This Month's Topic - Dystrophic Toenails
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 Thickened, dystrophic toenails can be quite a challenge! It seems that there is no end to the shapes the nails can form into. I have to admit that after 20+ years of doing toenail care as part of my podiatry practice, I still see new challenges every day.
The first thing I want to say today is that the challenge is the same whether there is toenail fungus or not. In our older patients, the dystrophic nails are primarily caused by lifelong damage to the nail root so that it can no longer form a perfect nail plate. 70+ years of banging around in shoes damages the root a little at a time. Add onto that ... stubbing injuries, inappropriate shoes, sports injuries and you can easily explain the prevalence of dystrophic nails in our older patients.
If you took a culture of the nail you probably WILL find fungal elements. But this is a situation where the fungus takes advantage of the situation. This misshapen nail is a perfect home and fungi are opportunistic. They happily take up housekeeping in all of the cracks and fissures of the bad nail plate. But treating the nails for this fungus will not ever change the look of the nail plate. Fungus is not the primary problem! The nail is just dystrophic as a result of long-term micro trauma and the fungus just hitches a ride. Even taking the nail plate off surgically to see if it will grow back shaped more normally is fruitless. The nail will grow back and look exactly the same. The damaged root is the problem.
Having said that, I feel patient education is our responsibility. There are hundreds of mycotic toenail cures being marketed. I can say without hesitation that none of them work. That is to say, none of them will change the way the toenail looks. And since that is the primary goal of the patient... the product is a waste of money. We need to let our patients know that while there may be some fungus in the toenail, the fact that it is now misshapen is a normal part of aging and cannot be "cured". Routine nail care and appropriate shoe gear is the best treatment.
Tricks of the TradeThe goal in dystrophic toenail care is to make it shorter and thinner. The extreme thickness of these nails can create a high pressure situation if the patient is not wearing proper shoe gear. I'm sure you've seen nails that are 1/4 or even 1/2 inch thick. Unless the patient is barefoot, there really is no appropriate shoe gear that will accommodate those nails. The result is pressure which can cause ulceration and infection.I always approach the thickness of the nail before the length of the nail when I am trimming them. It is much easier to use the toenail clipper to shorten the nail once you have reduced the thickness significantly. My choice of an instrument to sand the nail is the Dremel hobby drill. Dremel Sander~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Case #1
On the picture below, the nail is no longer growing in length. This is a common situation. Many senior's nails only grow thick, not long. In a situation like this one, the Dremel is perfect! It takes only a few minutes to flatten out the nail and make it better looking, more comfortable and safer from trauma. You would then use your dermal curette (see below) to explore the nail borders and clean them of debris or accumulated sloughed skin cells. And there you have it... a perfectly debrided toenail!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Curettes
A curette is a scoop-like instrument that is indispensable in toenail care. It is used to remove debris from under the nail, define the nail border and many other tasks. When used properly it is non-traumatic and can be used under any scope of practice regulations.
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Case #2
In this picture you see a nail which is growing both longer and thicker. I would start out the same way. I would use the Dremel to thin the nail as much as possible. Then I would take my clipper to shorten it at the distal edge. I always end by checking the borders with my curette to clean them up and then a gentle final sanding so that no sharp or rough edges remain.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
 Appropriate professional nail clipper~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I know that I need to say a word about the controversy over the toenail dust produced when you sand a thickened toenail. Some facilities don't permit the use of Dremel sanders in foot care. They are concerned about aerosolizing the fungal toenail debris. The truth is, there is no report in the literature, ever, about a provider or a patient contracting a fungal lung infection from nail dust. There is certainly a concern about particulate matter. If the person has asthma, bronchitis or similar problems, the nail dust can be problematic. But not because of any fungal elements in it. The risk is from the particles in the air that can be inhaled and irritate lung and bronchial tissue. Someone with underlying hypersensitivity or pulmonary problems might have some concern because of the airborne particles.Flushing a toilet aerosolizes bacteria, fungus and viruses that actually are a contamination risk. Trimming toenails is not a risk for that!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
If you are not able to form a partnership with someone who can mentor you in toenail care, just start slowly. But do start! Our patients need and deserve this care. Keeping their feet healthy is such an important part of keeping them active and enjoying their lives. Take it one step at a time. (so to speak!!) Do what you are comfortable doing and as time goes by your skill and comfort level will grow. I admire your dedication to your profession and to your patients.You need to form partnerships with podiatrists and other foot care specialists in your geographic area. You need to have a place to refer patients with more acute care needs then you can provide. Hopefully you will be able to get them to proctor you to increase your skills. But if that is not possible, we do offer a full day hands on skills lab near Seattle Washington. Check this link for more information.Rainier Medical Foot Skills ClassIf you have specific questions I can answer. Go to the blog at blog.RainierMedEd.com. I check there frequently and will post answers to any questions you about foot care in general or toenail care specifically. I hope you enjoyed this months newsletter. Please let me know of topics you would like me to cover in future newsletters.Now get out there and trim some toenails... and enjoy your summer!Dr. Julia |
