Nails

Nails

 Nails support and protect the sensitive tips of fingers and toes. Fingernails also help us to pick up objects, scratch an itch or untie a knot. Common causes of nail problems include injury, infection and skin diseases such as psoriasis.
Fingernails grow about three times faster than toenails.

Nail anatomy

 Nails are made from a protein called keratin. This is the same protein that makes up skin and hair. Nails grow from cells that multiply within the base of the nail, then layer on top of each other and harden. This is called keratinisation.
The structures of the nail include:
    Nail matrix – where nail growth occurs, tucked under the skin behind the nail.
    Nail plate – the visible part of the nail.
    Nail bed – the nail plate sits on top of the nail bed. The nail plate looks pink because of the blood-rich capillaries in the nail bed.
    Lunula – the ‘crescent moon’ shape that is sometimes visible at the base of the nail plate.
    Nail folds – the slender skin grooves that hold the nail plate in place.
    Cuticle – the flap of thin tissue over the base of the nail plate.
Nail conditions
Some conditions that affect the nail include:
    Discolouration – causes typically include medications such as antibiotics or antimalarial drugs, nail varnish, certain infections, injury to the nail bed, staining from cigarette smoking and melanoma.
    Thickened nails – toenails are more commonly affected than fingernails. Causes include neglect, injury, poor circulation, arthritis in the toes, altered gait (walking) patterns and ill-fitting shoes. The elderly are at increased risk.
    Ridged nails – typically caused by medical conditions such as rheumatoid arthritis or peripheral vascular disease.
    Infection – can be bacterial or fungal. Examples include onychomycosis and paronychia.
    Skin diseases – such as psoriasis, lichen planus or lupus can affect the nail. Abnormalities may include pits, grooves or crumbling nails.
    Ingrown toenail – the nail grows into the skin. Causes include ill-fitting shoes and cutting the nails incorrectly.
    Unusual nail shape – such as the nails becoming concave. Causes include iron deficiency.
    Nail tumours – including squamous cell carcinoma, usually caused by infection with the human papilloma virus (HPV). Melanoma can also affect the nail.
    Splinter haemorrhages – thin lines of blood running along the nail bed. Causes include injury, severe anaemia, infective endocarditis (inflammation of the inner tissue of the heart) and certain diseases such as rheumatoid arthritis.
    Congenital disorders – conditions that are present at birth such as nail-patella syndrome, where the nails are improperly formed or missing.

Nail problems

 Nail problems affect people of all ages. Common causes of nail problems include trauma, infection and various skin diseases, such as eczema and psoriasis. Diet is generally not responsible for abnormal nail changes, unless the person is suffering from severe malnutrition. Some nail conditions need professional treatment from either a doctor or a dermatologist, while others respond to simple self-help techniques and minor lifestyle changes. When in doubt, seek medical advice.
The structure of the nail
Nails are made from a protein called keratin. The strength, thickness and growth rate of nails are inherited characteristics. The structures of the nail include:
    Nail plate - the visible part of the nail.
    Nail bed - the nail plate sits on top of the nail bed.
    Nail folds - the nail plate rests inside slender skin grooves.
    Cuticle - a thin flap of tissue that lies over the base of the nail.
    Nail matrix - the site of nail growth, tucked under the skin.
Common conditions
Some of the more common conditions that affect nails include:
    Discolouration
    Thickened nails
    Ridged nails
    Splitting nails
    Lifted nail plate
    Bacterial infection
    Fungal infection
    Trauma
    Skin diseases
    Other diseases
    Advancing age.
Nail discolouration
The healthy nail plate is pink, and the nail looks white as it grows off the nail bed. Nails can be discoloured by various factors including:
    Nail polish
    Some medications, including antibiotics and anti-malarial drugs, and some of the drugs used in chemotherapy
    Nicotine from cigarette smoking
    Hair colouring agents.
Thickened nails
This condition most commonly affects the toenails. Causes of thickened nails include:
    Fungal infection
    Psoriasis.
Ridged nails
Ridges running either the length or width of the nail plate can have a number of causes, including:
    Age-related changes
    Trauma to the nail matrix
    Overzealous attention to the cuticles
    Fever or illness
    Eczema
    Rheumatoid arthritis
    Lichen planus infection.
Splitting nails
This condition is characterised by the splitting or layering of the nail plate as it grows off the nail bed. Common causes include:
    Having constantly wet hands, especially while using soap and washing detergents.
    Frequently using and removing nail polish.
    Continuous mild trauma such as habitual finger-tapping or using the nails as tools (to pick between the teeth, for example).
Lifted nail plate
The healthy nail plate adheres to the underlying nail bed and appears pink. The nail looks white as it grows off the nail bed. If the nail plate lifts off the nail bed, it will appear white. Common causes include:
    Overzealous cleaning under the fingernails
    Nail polishes that contain hardening chemicals such as formalin
    Rough removal of artificial nails
    Psoriasis
    Tinea (a fungal infection).
Bacterial infection
The Staphylococcus aureus bacterium is a common cause of bacterial infection of the nail. Typically, the infection first takes hold in the fold of skin at the base of the nail (proximal nail fold). Without treatment, the infection can worsen to include inflammation and pus. It is often associated with candida infection, particularly when it becomes chronic. Activities that predispose a person to a bacterial nail infection include:
    Having constantly wet hands
    Overzealous attention to the cuticles
    Severe nail biting, which can expose underlying tissues to infection
    Eczema around the fingernails.
Trauma
A blow to the nail or compulsive nail biting can cause a range of problems, including:
    Bruising of the nail bed
    Lifting of the nail plate
    Loss of the nail plate
    Nail ridges
    Subsequent deformed growth of the nail plate, if the nail matrix is injured.
Feet - toenail problems
Toenail problems can affect people of all ages, but tend to be more common with advancing age. Causes of nail problems include trauma, ill-fitting shoes, poor circulation, poor nerve supply and infection. Problems with toenails can be successfully treated by a podiatrist.
Ingrown toenail
One of the most common problems treated by podiatrists are ingrown toenails. The big toe is particularly prone to this painful condition.
Causes may include:
    Incorrect trimming technique
    Trauma (such as stubbing your toe)
    Nails that naturally curve sharply on the sides and dig into the skin
    Wearing tight shoes.
Treatment from a podiatrist depends on the severity of the injury, but may include removing the ingrown nail section using a local anaesthetic.
Suggestions to prevent an ingrown toenail include:
    Trim nails straight across rather than rounding off the edges.
    Wear comfortable, well-fitting shoes that don’t press on the toes.
Fungal infections
Symptoms of a nail with fungal infection include discolouration and thickening of the nail, and the separation of the nail from the nail bed. There may also be a white, yellow or green, smelly discharge. Without treatment, the nail bed itself can become infected.
Treatment for fungal infection includes:
    Use of antifungal preparations applied topically (directly to the nail) or taken orally (by mouth)
    Professional trimming, shaping and care of the nail by your podiatrist.
Inflammation of the skin alongside the nail
The skin lying alongside the nail can become infected with bacteria, typically Staphylococcus aureus. This infection is called paronychia.
Symptoms may include pain, redness and swelling around the cuticle and yellow–green discharge.
Treatment for paronychia includes:
    Keeping the feet as dry as possible
    Use of barrier creams, antiseptic lotions and antifungal preparations
    Antibiotic therapy (in acute cases).
Chronic paronychia (where the condition is present for a long time) is more difficult to treat. In chronic paronychia, the nail may distort and become discoloured, and the skin may lift at the site of infection. Sometimes, the inflammation spreads from one nail to another. A range of micro-organisms working together are responsible for chronic paronychia.
Deformed or brittle nails
A violent toe-stubbing, dropping a heavy object on the toe or some other trauma can injure the nail bed and cause the nail to grow in deformed ways. The nail may be thickened or ridged. It is a normal aging process for nails to thicken.
Certain skin conditions may also affect the nails, causing thickening (for example, psoriasis). Deformed or brittle nails can benefit from regular professional attention. Trimming, shaping and nail care from your podiatrist can improve the health of your nails and help diagnose and treat more serious nail concerns
Tinea
Tinea is a contagious fungal infection that can infect the skin. The most commonly affected areas include the feet, groin, scalp and beneath the breasts. Tinea can be spread by skin-to-skin contact or indirectly through towels, clothes or even floors. Tinea is also known as ringworm, which is a misleading name since no worm is involved.
All fungi need warm, moist environments and tinea is no exception. This is why the hottest, most sweat-prone areas of the body are the likely targets of a tinea infection. Communal showers and locker rooms are typical places where infection may be spread.
Treatment includes antifungal medication, antiperspirants and good hygiene.
Types of tinea
Tinea infections are known by specific names, depending on the part of the body that is affected. The most common types of tinea include:
    Athlete’s foot – tinea of the foot, known as tinea pedis.
    Jock itch – tinea of the groin, known as tinea cruris.
    Ringworm of the scalp – tinea of the head, known as tinea capitis (mainly affects children).
    Ringworm of the body – tinea of the body, known as tinea corporis.
    Nail infection (onychomycosis) – tinea of the toe or finger nails, known as tinea unguium.
Symptoms
The symptoms can include:
    Itching and stinging
    Red scaly rash that is shaped like a ring (annular)
    Cracking, splitting and peeling in the toe web spaces
    Blisters
    Yellow or white discoloration of the nails
    Bald spots on the scalp.
How to avoid infection
Overheating and perspiration contribute to tinea infections. Suggestions to avoid tinea infection include:
    After washing, dry the skin thoroughly, particularly between the toes and within skin folds.
    Expose the skin to the air as much as possible.
    Wear cotton socks instead of synthetics.
    Use antiperspirants to control excessive perspiration (sweating).
    Wear thongs to swimming pools, locker rooms, gyms and other communal areas.
Treating an infection
Tinea infections respond well to antifungal creams. Some infections are harder to shift and might also require an antifungal medication in the form of a tablet.
Preventing the spread of tinea
It is important to remember that tinea is contagious. Suggestions on how to prevent the spread of infection to others include:
    Treat tinea infections with antifungal cream.
    Wash your hands after touching infected areas.
    Do not share towels.
    Do not walk around barefoot if you have tinea pedis (tinea of the feet).
    Clean the shower, bath and bathroom floor after use.

Self-help strategies

 You can reduce the risk of nail problems in a variety of ways, including:
    Practise good personal hygiene.
    Wear protective gloves for wet jobs such as washing the dishes.
    Avoid harsh chemicals such as strong soaps and detergents.
    Avoid or limit the handling of chemicals such as hair dyes.
    Take care with the use of nail polish.
    Don’t clean under your nails too frequently or too aggressively.
    When giving yourself a home manicure, do not push back the cuticles.
    Resist the urge to bite or tear off hangnails - use nail clippers.
    Don’t bite your nails.
    Remove artificial nails carefully and according to the manufacturer’s instructions.
    Don’t smoke.
    Moisturise the hands frequently, particularly after washing them.
    Remember to rub the moisturiser over your nails and cuticles too.
    Treat any sign of eczema on your hands promptly.
    To protect yourself from fungal infections, don’t share towels, always dry yourself thoroughly after bathing (particularly between the toes), and wear thongs in communal bathing areas such as the local gym or swimming pool.
    Make sure your shoes are well-fitting and have plenty of room for air movement.
Professional diagnosis and treatment
Any abnormal changes to your nails should be medically investigated. See your doctor for treatment or possible referral to a dermatologist. If the cause of your nail problem is not immediately apparent, nail clippings and scrapings from beneath the nail may be taken for laboratory analysis. Fingernail infections usually respond faster to treatment than toenail infections. Depending on the cause, treatment options may include:
    Antibiotics for bacterial infections.
    Anti-fungal preparations, mainly oral tablets, for fungal infections in the nails.