Toenails

Dr. Karpati on Foot Care

•  Foot sweat
•  Foot powders
•  Foot pain
•  Blisters & skin
•  Toenails

1. Question:
My question is about nail fungus. I have a minor case on three toes. I have been prescribed a cream called Nizoral 2% cream. I am choosing not to take the oral medications since I do not have the time/access to taking the blood tests. I was told I could have developed the nail fungus when wearing my leather Topsider boat shoes without socks. Have you seen cases of nail fungus from wearing boat shoes without socks? Also, is their a better way, other oral, to rid the fungus?

Dr. Karpati's Answer:
Yes there is a better topical way to attempt to eradicate the nail fungus. Onychomycosis, which is the fungus that you see on your nail, has its roots in the nail bed. There is a prescription called Penlac whose mechanism is to penetrate the nail plate over time, eventually reaching the nail bed and killing the fungus where it grows. This is the only FDA approved topical medication that can actually eliminate the fungus on the nail bed. Improvement is seen as the new nail grows out, which typically takes six to nine months. Recommended use for this product is one year or more. I would probably give it a success rate of about 70% in its ability to completely eliminate the fungus on the nail bed (this is called a mycological cure). Most people however do relate a significant improvement in their nail appearance even though they might not have a mycological cure. Unfortunately, the saying “fungus among us” is true! The fungus is everywhere and one can inoculate themselves at any point in time. Typically, a moist, warm environment is ideal and that is why many people inoculate themselves in locker rooms, showers, by the pools, or on the lake. I have seen many people who have fungus who do not usually wear socks with their shoes. Repetitive trauma to the nail is also a good way for fungus to inoculate itself. This is typically seen with people that exercise. I do recommend you visit with a podiatrist in your area to make sure that what you are describing is in fact onychomycosis so that the appropriate prescription can be written.



2. Question:
Why does my toddler have yellow toenails? What could be some reasons for this?

Dr. Karpati's Answer:
Hard to know without taking a look at them. Young children typically do not have nail fungus. Are his//her finger nails the same color? Did his/her nails use to be whiter? I would find a podiatrist in your area at www.apma.org if you are concerned for a quick look. This may give you piece of mind!



3. Question:
My boyfriend who is 46 yrs old has had toenail fungus for quite some time now. His toenails quite frankly look very gross!!! I don't mean to be rude but it's a HUGE turn off... they just look very appalling. All of his toenails are affected by it. I take great care of my own feet with weekly pedicures and I expect my partner to as well but he refuses to get treatment for his toenail fungus because he has Crohn's disease (takes medication for the Crohn's) and cannot take the oral medications to attempt to eradicate the toenail fungus because those medications would put his already at high risk liver into too much jeopardy.

Also I feel even if he did take the oral medications and managed to eradicate his toenail fungus it would be entirely pointless because the fungus would come back eventually for certain. I say this because he is a stubborn man and refuses to wear sandals and insists on walking around the entire day in these sweaty boat shoes with no socks! When he takes these shows off you can tell that they are a breeding oasis for bacteria just by the way it smells! Why anybody would do that who is prone to toenail fungus is beyond me. It just boggles my mind and I am reaching my wits end. And of course those ointments you can put on the actual nails are not effective.

Therefore I brought up the subject of PERMANENT toenail removal to him. Not temporary removal because that does not get rid of the fungus of course (but permanent toenail removal) for ALL of his toenails since he is unable to or refuses to take care of them whatsoever and the fungus has been there for a long time and is slowly getting worse. So my main question is... is this a GOOD solution do you think? Basically I want him to be de-clawed like a cat!

But what I'm mostly concerned about is will the skin be perfectly normal after the toenails have been removed and it has healed? Or will the skin be very strange in that area where the nails used to be? And what about the cuticle... When you do permanent nail removal how do you ensure that the cuticle NEVER grows back? Because that would be very strange to not have any nails but have cuticles still growing on your toes when you don't have any nails on them. Or am I incorrect in thinking this and the cuticles would also be prevented from growing back along with the nail??? When you remove the nail bed I suppose the cuticle is also permanently stopped from returning, am I correct?

Dr. Karpati's Answer:
You have definitely thought this one through! I agree that oral medication is out of the question given his medical history. The only other option for treatment is prescribed topical Penlac which takes about a year of use for any true result to be determined. If he is non-compliant with this medication, he may never get rid of it. You are also right about the increased probability of getting it back wearing those shoes!

Removal of all of his toenails is a pretty radical solution for this problem, especially if they do not cause him pain, because of the potential risk for infection (as is the case for any procedure). If his case is as extensive as you say involving all of his nails, then there is potential for transmittal to his foot resulting in Athletes foot. If this is a chronic problem, then permanent removal is a very good option for him. Permanent removal (called a Matrixectomy) is usually accomplished under local anesthesia using chemical called Phenol at the nail root, which sits underneath the cuticle, to keep the nail root from producing nail. It is about 90% effective in preventing the nail from coming back. The cuticle does not grow, and stays as is. The nail bed may be sensitive for some time after that, but that usually resolves and most people are happy with the appearance of the nail bed. I suggest you consult with your podiatrist for their experiences with Matrixectomies as I am only speaking of my own.

I also want to caution you about the potential for getting nail fungus from your weekly pedicures if you go to a salon. Be sure your salon/spa is reputable and that they have enough time between clients to clean their instruments/ whirlpools. Better yet, bring your own files, nail sticks etc. to minimize the risk!

Finally, the very least your boyfriend should do is get some Summer Soles into those shoes to help wick away that sweat (and hopefully some of that smell!)



4. Question:
My big toe, just one, has no cuticle. It is possible that I may have a fungus starting. I have been using a topical on the nail for awhile. My nail is not thickened or yellow, but has got white spots. I wanted to try right away to stop it if it was a fungus. The rest of all my nails look fine. I have however been spooked and have been treating all of them, just in case. I have also tried tea tree oil. This one nail seems to be very stubborn. Since this toe was the only one that I noticed had no cuticle, I know something must be lingering there. Does a cuticle ever grow back? That would mean that maybe it was healing, but I see no signs of a cuticle even trying to form. Is this weird?

Dr. Karpati's Answer:
The cuticle is basically the skin at the base of the nail, so you definitely have one. I think you may be speaking of the lunula, which is the semi-circular lighter area at the base. This may be occluded by the fungus. It also sounds like you have only tried the over-the-counter remedies for the fungus. If it hasn't cleared, you should try something prescriptive. A prescription will give you the best chance of getting rid of it at this point and getting back a more normal appearing nail.



5. Question:
I would like to know what causes your toe nail at the cuticle to turn black. Would I need some type of cream to restore the color to my toe?

Dr. Karpati's Answer:
Darkening of the cuticle region could be secondary to trauma to the toe or possibly a fungal infection. It is difficult to tell without proper evaluation. I do recommend that you visit with the podiatrist for evaluation. You can find one in your area by visiting www.acfas.org.



6. Question:
I have a nail fungus on my two big toenails. I am currently taking Lamisil for it. One of my nails is about to fall off and it looks kind of gross. I was wondering if it would hurt anything if I got a press on nail when my nail fell off. Would that cause any problems with the healing process?

Dr. Karpati's Answer:
I am not too thrilled about the idea of a fake nail on top of the nail bed that is trying to heal from fungus. The warm and moist environment that you will be creating with a press-on nail is very inviting for re-inoculation of fungus. For this one, I say let Mother nature take its course and allow a fresh new nail to grow unimpeded.



7. Question:
I used to get pedicures all the time, but ever since my big toes on both feet have this ugly look to where I have to keep them polished. Its not nail fungus according to my ARNP that I see (she couldn't give me an answer), but they look like they have been "scraped" maybe with a nail file or something. It just has a white, scraped look to it. Do you have any idea what it is and what could I do to fix it? I haven't had my nails done in a long time, I just polish them myself since I think the cause is because of the salon.

Dr. Karpati's Answer:
It does sound like your nails have contracted some fungus (known as "onychomycosis"). I have no idea without looking at it myself how involved your nails are, but if it is only a minimal superficial portion of the nail, you may be able to get away with using something like Nailstat which you can purchase over the internet. If this does not work or your nails are much more involved, you will probably need a prescription.



8. Question:
How is the temporary toenail removal process done? I have toenail fungus on my big toe on my right foot. The podiatrist stated that if the topical cream doesn't work, that I could think about temporary removal of the toenail.

Dr. Karpati's Answer:
First of all, an anti-fungal cream will not work on toenail fungus. I am hoping your podiatrist was recommending topical Penlac (ciclopirox), that you paint onto your nails, rather than a cream. This is the only FDA approved topical medication for your nails. It needs to be used for at least a year consistently to see results. Oral medication is more effective and is only a 3 months treatment. The downside to this one is that you need to get blood work done first to check your liver function, which is no big deal to most people. If your nail is not painful, then there really is no need to remove it. If it is painful, then the process involves numbing the toe with a local anesthetic (yes, this is a shot). The nail is removed and healing takes several weeks.



9. Question:
I have a corn on my toe. I have shave the skin all the way down. Does it mean my natural skin will grow back. How do I keep the corn from coming back?

Dr. Karpati's Answer:
A corn on the toe is usually a result of a boney prominence (such as a hammertoe) or a bone spur in the toe bone. Unfortunately, because the cause is from the bone in the toe, the corn will continue to grow back if you do not change the anatomy of the toe through surgery. To avoid surgery, you can conservatively use a pumice stone in the shower or after a foot soak when your corn is softer to work off the build up. I do not recommend shaving it because if you even nick yourself, scar tissue will form and your corn can get larger!



10. Question:
I have 2 corns on my third and forth toes on the right foot. It's been over a month now, I tried Dr. Scholl's corn remover bandage and liquid remover and nothing works. After 3 days the skin will peel off but it still is hard and looks like high bumps and very unattractive on my toes. Please help, because I can't wear any flip flop or sandals and it's summer.

Dr. Karpati's Answer:
You have what are called "hammertoes" and there is no patch, cream or pad that will make them go away. It is a skeletal condition which may require surgery if it is painful.



11. Question:
My big toe is infected. It is swollen with pus and red just below the nail. My podiatrist gave me an antibiotic and suggested removing the nail so the pus can drain. Then he said the nail may grow back healthy and pretty, or thick, yellow and ugly or never grow back at all. He did not tell me what type of infection it is – bacterial, fungal, etc. and did not give any reason as to why it happened. Removing the nail seems so radical. Is this a good idea? Is there another alternative?

Dr. Karpati's Answer:
At this point, there does not seem to be an alternative. If you do not remove the nail, it will continue to in grow and will continue to have pain fan your infection could get worse. These infections are typically bacterial and usually happens when the nail grows into the surrounding nail fold. When you go back to see your podiatrist, please discuss your concerns. Your podiatrist will be able to give you more information than I can because she/he has the added benefit of having seen your toe!



12. Question:
I am 19 years old and have been dealing with hereditary ingrown toe nail problems for years. About a year ago I lost one of my toe nails after accidentally kicking it into a door. The nail fell off and it healed over in no time with no problems. The nail has mostly grown back by now but I'm finding that I'm having even more problems with the nail than I had before. I try different ways of trimming it and everything but nothing seems to work. Half of the time I can't wear a shoe because of swelling and the pain the rubbing of the shoe causes. I've been considering permanently removing the nail for a long time now but the only issue is cost. Would you be able to give me any idea of how much it would cost to permanently remove this annoying nail before I contact a doctor. Just so I can have a basic idea before hand of what I'd be in for.

Dr. Karpati's Answer:
Every doctor's office is too variable to give you cost. I have been asked cost questions before and I can never give an answer. Your best option is to call several doctors offices in your area and get a rough estimate. It would only take you a few minutes.



Medical conditions are fact-dependent, so in addition to Dr. Karpati's insights, it is important you consult with your personal physician before undergoing any footcare treatment.

Dr. Adriana Karpati is a trusted Summer Soles Advisor and frequently tests Summer Soles products before they are brought to the public. Over the years, she has answered countless footcare and podiatry-related questions – many of which are posted here. Her practice is located in Grapevine, Texas. Her office can be reached through www.faant.com, for medical appointments and established patients only please.