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Patients are often surprised to learn that dermatologists care for more than just the skin. “Do you do nails, too?” is a common refrain in my practice. Indeed, we also help patients with their fingernails and toenails for conditions such as fungal infections, discoloration, brittleness, and breakage.
Concerns of the nails should not be lightly dismissed. Pain of the nails, a new growth, or a new pigmented band should always be examined—these could indicate a serious health problem such as an inflammatory disease or even cancer of the skin of the nail unit.
If you’ve been dealing with unsightly or uncomfortable nail symptoms, talk with a dermatologist. We can help you get to the root of nail concerns and back to feeling and looking your best. Many nail conditions can be treated or cured with over-the-counter or prescription medications. It is wise to avoid clipping your nails or applying cosmetics prior to seeing us for nail concerns.
Let’s take a look at the common and less common causes of finger- and toenail conditions our dermatology team diagnoses and treats.
Common causes of nail conditions.
Fungal infection: One of the most common nail disorders, a fungal infection is often associated with nearby skin infections, such as athlete’s foot. Symptoms can include thickening, crumbling, or discoloration of the nail. Fungal infections of the toenail can be painful and can cause trouble walking.
Some treatments for fungal infection are applied directly to the nail (topical), while others are taken in pill form (oral). To prescribe the correct medication, many dermatologists will examine a sample of the nail to identify the fungus at fault.
Dark streaks: A new or changing dark streak under the fingernail could be melanoma, a type of skin cancer. The same types of cancer that occur on the skin can also develop in the nails. Not all dark streaks are cancer, but all should be examined by a dermatologist right away.
Psoriasis: A disease in which the skin reproduces too rapidly because of overactivation of the immune system. Patients and providers alike often think psoriasis is a skin and joint disease, but some psoriasis manifests in the nails alone as crumbling, discoloration, or pitting. Dermatologists may perform nail clippings to rule out an underlying fungal infection, X-rays to rule out joint manifestations of psoriasis, or a biopsy in difficult cases.
Treatments range from topical psoriasis therapies to steroid injections into the nail unit to oral or injected systemic therapies.
Brittle, soft, or splitting nails: Known as onychoschizia or onychorrhexis, these findings become more common with advancing age. If fingernails are affected but not toenails, the cause is often external. For example, repeated wetting and drying of the hands can worsen brittle nails in winter when air is dry. Sometimes, brittle nails can be caused by an iron deficiency. Your dermatologist will likely recommend a nail care routine to keep the hands hydrated and protected.
Discoloration: A change in the color of your nails can indicate an underlying health issue. Nails can become thickened and yellow, indicating a fungal infection, psoriasis, or eczema. A nail clipping or biopsy may be needed to distinguish between these diseases, as they may closely resemble each other.
Injury: Damaging a nail during sports, at work, or at home can cause broken or bruised tissue. Sometimes a nail injury leads to a subungual hematoma—blood gets trapped under the nail, causing discoloration. Severe injuries can result in a deformed nail. To treat an injury, your dermatologist may drain fluid that is building up beneath the nail.
Less common causes of nail problems.
Autoimmune conditions that can cause brittle, or thinning nails may include:
- Vitiligo: A chronic immune disorder that causes portions of the skin to lose their color, or pigment.
- Lupus: An autoimmune disease in which many different body systems can become inflamed, including the brain, blood cells, heart, lungs, and skin.
- Alopecia: A condition in which the immune system attacks the structures that produce hair, causing it to fall out.
- Autoimmune arthritis: An inflammatory disease in which the body’s immune system mistakenly attacks healthy cells, resulting in painful swelling, often in the joints.
- Hashimoto’s disease: A disorder in which the immune system creates antibodies that attack the cells of the thyroid.
Growths: About half of new growth and changes in nail texture are caused by fungal infections. The remaining half may be due to traumatic injury, genetics, psoriasis, or, in rare cases, cancer. See a dermatologist to understand whether a new growth is serious and which treatments can help.
Pitting or swelling: Though skin and nail conditions are often found together, sometimes the nails are the only place where they develop. Small dents or bumps in the nails—with or without itchy, irritated skin elsewhere—can be a sign of an underlying skin condition such as eczema, psoriasis, or alopecia areata.
This is not a complete list of the conditions that can cause you to seek care for your nails. Your dermatologist can identify the root cause of your nail concerns and provide appropriate treatment.
Effective treatments for any nail problem.
There are almost as many types of treatments as there are conditions of the nails. Early treatment is always better, as we can intervene soon to correct any nail issues and ensure they don’t come back. Some problems can be cleared up in just one visit with a dermatologist.
Whenever necessary, I take a sample of the affected nail before deciding upon a treatment. Getting a microbiological diagnosis can tell us exactly what’s causing your symptoms so we can precisely tailor the best treatment for you.
Topical treatment: For dry, cracked hands caused by environmental stressors, such as dry winter air or frequent handwashing, we may recommend specialized creams or lotions such as moisturizers or prescribe topical steroids or antifungals. Wearing gloves when doing household chores like washing the dishes can help protect your hands.
Medicated antifungal creams such as tavaborole, ciclopirox, and efinaconazole can help kill fungi or yeast, allowing the affected tissue to heal. Side effects are usually mild and can include stinging or burning when the medicine is applied.
Injectable treatment: For certain inflammatory diseases limited to the nail, such as psoriasis, we sometimes treat with corticosteroid injections into the nail unit. During these procedures, we use multiple methods of analgesia at once, and patients are often surprised at how well they tolerate these injections.
Oral medication: Pills taken by mouth like fluconazole, griseofulvin, or terbinafine can help eliminate yeast and fungi. These pills usually work more quickly than creams or lacquers, but you may need to have blood tests to check for side effects. Sometimes, oral steroids such as prednisone may be used for inflammatory diseases of the nail.
In-office procedure: Some tumors or pigmented bands of the nail may have to be biopsied to rule out cancer of the nail unit. This may involve removal of all or part of the nail plate to sample deeper parts of the nail unit.
A severely damaged nail may have to be removed so a new, healthy one can grow in its place. Known as nail avulsion, this procedure separates the body of the nail from its surrounding structures. The dermatologist may perform a simple surgical procedure or use chemicals to dissolve the nail. With any nail procedure, you will get numbing medication as an injection or a cream.
Referral to a specialist: Some nail problems are caused by an underlying condition, such as thyroid problems or an autoimmune disease. If we suspect you have a more serious condition, we will refer you to a MedStar Health specialist who can help develop a treatment plan that addresses your personal health needs.
You don’t have to simply deal with an uncomfortable or unattractive nail condition. Talk with a dermatologist to get on the path to smooth, healthy nails.