NAIL DISORDERS

Evaluation and Treatment of Fingernail and Toenail Conditions

OVERVIEW

Changes in the fingernails and toenails may result from infection, inflammation, trauma, repetitive pressure, skin disease, abnormal nail growth, or lesions involving the nail unit. Nail disorders may cause discoloration, thickening, splitting, separation, pain, swelling, or changes in the shape and texture of the nail.

Common nail conditions include fungal nail infections, ingrown nails, paronychia, traumatic nail changes, nail dystrophy, and nail changes associated with psoriasis and other inflammatory skin diseases.

Not every thickened, discolored, or distorted nail is caused by fungus. Similar changes can occur from repetitive trauma, chronic pressure, inflammatory disease, aging, or disorders of the nail matrix and nail bed, making accurate diagnosis important before treatment is started.

Pigmented changes of the nail also require appropriate evaluation. A new or changing dark streak, band, or pigmented area beneath or around a nail may have a benign cause, but melanoma can arise within the nail unit. Subungual or nail-unit melanoma is uncommon but important to recognize, particularly when pigmentation is new, changing, irregular, widening, or extending onto the surrounding skin.

COMMON NAIL CONDITIONS

Commonly evaluated nail problems include:

Fungal Nail Infection (Onychomycosis) — Thickening, discoloration, crumbling, separation of the nail plate, or accumulation of material beneath the nail.
Ingrown Nails (Onychocryptosis) — The edge of the nail grows or presses into the surrounding skin, causing pain, inflammation, swelling, and sometimes secondary infection or granulation tissue.
Paronychia — Acute or chronic inflammation involving the skin around the nail, sometimes associated with bacterial or fungal infection, repeated moisture exposure, irritation, or trauma.
Nail Dystrophy — Abnormal nail growth, thickening, splitting, ridging, discoloration, or deformation caused by a variety of local or systemic conditions.
Traumatic Nail Changes — Repetitive pressure, footwear, occupational activity, sports, or direct injury can alter the nail plate or produce bleeding beneath the nail.
Psoriatic Nail Disease — Psoriasis may produce nail pitting, thickening, discoloration, separation of the nail plate, or accumulation of material beneath the nail.
Pigmented Nail Changes — Brown or black streaks, bands, or localized pigmentation may have several causes and occasionally require further evaluation to exclude a melanocytic lesion or nail-unit melanoma.
Other Nail-Unit Lesions — Growths involving the nail fold, nail bed, or surrounding tissue may require additional evaluation, biopsy, or surgical treatment.

NOT EVERY ABNORMAL NAIL IS FUNGUS

Thick, yellow, brittle, distorted, or partially separated nails are frequently assumed to represent a fungal nail infection, but appearance alone does not always establish the diagnosis.

Similar nail changes may result from:

Repetitive trauma or pressure
Psoriasis or other inflammatory skin disease
Chronic nail dystrophy
Previous nail injury
Changes involving the nail matrix or nail bed
Other infectious or dermatologic conditions

When the diagnosis is uncertain, nail clippings, fungal testing, or other diagnostic evaluation may be used before prolonged treatment is considered.

Establishing the cause of the nail abnormality helps avoid unnecessary treatment and allows management to be directed toward the underlying condition.

INGROWN NAILS & NAIL AVULSION

An ingrown nail develops when the edge of the nail plate presses into or penetrates the surrounding nail fold. It most commonly affects the great toenail and may produce localized pain, redness, swelling, drainage, inflammation, or excessive granulation tissue.

Early or mild cases may sometimes be managed conservatively. More persistent, painful, inflamed, or recurrent ingrown nails may require a procedural approach.

NAIL AVULSION

At IVSI, partial or complete nail avulsion may be performed when appropriate based on the nail abnormality and clinical findings.

During partial nail avulsion, the problematic portion of the nail plate is removed while preserving the remaining nail when possible. Complete nail avulsion may be appropriate for selected conditions involving a larger portion of the nail plate.

Nail avulsion may be used for:

Persistent or recurrent ingrown nails
Painful nail deformity
Significant nail thickening or dystrophy
Selected infections or inflammatory conditions
Diagnostic access to the nail bed or underlying tissue when necessary

Treatment selection depends on the cause of the nail problem, extent of involvement, surrounding inflammation, and condition of the nail plate and nail unit.

PARONYCHIA & INFLAMMATION AROUND THE NAIL

Paronychia is inflammation involving the tissue surrounding a fingernail or toenail.

Acute paronychia may develop rapidly with pain, redness, swelling, or accumulation of purulent material and is commonly associated with disruption of the protective barrier around the nail.

Chronic paronychia may develop gradually and is often associated with repeated moisture exposure, irritation, inflammation, or disruption of the nail folds.

Management depends on whether the process is primarily infectious, inflammatory, irritant-related, or a combination of these factors.

NAIL CHANGES ASSOCIATED WITH PSORIASIS

Psoriasis can involve the nails even when skin disease is limited. Nail findings may include:

Pitting of the nail surface
Separation of the nail from the nail bed
Thickening or distortion
Yellow-brown discoloration
Accumulation of material beneath the nail

Psoriatic nail changes may resemble fungal infection, and the two conditions can sometimes coexist.

Nail involvement is also clinically important because it may occur in patients with psoriatic arthritis.

👉 Learn more about Psoriasis

PIGMENTED NAIL CHANGES & SUBUNGUAL MELANOMA

Pigmentation involving a fingernail or toenail may appear as a brown or black streak, longitudinal band, localized dark area, or pigmentation involving the surrounding skin.

Many pigmented nail changes are benign and may result from trauma, bleeding beneath the nail, normal melanocytic pigmentation, medications, or other causes. However, persistent or changing pigmentation should not automatically be attributed to trauma or infection.

Melanoma can develop within the nail unit. This is often referred to as subungual melanoma, although nail-unit melanoma may arise from different structures associated with the nail.

Features that warrant particular attention include:

A new or changing pigmented band
Progressive widening or darkening
Irregular pigmentation or multiple colors
Distortion or destruction of the nail plate
Pigmentation extending onto the surrounding nail fold or skin
A persistent pigmented lesion without a clear explanation

Suspicious nail pigmentation may require additional evaluation and biopsy to establish a tissue diagnosis.

👉 Learn more about Melanoma

DIAGNOSTIC EVALUATION OF NAIL DISORDERS

Evaluation begins with examination of the nail plate, nail folds, nail bed when visible, surrounding skin, and other affected nails.

Depending on the clinical findings, additional evaluation may include:

Nail clipping or sampling for suspected fungal disease
Microbiologic testing when infection is suspected
Dermoscopic examination of selected nail abnormalities
Biopsy of suspicious nail-unit lesions
Histopathologic examination of tissue when indicated

The goal is to determine the cause of the nail abnormality before selecting treatment, particularly when the appearance could represent more than one condition.

TREATMENT OF NAIL DISORDERS

Treatment depends on the diagnosis and may include:

Topical or oral medical therapy
Treatment of an underlying inflammatory skin condition
Management of infection when present
Modification of repetitive pressure, trauma, or environmental exposure
Partial or complete nail avulsion
Biopsy or surgical treatment of selected nail-unit lesions

Some nail disorders require prolonged treatment because fingernails and toenails grow slowly. Improvement in the underlying condition may therefore occur before a normal-appearing nail has completely grown out.

Evaluate Nail Changes

Persistent nail discoloration, thickening, deformity, pain, inflammation, ingrown nails, or new and changing nail pigmentation can be evaluated to determine the underlying cause and appropriate treatment.

📞 Call (847) 518-9999 to schedule a dermatology evaluation.

Medical Disclaimer
This information is provided for educational purposes only and does not replace individualized medical evaluation. Treatment recommendations depend on clinical findings, diagnostic requirements, and patient-specific factors. Outcomes may vary, and no specific medical result can be guaranteed.

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