A Thickened Toenail - A Dilemma?

It is actually possible that you do not have a fungal nail (see Thickened toenail or Fungus toenail 101) and just have a thickened toenail instead.

The most common cause of a toenail fungus is the fact of misdiagnoses. It is common for someone to seem to have a toe nail fungus and have all the treatment but fail in that treatment. The main cause is that they didn't have a fungus problem to start with! So far, the majority of cases that have come into our clinic are from patients who state that they have a toe nail fungus is in fact incorrect.

A lot of people have been sampled and then that has been sent to a lab to get a true diagnosis. Lab testing is how you can get a 100% diagnosis and is recommended by Doctors. Most times though, human error causes problems with this great testing method. And because of this you get a sample coming back that is negative even though you know for a fact that it is a fungal nail. There are many reasons why you can get negative results from a 100% testing system.

You see, the fungus doesn't actually stay at the top of the nail, (Candida (a yeast infection) works from the bottom of the nail and up) it works its way from the top of the nail all the way down to the base leaving behind dead nail and fungus poop, and stays there. So where normal nail meets fungal nail, that is where the active fungus is. However most samples are taken from the top- where the dead toenail fungus is and where its poop lays- so obviously there is no live fungus to test! So cutting the nail back to that normal junction and then scrapping the nail bed is the best sample method.

So now the clinician has got a fungus, however, the journey to the testing lab can usually kill 50% off fungus spores because they are transported wrongly, so no live toenail fungus to test!

If they do test you and it comes back negative don't worry. The next thing is the look and position of the nail.

The look of the nail.

If your nail is:

thick, yellow, brown, spongy to cut and contains in appearance "moth eaten" nail then more than likely you have a toenail fungus.

But if you have just a thickened toenail and is hard, then it is unlikely a toe nail fungus is present.

If you dropped something onto that toe or damaged it in the first place then you probably have a thickened toenail because of trauma to the nail bed which causes the thickening. It is called Onychauxis (ony-cox-is).

Nails need nourishment to grow properly. If you have poor circulation, and over a period of time, you will find that your nail will not grow properly, the nail bed lacks nourishment and becomes thickened.

thickened toenail

As the above picture shows, the nail can be very similar to a fungus one. But I hope you notice how uniform the coloring is. There are no yellow/ brown patches- it just looks like a thickened nail...that's, like, thick :)

Where the nail is.

The big toenail is the usual area for toenail fungus to start. But if you have steel toecapped shoes or even play soccer that is likely to cause a trauma to your big toe and cause a thickened toenail instead. Many sports people can get a combination of fungal nails and thickened nails because of traumas and sweaty feet.

If you have thickened toenail on the 5th toe then those nail are likely to be damaged by micro-trauma. Shoes are the main culprits and if they are too tight your little toenails will hit the outside of your shoe quite easily and cause thickening over time (the above picture shows this to great effect). This occurs because when you put your foot to the floor it splays out, making your foot wider. Your little toe also minutely rotates so that the nail is pointing to the outside rather than straight.

Micro trauma is trauma that has been there all the time, minutely constantly tapping at your nail, rather than one big whack. The body doesn't want anything broken so it starts to thicken up your toenail.

Once that toenail has been damaged it can not go back to normal, because where the nail grows from, the matrix, has been damaged. Toenails grow like a tube of toothpaste. Forces from the top and the bottom press down on the nail itself when it grows. So as the nail grows it grows flat and straight. If one of those forces are interfered with then the nail doesn't grow straight or flat. It will bulge where the force is less, so the nail looks thickened.

Slip-on shoes and court shoes are poor shoe choices if worn regularly. This is because they can not fit your foot properly. Normal feet are two different sizes- not really noticeable, but it's there. Now slip-on shoes are one size. So one foot is going to fit and the other foot will not. So now without a lace or Velcro to stop your foot moving around...your foot moves- very slightly. You then get micro-trauma to the nails as your feet bash to the ends of your shoe.

What also happens is that your toes will start to claw to stop your foot from moving around. This is a normal mechanism to try and stabilize your foot. But it causes your toes to claw which in turn makes your toe ends hit the floor. Again your nails will be the subject to micro-trauma as they hit the floor. Hammer toes (usually the 2nd toe) becomes thick due to the nail hitting the floor because of the hammer deformity.

Again, picking on the court-shoe (also known as a dress shoe) your heel is pushed up into the air and your toes are pushed down into the end of the shoe. Trauma to the nail then occurs.

Treatment

Treatment for thickened toenails is actually quite easy. There are 3 main treatment options.

1. Filing.

Filing your thickened toenail with a footfile when your nails are dry is an easy method to keep down the thickness. You file over the nail, rather than across twice a week, when dry, and this keeps the nail down to a manageable thickness.

However, If your thickened toenail is too thick, then treatment option 2 will need to be done because a file will take too long and needs the nail to be a lot less thick.

2. Drilling.

This is a very common, simple, and painfree treatment method and what happens is that a Chiropodist/ Podiatrist will use a drill and carefully reduce the thickness of your nail down. I would not recommend for you to do this at home because for one it is not safe, two- you will not have clean tools and three- you can injure yourself quite easily.

3. Removal Of The Nail.

Sometimes we have had patients come into our clinic with infections and a toenail that is routinely getting out of control and causing them misery in their life. If this is the case then removal of the thickened toenail under LA with a chemical to stop the nail from regrowing is usually warrantied, with the patient having great relief. It is an extreme case treatment method, but they can not ruled out.

Fungus toenail?