Skin/Nail

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 swelling.

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.

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 deliver.

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 10-14 days.

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 tremendously.

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 ClearZal Bac, Elon Dual Defense Antifungal and Tineacide.

Onychomycosis can reoccur if your shoes are not properly treated, therefore an antifungal shoe 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 drying solution 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 economic value.

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 two examples;

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.

Fungus, 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 foot infections

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 mild 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 drying solution.

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.

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 (see below).

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 protrusion.

Another 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 periodic debridement.

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 mechanical friction.

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 a corn.

Corn pads and 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.

Periodic paring (debridement) of a hard corn can help to reduce the thickness of the callus. This can be accomplished with a safety razor, callus file or pumice stone. 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 neuropathy).

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 your corn.

Well fitted shoes, a dose of prevention and a knowledge of treating corns can make a world of difference in your comfort.