Patient Information

Fungus Toe Nails - Onychomycosis

WHAT'S THE PROBLEM?
Fungal Nails are an unsightly infection of the nails, causing thickened, brittle, yellow, discolored and sometimes painful nails. It is difficult to cure. It is caused by one of several microscopic organisms, similar to those that cause Athlete's Foot (dermatophytosis) These are plant like organisms that thrive in a dark, warm, moist environment, such as within shoes and stockings. They grow in the nail bed, beneath your nails, and live off Keratin, the protein in the nail. The condition usually begins toward the far end of the nail and may cause white or yellow-white areas that appear to be rotten or dead. If the infection continues to the base of the nail, it can invade the nail root (matrix) and cause the nail to grow thickened and deformed. Many people complain of a foul odor associated with this condition. It can also spread to other nails. The fungus can also spread to the adjacent skin surrounding the nail.

HOW DOES IT FEEL?
It may not be painful in the beginning, and may only look slightly different than the normal nails. Later, the nail may begin to show small patches of white or yellowish-tan color and may become brittle and split. As it progresses, the nail becomes thicker and deformed and may begin to grow at an angle and become an Ingrown Nail. Pain develops, due to the ingrown or thickened nail deformity, and becomes aggravated by pressure applied by shoes. Inflammation can develop due to this pressure and a secondary bacterial infection may occur, leading to more pain. Even without inflammation, shoe pressure on the fungal nails can cause pain, making it difficult to walk or stand for periods of time. This can also influence one's involvement in day to day activities.

LET'S DO A TEST!
Correct evaluation and diagnosis is important, as other common medical conditions, such as psoriasis, can look like Fungus Nails. Your doctor may make this decision by examination alone. He may also examine scrapings from the nail under the microscope or send these scrapings to the lab for accurate identification, to determine if the condition is a fungus and what type of fungus is responsible.

HOW DID THIS HAPPEN?
Many types of fungus are common in our environment. Among them are the dermatophytes, which do not require sunlight for growth. Sweaty tennis shoes and moist socks create the perfect conditions for them. The fungus thrives in a warm, moist, dark environment and they eat the protein keratin that our skin produces. Although the fungus may be present in the skin around the nails, one may not develop a nail infection without history of injury, such as bruised nails from short shoes, inflammation from an ingrown nail, or from cutting the nails incorrectly or too short. In other words, the organisms do not invade intact, healthy, normal skin or nails. Other contributing factors would be excessive perspiration, and Dermatophytosis (Athlete's Foot), which is caused by similar fungi. Some individuals appear to be more susceptible to infection. These would include those with medical conditions such as diabetes and poor circulation and HIV. For that reason, even if treatment is successful in eliminating the condition, the susceptible person may become re-infected in the future.

WHAT CAN I DO FOR IT?
Newer topical medications can be effective but not in all cases, because the infection starts growing under the nail. Topical medicines find it difficult to penetrate deep enough into and through the nail, to treat the living organisms under the nail plate. Unfortunately, in this condition, any self treatment is, at best, temporary. Use of a topical antifungal medicine may prevent spread of the fungus to, as yet, unaffected nails or the surrounding skin.

WHAT WILL MY DOCTOR DO FOR IT?
First of all, the doctor will do a physical examination to determine if there is a fungus present and not some other kind of medical condition. After determining the type of fungus, treatment may range from topical solutions to oral, systemic medications. The nails may be trimmed and reduced with an electric grinder periodically, and you may be asked to participate in some way at home. Surgical  treatment may address removal of part or all of the nail with additional medications to prevent recurrence as the new nail grows.
Fortunately, oral medications are now available that have proven very effective in curing these difficult infections. These medicines reach the nail through the blood stream and create a barrier between the old infected nail, and the newly formed nail, effectively killing all living fungus organisms.. The medications are taken for about three months. During that time, they penetrate into and saturate the growing part of the nail. Even after you stop taking the medicine, the medicine that has gotten into the nail continues to treat the nail from inside for another six to nine months, until a healthy nail has completely grown out. Although these medications are safe, there are some side effects in a small percentage of patients and they require a blood test to monitor blood levels. Your doctor will discuss the advantages and disadvantages of oral therapy and other alternatives with you, to determine the most appropriate treatment in your situation.

CAN I PREVENT FROM IT HAPPENING AGAIN?
You may be asked to treat the insides of your shoes, which have become contaminated by the fungus. This is to make sure that the new healthy nail doesn't become contaminated by any fungus hiding in the shoe.
To prevent the fungus infection from coming back, the best offense is a good defense. We must control moisture and create a drier environment for your feet. Use powder in shoes, to absorb perspiration. Avoid synthetic or nylon socks that trap, rather than absorb perspiration. Cotton socks absorb moisture and wick it away from the skin and nails. Keeping your feet dry and protected from injury is essential to avoid any fungus infections. If you have been cutting your nails too deeply, or treating an ingrown nail on your own, this may have allowed the fungus to grow under the nail. If shoes have become contaminated while you had the condition, they may be sanitized by spraying them with a topical antifungal spray, to prevent a recurrence of the Fungal Nail condition.

Ingrown Toe Nail

WHAT'S THE PROBLEM?
An ingrown nail occurs when a portion of a toenail on either side of the toe turns downward and presses into the skin. Nails normally are nearly flat, with just a slight arcing downward at the borders. When the border of the nail is turned downward, it begins to injure the skin.

HOW DOES IT FEEL?
Patient's usually feel pressure and eventually pain, as the hard and sharp nail edge creates further injury. Shoes that apply pressure to the toe increase the pain. If an infection develops, the pain becomes intolerable.

LET'S DO A TEST!
An Ingrown Nail is identified by the doctor's physical exam. If an infection has developed, the doctor may send a sample of the drainage to a lab, to identify what bacteria has caused the infection and which antibiotics will most easily cure the infection.

HOW DID THIS HAPPEN?
A progression of events occurs. Routinely cutting the nails improperly, down at an angle instead of straight across, is the most common cause of Ingrown Nails. Wearing narrow or pointed shoes can apply enough pressure to a normal nail to turn the nail edge downward. Once the nail matrix, the tissue where the nail grows from, gets injured in this way, it continues to produce a nail edge that is more vertical than horizontal. From this abnormal nail growth, the nail edge applies mild pressure on the skin over a long period of time. The skin at the nail edge thickens and becomes hardened. You may begin to notice an enlargement or swelling of the skin around the nail edge. This can be accompanied by an increase in pain. The condition can progress as a result of other factors. These factors include: pressure from a tight or pointed shoe, injury such as stubbing a toe, excessive wetness, either from perspiration or application of ointments or creams, or improper cutting of nails If these factors come into play, the possibility increases that the nail edge can then penetrate the skin, just like a knife, and cause an infection. The skin at the nail edge becomes reddened and swollen. You may notice drainage or pus from the area and the pain becomes intolerable.

WHAT CAN I DO FOR IT?
In advanced cases, where pain, swelling, redness or obvious infection is present, seek the attention of a doctor.

WHAT WILL MY DOCTOR DO FOR IT?
In the most minor cases, the podiatrist will simply cut the nail to shorten it, and show you how to cut the nail in the future, to prevent ingrowing of the nail again (See below for instructions on proper nail cutting). In more severe cases, but not those in which an infection hasn't developed, the podiatrist may gently remove the ingrown portion of the nail. This affords considerable relief, but is temporary. After a few weeks, when the nail grows long again, it may again grow in. In cases where the nail has grown in repeatedly, or more critically, when the nail edge has penetrated the skin and caused an infection, the podiatrist will perform a minor procedure called an Ingrown Nail Correction or Matrixectomy. The podiatrist will gently numb your toe, reshape the nail edge and finally, apply a medicine which will, in most cases, permanently prevent the nail edge from growing improperly again.

CAN I PREVENT FROM IT HAPPENING AGAIN?
CUTTING NAILS PROPERLY TO PREVENT INGROWN NAILS
Cutting toe nails properly goes a long way toward the prevention of ingrown nails. Use a safety nail clipper, available at every drug store on the planet. Cut the nails STRAIGHT ACROSS, so that the nail corner is visible. If you cut the nail too short so that the nail corner is not visible, you are inviting the nail corner to grow into the skin. It is the natural tendency, when the edge of the nail starts to grow in, to cut down at an angle at the nail edge, to relieve the pain. This DOES relieve he pain TEMPORARILY, but it also starts the downward spiral, training the nail to become more and more ingrown. What happens is that cutting down at an angle creates a space at the nail edge. When the advancing nail edge reaches the space, it rolls downward, taking the course of least resistance. The edge becomes more and more ingrown, until it pierces the skin and makes an infection.

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Heel Spur-Plantar Fasciitis

WHAT'S THE PROBLEM?
A pain has developed at the bottom of the heel, and it has gotten worse. The patient was not aware of having had any injury that caused it.

HOW DOES IT FEEL?
It feels like a dull ache most of the time, but when the patient first gets out of the bed in the morning, or when getting up after sitting for a period of time during the day, the pain in the heel is impressive. It almost feels like the heel has been bruised, from falling on a rock barefoot, but it is worse.

LET'S DO A TEST!
Since there are several causes for heel pain, we need to pin-point the exact location of the pain is in order to diagnose the basic underlying cause for the problem. Testing is simple and generally pain-free. It's important to find out WHERE it hurts, not just HOW MUCH it hurts. After excluding general medical conditions that might cause the condition, the exam is localized to the heel and surrounding structures. The important anatomical structures are the heel bone (calcaneus), the tissues that attach to the bottom of the heel (plantar fascia) and the nerves that pass from the leg into the bottom of the foot (posterior tibial nerve and its branches). The exam begins with an assessment of the blood vessels and nerves that end in the foot because blood and nerve supply affect treatment.
 

We may do a radiographic examination of the feet using an X-ray machine looking for evidence of abnormal bone growths.

HOW DID THIS HAPPEN?
There is a tight ligament (band of fibrous tissue) that stretches across the arch, from the ball of the foot to the heel bone, called the Plantar Fascia. When we walk, our feet have a tendency to roll inward, toward each other, in a motion that we call pronation. When feet pronate, they flatten, stretch out and the arch elongates. This causes excessive pulling on the Plantar Fascia ligament and attachment of the ligament to the heel bone begins to separate. An injury occurs where the ligament progressively tears off of the heel, fiber by fiber. Bleeding occurs next to the bone and inflammatory fluids accumulate between the ligament and the bone, forming a Bursitis, or fluid-filled sack. Over time, the body lays down scar tissue, in an attempt to "glue" the detached ligament fibers back on to the bottom of the heel bone. Over the course of 3-5 years, the scar tissue calcifies, and this calcium deposit eventually becomes visible on X-Ray as the Heel Spur. This inflammation of this Plantar fascia ligament is called Plantar Fasciitis, and in addition to the Bursitis, is what causes the pain. The bone spur itself has no nerve endings and doesn't hurt. It is just an associated finding that tells us that the inflammatory process, the Bursitis and Plantar Fasciitis have been present for a long time.

 There are several reasons that this chronic injury can occur. Recent weight gain and increased activity level often start an episode. A person who has been mostly sedentary, who walks a lot at Disney World for 3 days is a prime candidate. A change of shoes from well supporting walking or athletic shoes to floppy sandals can do it. When the arch of the foot collapses or flattens, the Plantar Fascia is stretched, causing the injury where it attaches to the heel bone. Finally, conditions which cause generalized increased inflammation, like osteoarthritis or rheumatoid arthritis can cause this.

WHAT CAN I DO FOR IT?
It is better to rest the heel as much as practicable. When you are off your feet, the injury is healing and getting better. When you are standing, without any foot support, the heel is getting injured further. When you are standing when wearing orthotics (foot supports) and well supportive shoes, the injury decreases dramatically, but usually is not eliminated altogether. So, during the treatment period, if you have the choice of sitting or standing, sit !

WHAT WILL MY DOCTOR DO FOR IT?
First, we need to protect the bone from the pulling of the plantar fascia. We do this by using some kind of in-shoe arch supporting device. Some patients will find relief from an over-the-counter pairs of insoles such as the Spenco PolySorb Insoles. Others may need a custom made orthotic (foot support). They come in pairs, one for each foot.
 

Next, we encourage the patient to stretch the tissue on the bottom of the foot. Three times a day, sit erect with the legs extended and loop a belt, scarf or towel around the forefoot. Pull the forefoot toward the upper leg. Expect to feel a mild pulling sensation at the back of the leg and in the arch. Stretching should not be done to the point of pain. This position is held for 30 seconds, and is repeated 3 times. The 3 repetitions at 30 seconds, 3 times-a-day is easy to remember.

Because of the risk of stomach upset, non-cortisone anti-inflammatory medication can only be used for some patients and only for a short period of time. With a good response to the medication, it is a good idea to taper off over the next several days so as to avoid an abrupt rebound of pain.

In addition to the above, we begin an aggressive course of physical therapy and cortisone injections. For physical therapy, the doctor may employ ultrasound, galvanic stimulation or any of a number of anti-inflammatory modalities in the office or at the offices of a physical therapist. The most effective way for physical therapy to work is if it is applied regularly, at least three times a week.

Cortisone injections are usually done at weekly intervals, and most cases require 1-3 injections. The skin can be desensitized before the injection with a cold freezing spray designed to provide brief anesthesia. The injection is done from the inner side of the heel, not from the bottom.

These measures will eliminate the problem in about 75% of patients within 3 weeks. Some get better quickly, others take longer.

Surgery becomes necessary for the few who do not benefit from treatment. If the problem is due only to the inflamed fascia, the easiest procedure involves lengthening the fascia near the heel. The procedure is often done endoscopically today, through tiny incisions, using a small television camera inside the heel, very much like most knee surgery is done. Recovery is rapid and the success rate is better than 90%. If there is evidence that the nerve is being compressed at the side of the heel, we relieve the pressure by surgically freeing the tissue over the nerve. Heel spur removal is done only in the rare instance where the bony projection is directed downwards.

CAN I PREVENT FROM IT HAPPENING AGAIN?
Recurrence is rare after treatment, if the patient continues to employ good mechanical foot control by continuing to wear orthotics and good supportive walking or athletic shoes.

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Plantar Warts-Verruca Plantaris, Plantar Warts

WHAT'S THE PROBLEM?
A plantar wart is a small skin lesion that resembles a callus and is found on the bottom of the foot or toes. The term "plantar" doesn't mean only farmers get them. "Plantar" means they occur on the bottom surface of the foot. It is usually under 1 cm diameter, but can occur in clusters and be much larger. Sometimes a single larger wart is surrounded by many smaller warts. In this case, they are called mosaic warts.

HOW DOES IT FEEL?
A plantar wart feels like a lump under the foot. They are only painful is they are squeezed or pinched from side to side, or if you bear direct weight on them. Warts on other parts of the body, such as the hands, grow elevated above the skin's surface. We bear weight on warts on the bottom of the foot, so they get flattened and pushed into the skin. Most people liken this to walking with a rock attached to the foot, as the thickened callous tissue becomes hard and painful as it gets bigger.

LET'S DO A TEST!
A plantar wart can usually be diagnosed by your doctor based on a characteristic appearance alone. When the doctor trims the hard callus tissue from the surface of the wart, a pattern of small black dots that are actually small blood vessels that feed the wart, is usually seen. The doctor will also test the wart by pressing directly down on it, and then pinching it, squeezing it from side to side. Most warts won't hurt when pressed directly down, but are very painful when pinched. If these findings are present, no further testing is necessary to identify a plantar wart.

HOW DID THIS HAPPEN?
All warts are caused by the Papilloma virus, a slow growing virus which invades the skin. The viruses are common in all of our environments and they don't readily grow on intact skin. But if there is a break in the skin, like a scratch or thorn penetration, this gives the virus the opportunity to get in and start growing. The virus only grows in the epidermis, the thick layer of the skin closest to the surface. It doesn't invade the dermis, the deeper layer of the skin. However, the epidermis and the dermis are closely entwined, and the dermis under the wart grows extra blood vessels and nerves in response to the virus infected cells above it in the epidermis. It is because of these nerves that the wart hurts when pinched and because of these blood vessels that it stays well nourished enough to grow. The virus particles can spread from the main wart, along the cutaneous (skin) nerves, to begin growing remote or satellite warts at a distance from the original site. If enough of this spread occurs, mosaic warts result.

WHAT CAN I DO FOR IT?
Over the counter products that contain the ingredient salicylic acid may be tried if you have good blood flow, good feeling in your feet, and the wart is small. However, their use is slow and frustrating. They are acids which slowing destroy the wart from the surface down. Diabetics or other people with numbness or bad circulation should not use these products, as it can be dangerous for them.

WHAT WILL MY DOCTOR DO FOR IT?
Your doctor has a number of choices for treating your Plantar Wart. Unfortunately, warts are stubborn entities and even the best methods for removing them allow a high rate of re-occurrence, around 15%.

He/she may choose to use medication that is stronger than what is available at the pharmacy. This can speed up the process. Depending on the size and number of warts, treatment can take from 1 - 12 months before the wart is completely gone, and like any infection, all parts of it must be completely eliminated, or it will grow back.

An additional option is to physically remove the wart at one time, surgically, with a spoon like instrument called a curette. The healing time is from 2-4 weeks, depending on the size.

CAN I PREVENT FROM IT HAPPENING AGAIN?
Keep your feet clean and dry. Inspect feet frequently for new warts and begin treating small ones immediately, before they increase in size or number.