail or re-attach the nail to the nail bed.
When all else fails, the fungal toe nail can be permanently
removed. This procedure is not difficult to perform and most patients
return to their normal shoes in just a Band-Aid in 24hrs. The removal of
the nail is permanent. The site once occupied by the nail heals with skin
that can been painted with nail polish as seen at left.
Which choice is right for you? Consider the following
Case 1. Sandy is a 24 year old hairdresser who has intimate,
hands-on contact with her clients on a daily basis. She has developed a
fungal infection in several of her finger nails. She is concerned that the
fungal infection will have a direct impact on her livelihood and does not want
to spread the infection to others.
Case 2. Joe is a 62 year old farmer and has a long history of
injuries to his hands and feet. His last visit to the doctor showed signs
of an increase in his liver enzyme studies indicating an overall decrease in his
liver function. Joe has developed onychomycosis in most of his toe nails.
I think the choices for Joe and Sandy are clear but in most cases
the criteria to make recommendations for treatment of onychomycosis are not as
obvious. In those cases, patients should consult their physician to discuss the
pros and cons of treating onychomycosis.
| fungal nail infection |
Athlete's foot is the
common term applied to a number of different fungal infections of the foot.
The medical term for this condition is tinea pedis; tinea referring to the
causative organism and pedis referring to the location of the infection.
The two fungal organisms we see most often are tinea rubrum and tinea
mentagrophytes. Tinea rubrum is often mistaken for dry skin and is the most
common fungal organism found in low-grade chronic fungal infections. Acute
athlete’s foot, on the other hand, is characterized by bubbles, blisters and
itching. T. mentagrophytes is the organism most often seen in acute
infections. Both organisms cause inflammation in the skin that leads to
or the plural, fungi, are non-flowering plants that lack chlorophyll.
As plants, fungi are
very sensitive to their environment. Fungus thrives in a warm, damp and
dark environment. Lacking chlorophyll, fungi can't synthesize their own food and therefore
have to live off other organic material. In the case of athlete's foot, the tinea organism is actually living off of the dead skin cells of our foot.
Treatment of athlete's
When working with
patients, the first thing I always stress is the difference between fungal
infections and bacterial infections. Bacterial infections are a finite
problem, meaning to say that you can cure most bacterial infections with an
antibiotic in a brief period of time. A good example would be the treatment
of strep throat with penicillin. A 10 day course of penicillin and the
strep infection is cured. Fungal infections of the foot cannot be cured and subsequently needs to be treated a bit
differently. To help explain fungal infections to my patients, I often draw
on the analogy between the treatment of fungal foot infections and
crabgrass. Both are nuisance plants. Both will reoccur
without ongoing treatment. My point is that you wouldn’t expect crabgrass
to disappear with a 10 day course of treatment. Nor can you expect a
fungal infection to clear with a short course of oral medicine. You need an
ongoing plan if you intend to control athlete’s foot.
Oral medications used
to treat fungal infections of the skin and nail have become popular over the
past several years. Medications such as Lamasil and Sporanox can be used
successfully to treat an acute fungal infection, but these medications will
not provide long term coverage. Their cost and profile of side effects are
significant. Oral medications simply can’t be looked upon as a cure
for athlete’s foot infections. Therefore, if you choose to use an oral
medication, remember that you will need to continue using a topical
medication once the oral medicine is discontinued.
Some of the
traditional methods used to treat fungal infections are really quite simple
and effective. We spoke of dark, warm and damp-well change that. Create
and environment in the shoe that is cool, dry and accessible to UV light.
Following these simple
suggestions can dramatically change the course of a fungal infection:
1. Rotate your shoes
every other day to allow them to dry thoroughly.
2. Avoid synthetic materials like rubber or vinyl, wear leather or cloth
that can absorb moisture.
3. Frequent changes of socks to wick away moisture.
4. Use talc or baby powder daily to wick away moisture.
One thing to remember
is that for many patients, 'curing' a fungal infection of the foot may never
happen. Those patients who are susceptible to re-infection will, in all
likelihood, be managing this condition for life. One of the best tools we
can offer is an education in how to decrease the tendency to re-infect.
We've already discussed the steps we can use to change the environment in
the shoe. I can't stress how important these steps are in decreasing
re-infection and managing recurrence. Also, the daily use of a
antifungal cream and antifungal soap is essential.
To prevent re-infection, an in-shoe
disinfecting agent is helpful. Control of perspiration is also
important and can be accomplished with daily application of a
When managing an acute
case of athlete's foot, we need to fall back on a prescription strength
topical creams or ointments. There are a number of different prescription
strength creams and lotions available from your doctor. There are also many
other effective topical medications that are OTC and can help manage the
acute phase of these infections. In limited cases where a fungal infection
is quite severe, we may even use an oral antifungal but these cases are few
and far between.
So how is athlete’s
foot best managed? There’s no single best method. Change the environment
in the shoe to be cool, dry and open to the light. And remember the
crabgrass analogy. If you’re sincere about a having a healthy lawn, you’ll
have an ongoing treatment plan. So when treating athlete’s foot, you’ll
need an ongoing plan and a commitment to treat your feet on a regular basis.
| foot fungus|
Why do we develop calluses? The formation of callus is
a protective mechanism used by the skin to respond to external mechanical
irritation. Any area of skin can form callus, but the most common
locations for callus on the foot include the bottom of the
foot, the side of the foot or even between the toes. Regardless of location, the cause of the callus is going to be external
pressure that pushes against a boney prominence. The skin becomes irritated and
thickens in response to this mechanical irritation. This thickening of the
skin is what we call callus. What is the cause of this external
pressure can be due to the ground (affecting the bottom of the
foot), the shoe (affecting the sides or the top of the foot) or even and
adjacent toe (affecting between the toes).
By definition, the build up of protective skin on
the bottom of the foot is called a callus. If the same problem
occurs on the toes, it's called a corn. There's a host of different types
of calluses some of which are described in the nomenclature section of this page
The most common spot for callus is on the ball of the foot just
behind each of the five toes. The ball of the foot is actually
anatomically analogous to the area of the palm of the hand where we tend to form
callus. Both of these areas are load bearing surfaces and areas of bony
common area of callus on the foot is on the rim of the heel. Heel callus,
or what are often called
heel fissures are a unique form of callus that form from tension placed upon
the rim of the heel.
The presence of a callus does not necessarily indicate that
there's a foot problem. Most calluses do not require the care of a doctor
and can be treated at home with
topical medicated callus creams and
| painful callus|
Corn And Callus
Inherent in walking or
running is the battle between a fixed surface (the floor) and the foot
delivering force with each step. Each step results in friction that can
irritate the ball of the foot and the toes. In a response to friction, skin will
often thicken to form a protective outer layer. We call this thickening a
corn or callus.
Corns and calluses come in all shapes,
sizes and varieties. Corns can be found on the tops of toes, between toes, at
the tips of toes or even adjacent to the nail. A corn is simply the formation of
a callus on a toe. The terms corn and callus can be used interchangeably, but
for sake of conversation, a callus is a build up of skin on the bottom of the
foot or heel, while a corn is a build up of callus on the toes. Initially, the
formation of callus can be a helpful process. As the skin senses a mechanical
irritation it responds by thickening, forming a callus. What do we mean by
mechanical irritation? Well that could be a shoe that is too tight, it could be
friction against the ground or it could even be the mechanical friction that
occurs between two toes. In each case, corns form by the recurrent rub of
The most common corn is
due to contraction of the toe (hammer toe) placing pressure on the top of the toe from the toe box of the shoe. This type
of corn, is referred to as a helloma dura (HD), or hard corn, and is often seen
in cases of hammer toes where the toe is contracted and pushing against the roof
of the shoe. Soft corns, on the other hand, are found between the toes. Soft
corns, also known as HM's (helloma molle) or kissing corns, are commonly
misdiagnosed as a chronic athlete's foot infection. With soft corns, we’ll see
a breakdown of the skin between the toes. This breakdown is usually between the
4th and 5th toes.
Treatment of corns
The most important aspect
of treating a corn is to be sure that the shoe is properly fit. Consider the
formation of a hard corn to be no more complicated than the analogy of a square
peg and a round hole. The foot is the square peg that just doesn't fit into the
round hole (the shoe). Our choices are to make the round hole (shoe) bigger or
softer by wearing a wider or softer shoe. Or we make the foot (square peg) more
narrow by surgically correcting the foot. Alternatively a corn pad can also be
used to cushion the corn. Common sense would tell us to first try to modify the
shoe or use a corn pad.
The distal end of the shoe that covers the toes is called the toe box. The
width and depth of the toe box are very important when trying to obtain a good
fit. An improperly fit toe box can contribute to developing corns. Try this
simple test. Stand barefoot on the floor. Place your shoe on the floor right
next to your foot. Now compare the shape of your forefoot and the shape of the
toe box. If the two are incompatible, you're looking for trouble and asking for
callus pads come in all
kinds of shapes and sizes. Choosing the correct pad depends upon three things;
(1) the location of the corn or callus (2) the type of shoe in which you intend to wear
the pad and (3) the activity you plan to participate in while wearing the pad.
Soft corns respond to the use of a pad that separates the toes.
Soft corn pads can
be made from silicone gel, soft foam or lambs wool. Many folks find relief with
a simple cotton ball that’ll separate the toes. Foam and gel toes sleeves are
another popular solution for hard corns. Hard corns can also be treated with
gel cushions and adhesive backed felt ‘cut out’ pads.
(debridement) of a hard corn can help to reduce the thickness of the callus.
This can be accomplished with a
callus file or
Topical callus creams can also be used to soften callus prior to
debridement. Care should be exercised with medicated callus creams in
patients with poor circulation or loss of sensation (peripheral
Permanent correction of
corns can be accomplished by a number of different surgical procedures. The
procedures vary dramatically based upon the type and location of the corn. Some
corns are quite easy to correct, others a bit more difficult. Your podiatrist
can help you determine whether you may be a candidate for surgical correction of
Well fitted shoes, a dose
of prevention and a knowledge of treating corns can make a world of difference
in your comfort.
| corn foot|
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