Below are "before and after" pictures of toenail debridement done by one of the students in our Hands-on" class as few weeks ago.    The student did a great job on some difficult nails! 

Let's look at what we are seeing in the visual exam of this foot...

The first thing that jumps out at you are the transverse lines across the third and fourth toes  (Toes are numbered 1-5 from medial to lateral).   These are deep and erythematous. You would suspect pressure of some sort.  Either from shoes or socks.  The sock and shoes had been off for several minutes by the time I took this picture and the lines are still quite deep.  This is definitely a significant problem. 

After checking the patient's shoes and socks, it was apparent that this line was from the seam in his sock.  Why didn't it crease the second toe as well?  I suspect that the 1/4 inch high toenail on the second toe lifted the sock away from the skin.  I don't mean to imply that there's an advantage of having a 1/4 inch high nails!  But in this case it prevented the sock pressure on the second toe.  There is trauma on the second toe.  You'll see a red spot just proximal to the nail.  A toenail this long wiggles back and forth with sock and shoe pressure causing significant trauma.  The fifth (baby) toe is simply too short to be affected.  The direction of the crease would seem to place the sock seam over the great toenail.  That's possibly why we don't see the pressure on that toe. 

Take a peek at the "after" picture below. You'll see that in the time it took to debride the nails (about 45 minutes) the pressure ridges resolved.  There didn't seem to be any residual tissue damage.  Needless to say, we advised the patient about the problem and educated him about proper socks.  (with flatter seams) We also educated him regarding the necessity of visually examining his own feet daily to assure that problems like this don't recur.

Before Nail Debridement

(2nd toenail 1/4 inch high) 

After Nail Debridement

What else are we seeing?

Look between the first and second toes.  The skin in that innerspace appears to be quite rough. There appears to be a slight amount of erythema there also.  But is it erythema?  Erythema implies acute tissue damage or infection. We see no other indication of that.  What this appears to be is more of a brownish color rather than bright red. 

The second toe appears to slightly overlap the Hallux (great toe).  There probably is quite a bit of rubbing between these two toes during ambulation.   I would diagnose this as  simple inflammatory  hyperpigmentation.  In other words, a result of chronic irritation. The dry, flaky skin we see there is also damage from the chronic rubbing.  There may be some tinea pedis in the area but that would be secondary to the hyperkeratinization from the rubbing. Putting antifungal creams on the area won't resolve the dryness.  So please don't jump to the conclusion that everything discolored is an infection.  Consider the more subtle clues... 

What would I do about this?  First of all, I would examine his shoes to make sure that there is enough toe room to allow free motion of his toes during gait.  The problem would certainly be made worse by tight shoes that cramped his already nonaligned toes.

Secondly, I would recommend the use of lamb's wool or possibly a thin foam rubber "toe spacer" in that innerspace.  This is something that the patient would have to continue to wear since, as we know, devices like that don't achieve permanent correction of a problem.  But spaces or lamb's wool would relieve the pressure and possible prevent blister or ulcerations. 

Let's talk about the nail debridement.  This was certainly a challenging foot.  These are long, thick nails that crumbled when cut or sanded.  You'll see a small drop of blood on the third toenail.  It is very common to have a nail bed (the skin under the nail) not be flat. Rather, in some people the skin under the nail is rounded up at the center.  So as you continue to thin the nail with a dremel or a manual sanding file you can break thru and scratch the skin under the nail.  I think that's the thing everyone is afraid of.  Isn't it?! 

What is more dangerous ... creating a small scrape that you will carefully cleanse, medicate and bandage - or leave the nails 1/4 inch tall, rubbing in his shoes to create lesions and infections.  I hope you see that appropriate debridement is the better choice for long term health.  You are professionals who are trained to appropriately care for a small scrape like this.  Even in a high risk foot the damage and risk is minimal.  But leaving long, thick nails is as much bigger risk in these high risk patients.  They don't always see an ingrown nail, or a torn nail until it becomes infected.  Managed care of the nails is the safest possible protocol.

Finally, what does this picture tell us about the vascular supply in this patient's lower extremity?  We're not seeing any hair on the toes or the forefoot that is visible here.  The skin isn't that thin but you can definitely see veins and deeper structures.  And the entire area appears edematous.  The swelling isn't extreme but we know that even moderate chronic edema affects the ability of the capillaries to deliver oxygen and nutrition to the tissues.  In years to come, this unmanaged swelling could certainly lead to a fragile foot that is prone to ulcerations.  I would work to reduce the lower extremity edema and get the patient into appropriate compression socks long term. 

I think you'll agree that the student did a great job on these challenging nails.  She has thinned them beautifully and assured that the corners are shaped in such a way that the nails will grow out without risk of becoming ingrown.  I'm very proud of her efforts.

These feet had a lot to teach us besides debridement technique.  And the teaching we did with the patient will empower him to keep his feet as healthy as possible.

See you next month!

Dr. Julia

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