An Overview of Common Toenail Problems

Toenails function like armor by protecting your toes' delicate bones, nerves, and soft tissues from injuries. Toenails are made of keratin—the same protein that forms your hair and the outer layer of your skin (the epidermis).

Your toenails can become irritated for many reasons, like wearing shoes that are too tight, cutting your toenails too short, or even being exposed to high heat and moisture in your environment.

Sometimes, toenail irritation is due to a common toenail problem, such as fungal infections, ingrown toenails, and trauma (injuries). You may notice toenail symptoms such as:

• Crumbling
• Thickening
• Discoloration (such as black toenail)
• Swelling
• Pain
• Warmth
• Falling off

This article provides an overview of the most common toenail problems, as well as their symptoms, causes, and treatment options. It also includes several toenail problems that are specific to females.

Ingrown Toenail

An ingrown toenail occurs when the edge of the toenail, usually on the big toe, grows into the skin next to it (called the lateral nail fold or medial nail fold).

Ingrown Toenail Symptoms

An ingrown toenail causes pain and swelling at the side of the toe. It may get infected, which can trigger:

• Redness or dark discoloration, depending on your skin tone
• Additional swelling
• Pain
• Warmth
• Discharge

Note that the ingrown part of the nail is usually unseen because it's below the skin. 

Causes of an Ingrown Toenail

Factors that increase your chance of developing an ingrown toenail include:

• A family history of ingrown toenails
• Abnormal toe shape
• Advancing age
• Fungal infections
• Health problems like poor leg circulation or lung disease
• Improperly fitting shoes or socks 
• Nail trauma
• Toenails that are clipped too short
  

Treating an Ingrown Toenail at Home

You can treat most ingrown toenails at home unless you:

• Suspect an infection
• Have diabetes
• Have nerve damage (neuropathy)
• Have poor circulation

In those cases, you should see a healthcare provider such as a podiatrist (foot specialist).

The first step for at-home care is to soak your foot in an Epsom salt solution using room-temperature water. Then massage the side of your nail gently to decrease inflammation.

Be sure to not cut your toenail. Consider wearing open shoes like sandals until the problem resolves.

In addition, you may have to take a closer look at the fit and shape of your shoes and socks to see if they're causing the problem. They may be too tight. The health of your feet, not fashion, should guide your shopping.

Medical Treatments for Ingrown Toe Nails

If you have a recurring ingrown toenail, suspect you have an infection, or at-home treatments are unsuccessful, see your healthcare provider or podiatrist for treatment. An infected ingrown toenail will typically clear up with antibiotics.

In some cases, an ingrown toenail may require a simple surgery known as a partial nail avulsion. The simple, in-office procedure removes part of the nail plate.

First, your healthcare provider will inject a local anesthetic into the toe. Once the area is completely numb, the ingrown part of the nail is removed.

Following the procedure, your healthcare provider may recommend phenol treatments to help guide nail regrowth. The podiatrist applies a small amount of phenol to the outer edge of the nail for one to four minutes. Repeat treatments are often needed as the nail grows back over the next two to four months.

Toenail Fungus

Toenail fungus, or onychomycosis, is a slow-growing infection of the nail and skin beneath it. Fungal infections usually occur underneath the nail and begin at the tip of the nail, where you trim it.

Toenail Fungus Symptoms

The most common symptoms of toenail fungal infections include:

• An increase in white debris beneath the nail
• Crumbling
• Discoloration beneath the nail (usually brown, white, or yellow)
• Loosening or separation of the infected part of the nail from the nail bed
• Thickening of the nail

Less often, an infection can appear as a white, powdery discoloration on top of the nail. 

Causes of Fungal Infections

Toenail fungal infections are usually caused by the same type of fungi that cause athlete's foot. In fact, people who are prone to athlete's foot may also be susceptible to toenail fungal infections.

Toenail fungus can affect anyone, but it becomes more prevalent with age, certain diseases (e.g., diabetes, circulation problems), and a suppressed immune system.

Other risk factors include:

• Frequent fungal skin infections
• Hyperhidrosis (a tendency toward sweaty feet)
• Wearing closed shoes for long periods of time (fungi thrive in moist, dark, and warm environments)
• Trauma to the nail

Treating Toenail Fungus

Treatment at a foot specialist (podiatrist)'s office will likely involve something called debridement (trimming away thickened areas). This can relieve pain from the thick nail pressing against your shoes.

Debridement may also make topical treatments more effective.

Oral (taken by mouth) antifungal medications and/or prescription-strength topical treatments (applied to the skin) may also be prescribed. However, oral antifungal medicines aren't always a good choice due to their potential side effects and cost.

You can buy a lot of over-the-counter (OTC) treatments for toenail fungus. However, since the fungus resides deep in the nail and underneath it, these medications have limited success in treating toenail fungus. This is especially true if it has spread significantly throughout the nail.

The good news is that other fungal nail treatments are available, including a laser treatment that has been cleared by the U.S. Food and Drug Administration (FDA).

Toenail Trauma

Trauma to the toenail can be chronic (long-lasting) or from an acute (short-term) injury.

Toenail Trauma Symptoms

Toenails grow from an area below the skin known as the matrix, which is connected to the blood vessel and nerve-rich nail bed beneath it.

Injury to the matrix can result in a number of possible toenail changes, including bruising beneath the toenail, thickening, and nail loss.

Causes of Toenail Trauma

Toenail trauma may happen because of repetitive rubbing against a shoe when walking or running. It may be that your new shoes are too tight or loose, which can lead to more friction against your toe.

Trauma can also be the result of a sudden injury, such as stubbing your toe or dropping an object on it.

If trauma makes any part of the nail become loose or separated from the nail bed, it can lead to a secondary bacterial or fungal infection. This can cause dark discoloration of the toenail.

Acute trauma may also result in a fracture (break) of the bone beneath the nail, which is in close proximity.

Treating Toenail Trauma

Depending on the injury, treatment for toenail trauma can include home care or a trip to see a healthcare provider.

For most minor toenail injuries, you can:

• Trim or file any rough edges so it doesn't catch on anything.
• Soak your toe in cold water for 20 minutes after trimming.
• Apply petroleum jelly (Vaseline).
• Cover with a bandage.

For a large tear, trim off the detached part or cover it with an adhesive bandage until it grows out enough to protect the sensitive skin underneath.

You can prevent an infection by:

• Soaking your foot in warm salt water for 20 minutes several times a day for three days
• Using petroleum jelly and a fresh bandage after each soak
• Keeping the area clean, dry, and covered until either the nail grows back or the nail bed becomes firm

See a healthcare provider if you suspect your toenail is infected. Symptoms include:

• Pain
• Swelling
• Heat
• Discoloration
• Draining pus

Sometimes, a healthcare provider will drill a hole in or surgically remove a damaged toenail. This is done to relieve pressure from swelling.

When the new nail grows in, it probably will be thickened or disfigured due to the damaged matrix.

Clubbed Nails

Nail clubbing is a condition that can affect the fingers or toes, in which the digits form a bulge at the end and the nail turns downward. Clubbed nails are not a standalone disease, and they are rarely idiopathic (without an underlying cause). Clubbed nails are almost always a sign of an underlying illness.

Clubbed Nails Symptoms

Clubbed nails are typically painless, but can result in the following symptoms:

• Softened nail beds
• Nails that become loosely attached to the nail beds
• Nails that form a sharp angle with the cuticle
• A bulge at the end of the finger or toe
• Warmth and redness of the finger or toe
• A down-turned fingernail that looks like the upside-down, rounded part of a spoon

Clubbed nails may develop slowly, sometimes over the course of years. But they can also develop within a few weeks.

Causes of Clubbed Nails

Clubbed nails form when there is a lack of oxygen in the blood, known as hypoxemia. Lung cancer is by far the most common cause of nail clubbing.

Other causes of clubbed nails include:

• Congenital (present at birth) heart defects
• Chronic lung infections due to conditions like cystic fibrosis or lung abscess
• Infection of the lining of the heart chambers or heart valves (infectious endocarditis)
• Lung disorders that cause the lung tissue to become swollen and scarred (interstitial lung disease)
• Celiac disease
• Liver diseases, including cirrhosis of the liver
• Dysentery
• Graves disease
• Hyperthyroidism (overactive thyroid gland)
• Other types of cancer, such as liver and gastrointestinal cancers, and Hodgkin's lymphoma

Treating Clubbed Nails

There is no specific treatment for clubbing, since clubbed nails by themselves are not a primary disease. Fortunately, clubbed nails tend to resolve quickly once the underlying condition is addressed.

For example, if the underlying condition is lung cancer, treatment may involve surgery, chemotherapy, radiation therapy, or a combination of these treatments. Or, if the cause is celiac disease, the clubbed nails should reverse once a gluten-free diet is started.

Discoloration of the Nail Plates

Discoloration of the nail plates, known as melanonychia, is the brownish or black discoloration of the nail plate. The condition occurs when pigment cells (melanocytes) deposit brown-colored pigment (melanin) into the nail plate.

Symptoms of Melanonychia

Melanonychia can present in three different ways:

• Longitudinal melanonychia refers to a longitudinal (top to bottom) brown-black or grey band that extends from the cuticle to the top of the nail.
• Total melanonychia refers to brown-black or grey discoloration of the entire nail plate.
• Transverse melanonychia refers to a transverse (left to right) brown-black or grey band that extends across the width of the nail plate.

Aside from nail discoloration, melanonychia isn't associated with other symptoms. However, there may be other symptoms present that are related to the underlying cause.

Causes of Melanonychia

Although melanocytes are normally present in the nail bed, they usually stay dormant unless trauma, infection, or inflammation triggers them to manifest in the nail plate.

Potential causes of melanonychia include:

• Pregnancy: Longitudinal melanonychia is associated with pregnancy. The discoloration may resolve or persist following delivery.
• Infections: Fungal, bacterial, and viral infections, particularly HIV, may result in longitudinal or transverse melanonychia.
• Nutritional deficiencies: Vitamin D, vitamin B12, and protein deficiencies are known to cause longitudinal or total melanonychia.
• Inflammatory disorders: Longitudinal melanonychia has been linked to psoriasis, lichen planus, chronic paronychia, and other inflammatory disorders that affect the skin and nails.
• Tumors: Longitudinal melanonychia can be a sign of certain cancers, such as onychomatricoma (cuticle tumor), squamous cell carcinoma, and basal cell carcinoma.
• Systemic diseases: Total or banded melanonychia is linked to such diseases as Addison's disease, Cushing's syndrome, hyperthyroidism, acromegaly, and AIDS.
• Cuticle trauma: Chronic biting, chewing, or picking at the cuticle can trigger melanocytes to diffuse into the nail bed, which may result in total or longitudinal melanonychia.
• Drug use: Drugs associated with transverse or longitudinal melanonychia include chemotherapy drugs, drugs used to treat HIV, immunosuppressive drugs like chloroquine, and fluconazole, which is used to treat fungal infections.

Treating Melanonychia

There is no specific treatment for melanonychia itself. Treatment depends on the underlying cause, and the discoloration of the nail plate usually resolves once the underlying cause is addressed.

Treatment may involve correcting a nutritional deficiency, resolving an infection with antibiotic or anti-fungal medication, withdrawing from an offending drug, or another condition-dependent treatment.

Nail-Patella Syndrome

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Nail-patella syndrome, also called Turner-Kieser syndrome, is a rare genetic disorder that causes changes in the nails, elbows, kneecaps, and hip bones. The disorder affects multiple body systems, placing the affected person at an increased risk of developing numerous chronic conditions, including kidney disease and glaucoma.

Symptoms of Nail-Patella Syndrome

Symptoms of nail-patella syndrome typically appear at birth or in early childhood and may include:

• Missing or underdeveloped fingernails and/or toenails
• Abnormally shaped fingers or toes
• Fingernail dysplasia, in which the fingernails are small, fragile, slow-growing, and develop pits or ridges
• Chronic paresthesia (pins and needles) in the fingers and toes

Nail-patella syndrome is a systemic disorder, meaning that it affects multiple body systems. In addition to symptoms affecting the fingers, toes, and nails, people with nail-patella syndrome may have:

• Abnormal coloration of the irises
• Chronic constipation
• Loss of elbow and knee joint motion
• Decreased muscle mass
• Abnormalities of the eyes
• Gastrointestinal problems
• Abnormally high forehead
• Reduced ability to feel temperature changes

Furthermore, people with nail-patella syndrome have an increased risk of developing kidney disease, glaucoma, arthritis, nerve problems, and a number of other issues.

Causes of Nail-Patella Syndrome

Nail-patella syndrome is caused by genetic changes in the LMX1B gene, a gene responsible for the development of the upper and lower limbs, as well as certain components of the kidneys and eyes.

This disorder is inherited in an autosomal dominant manner, meaning that a child can be born with it if just one of their parents carries the mutated LMX1B gene.

Treating Nail-Patella Syndrome

There is no cure for nail-patella syndrome. Treatment involves detecting symptoms early and managing them individually.

While people with nail-patella syndrome are able to live a normal lifespan, they will need to be routinely monitored for kidney disease and hypertension in order to prevent kidney damage and other potentially life-threatening problems.

Leukonychia

Leukonychia is a common nail condition in which the nails develop white discoloration. It is linked to a wide array of underlying causes, from simple manicuring habits to congenital conditions and other serious disorders. Most of the time, though, it is not something to be alarmed about.

Symptoms of Leukonychia

The main symptom of leukonychia is white discoloration of the nail, typically presenting as small cloud-like white spots or lines in the nail that may change in number and pattern as the nail grows.

Leukonychia can present in four different ways:

• Total leukonychia, in which the entire nail is white with discoloration
• Punctate leukonychia, in which there are tiny white spots on the nail
• Longitudinal leukonychia, in which there is a white band extending from the top to the bottom of the nail
• Transverse leukonychia, in which there is a band of white extends across the width of the nail

Aside from the white discoloration, leukonychia doesn't cause other symptoms. In fact, the discoloration is often so minimal that the leukonychia goes unnoticed.

Causes of Leukonychia

The white discoloration in leukonychia occurs when blood vessels under the nail bed become compressed. It is not a standalone condition, but rather a sign that an underlying condition is present.

One of the most frequent causes of leukonychia is the use of irritating nail products, such as nail polish and remover, fake nails, and nail glue.

Other potential causes of leukonychia include:

• Nail trauma: Trauma to the nail and cuticle due to pressure on the nail plate, as well as irritating nail cosmetics, can cause the nail to become fragile.
• Neurovascular disorders: Epilepsy has been linked to leukonychia.
• Blood disorders: Acute myeloid leukemia, Hodgkin's disease, and sickle cell anemia have been linked to leukonychia.
• Skin diseases: Leukonychia is seen in skin diseases like psoriasis, alopecia areata, and vitiligo.
• Zinc or selenium deficiency: People who don't get enough zinc or selenium in their diet can develop leukonychia.
• Drugs: Certain drugs, including the immunosuppressive drug cyclosporine, chemotherapy drugs, and retinoids can result in leukonychia.
• Hormones: Leukonychia is known to appear as a result of menstrual hormones.
• Infections: Bacterial, viral, and parasitic infections may cause leukonychia, including HIV.
• Systemic diseases: Leukonychia can be a sign of lupus, Crohn's disease, anemia, chronic kidney disease, congestive heart failure, rheumatoid arthritis, and more.
• Cancer: In rare cases, leukonychia can signal the presence of a carcinoma.

Treating Leukonychia

Most of the time, punctate leukonychia is caused by poor nail care and can be reversed by:

• Avoiding nail polish and remover, fake nails, nail glue, and other irritating nail products
• Keeping the nail area moisturized
• Avoiding shoes that are too tight

Otherwise, treatment depends on the underlying condition. Once that is addressed, leukonychia should resolve on its own.

Onycholysis

Onycholysis is a common nail disorder in which the nail plate separates from the nail bed, usually causing white or yellow discoloration at the top of the nail that can progress toward the cuticle.

Symptoms of Onycholysis

The separation of the nail plate from the nail bed typically happens gradually and is painless. As it progresses, the outside edge of the nail becomes discolored with opaque white to yellow or green, and the discoloration can affect the entire length of the nail.

In some cases, the skin beneath the nail can thicken, causing the nail to have a deformed shape or form pits or indentations. Also, the end of the nail may become course or bend over. Onycholysis may also cause throbbing pain.

Causes of Onycholysis

The most common cause of onycholysis is trauma. An acute trauma, such as an object falling on the nail can lead to onycholysis. Chronic trauma, like repeatedly tapping your nails against a hard surface, can also cause it.

Other possible causes of onycholysis include:

• Manicure tools that are pushed beneath the nail to clean away dirt can cause the nail plate to lift from the nail bed.
• Fungal infections of the nail can cause the tissue under the nail plate to thicken, causing the edge of the nail plate to separate.
• Skin conditions like allergic dermatitis and psoriasis commonly result in onycholysis.
• Drugs, particularly some antibiotics and certain drugs used to treat psoriasis and vitiligo have been linked to onycholysis.
• Hyperthyroidism can lead to onycholysis, upon which it is referred to as Plummer's nails.
• Iron deficiency can cause various nail abnormalities, including onycholysis.
• Excessive moisture in the environment can cause the nail structure to weaken and eventually, the nail plate can separate from the nail bed.

Treating Onycholysis

Once a nail detaches from the nail bed, it will not reattach. Onycholysis only goes away once a new nail grows in, which can take four to six months to completely regrow.

If an underlying condition is involved, the nail separation should stop occurring once the underlying condition is addressed. Until then, it can help to trim the nail close to where it separated from the nail bed, and wear comfortable, loose-fitting shoes that do not irritate the affected toe.

What Are the Most Common Toenail Issues Affecting Females?

Some females may be more likely to develop certain nail disorders due to the use of nail cosmetics, complications from nail grooming, and the aging process.

Toenail issues that commonly affect females include:

Onycholysis

Females who wear acrylic nails are more prone to developing onycholysis, as the glue used to attach the acrylic nail to the nail plate is stronger than the natural bond between the nail plate and the nail bed. Thus, as the acrylic nail is removed it can easily lift the nail plate from the nail bed along with the acrylic nail.

Furthermore, acrylic nails reduce the nail's natural ability to evaporate water from the nail. This leads to excessive moisture beneath the nail, which increases the risk of onycholysis. The use of sharp tools to clean beneath the nail plate during the nail grooming process can easily lead to the nail plate's separation as well.

Brittle Nails

Brittle nails are a common nail problem in females, particularly over 50 years of age. With brittle nails, the nails can split, flake, crumble, become soft, and lose elasticity, increasing the risk of nail infections and inflammatory nail disorders. It can also lead the nail to catch on clothes, bed sheets, and other objects.

The use of harsh nail grooming products, such as nail polish remover, increases the risk of brittle nails. Females who take roles that require them to repeatedly wet and dry their hands, such as homemakers, hairdressers, and nurses, are also more prone to developing brittle nails.

Ingrown Toenails

Females who wear narrow, pointed, or high-heeled shoes are particularly at-risk for ingrown toenails (onychocryptosis) due to the pressure and repeated micro-trauma these shoes place on the toes. The big toe is especially prone to developing an ingrown toenail.

Paronychia

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Paronychia refers to inflammation of the nail folds—the skin that surrounds and protects the area where the bottom of the nail plate meets the cuticle. It is caused by nail trauma, often due to nail filing, cuticle trimming, and other manicuring procedures. Paronychia can cause painful swelling of the skin surrounding the toenail and increases the risk of nail infection.

When to See a Healthcare Provider

If you are experiencing an issue with your toenail that continues to worsen despite self-care efforts, give your healthcare provider a call. Depending on the symptoms you describe, your provider may suggest an in-person visit to evaluate your symptoms.

You should also see your healthcare provider for any of the following:

• Progressive discoloration
• Progressive nail thickening or splitting
• Excessively brittle nails
• Misshapen nails
• Pain, swelling, or tenderness around the nail
• Skin that is red or warm to the touch
• An abscess or pus
• Severe pain
• A nail that has fallen off
• Bleeding around the nails

Reach out to your healthcare provider if you have diabetes and are experiencing signs of infection. If you are experiencing any new or unsettling symptoms, don't hesitate to contact your healthcare provider.

Summary

Toenail fungus, ingrown toenails, and toenail trauma are three of the most common toenail problems. Each one can be traced to various causes, which in turn leads to varying treatment options.

You may be able to treat your toenail problem at home. However, certain problems warrant medical attention. You may need oral medication or a procedure like a debridement or toenail removal.