Are your toenails ready for summer?

One of the joys of spring is that the weather permits people to shed their heavy shoes and wear sandals. However, if you suffer from a fungal infection in your toenail(s), exposing your toenails to the public is probably the last thing in the world you’re interested in doing.

If you have a toenail fungus, you know what it looks like, and you don’t like it. Toenails that are infected become dark, thick and crumbly. Quite often, the toenails can reach a point where they are thicker than long. There are other causes of toenail discoloration and thickening, and your doctor may perform tests to confirm a diagnosis of onychomycosis (the medical term for fungal infected toenails).

Fortunately, there are ways to correct and cure the problem, but you need to start the process now. I am aware of no treatment for onychomycosis that will solve the problem overnight. The underlying problems in treating this disease are that first, the fungus that causes the infection is not conveniently located on the surface of the toenail – it is imbedded deep within the toenail. This makes it difficult for topical treatments and home remedies to effectively kill the fungus when they are applied to the surface of the toenail in all but the mildest cases. Second, once the fungus is killed, the toenail does not miraculously return to normal. What has to happen is that the toenail must be replaced by new nail growing out from its base. And since toenails grow slowly (when compared with fingernails), it can take many months for the new, clear, non-infected toenail to replace the infected portion of the toenail.

So, what is the best treatment available? What works? I have found that terbinafine (Lamisil) to be quite effective. It is a pill that is taken once daily for three months. As the medication is taken, it gradually becomes deposited into the toenails and fingernails. There, it can begin eliminating the fungus. What the patient sees is gradually clearing of the nail from the base as new toenail begins to grow. Certainly, any medication taken orally has the potential for side effects, but I have found side effects with terbinafine to be quite infrequent, and they go away when the medication is discontinued. For patients with a history of liver disease, this is not the medication for you. Perhaps the most limiting side effect in the past was the cost. A three month course of treatment used to be upwards of $1200. A few years ago, the medication became available in a generic form. In our area, we have found three pharmacies that offer terbinafine for just $10 for the three month course of treatment!

So, if you are not happy with the appearance of your toenails, or if they are causing discomfort, see your podiatrist. Most likely, there are treatments available that can greatly improve your condition!

Ingrown Toenails

One of the more common problems that causes patients to come see me is for the treatment of ingrown toenails. They are painful, persistent, and can really make life miserable. For some reason, I see a lot of fear on my patients when it comes to the treatment of this problem. I would like to explain what causes ingrown toenails, and what the preferred treatment is for most of my patients.

Ingrown toenails can affect people of all ages. I have seen infants with ingrown toenails, elderly patients, and everyone in between. What causes them to occur? Sometimes it is just the inherited shape of the toenail that predisposes people to develop ingrown toenails. Other times, it can be caused by wearing shoes that are too tight, or an injury to the toe that drives the nail into the surrounding skin. Fungal toenails, because they are often thicker, can also be a factor. Finally, if toenails are cut too short, especially long the sides of the toenail, they can become ingrown as they start to grow back out. Once the problem starts, the surrounding skin will often become infected and inflamed, As it does so, it will cause the entire area around the toenail to be painful.

Treatments at home can and probably should be tried first in mild cases. This includes putting a little bit of cotton under the nail, foot soaks, and avoiding wearing tight shoes. However, if you don’t see results after a week or so, it’s time to let your podiatrist take over. The treatments he can offer range from controlling the infection, to permanently correcting the problem so it does not happen again.

As mentioned above, the toe often becomes infected when the toenail is ingrown. The right antibiotic can treat the infection and greatly reduce the pain. But if that is all that’s done, your relief may be short-lived. Antibiotics do nothing to treat the underlying cause of the problem, namely, the toenail digging into the toe. Under local anesthesia (yes, that does mean a shot!), a portion of the toenail can be removed. Once this is done, the pain is dramatically reduced in most cases, and it also helps to clear the infection. I have found that when just a portion of the nail is removed (as little as 1/8”), the toe heals up within a week or so following the procedure. The one problem with this method is that while the pain is gone, the part of the toenail that was removed will grow back, and often will grow back ingrown.

So what do I do? I have found that for most of my patients, the best alternative is to remove the ingrown portion of the toenail permanently. Not the entire toenail, just the tiny portion along the side that is causing all the problems. Essentially, the same procedure is done as was described above, but I also use a medication to kill the root of the portion of the toenail that was removed. When done correctly, this will prevent the portion of the nail removed from growing back, thus solving the problem for good.

One of the first questions that people ask me is “how much does it hurt to have my ingrown toenail fixed?” Since I believe that it’s best to be straight with patients, I will admit that when the toe is made numb during the injection, there is discomfort. However, that does not last very long, and the rest of the procedure is painless. Afterwards, the biggest surprise most have is how little pain there is once the numbness wears off. Certainly, there is some tenderness, but by far the vast majority of patients tell me when they come back to see me one week later for their follow up appointment that they are happy, they feel much better, and they wish they had taken care of the problem sooner.

Once the toe is healed up completely, the toenail will be a little narrower. Other than the patient herself though, very few will be able to tell that anything had ever been done.

So, my advice is that if you have trouble with a painful ingrown toenail, decide to get it fixed and fixed for good. You’ll be glad you did!

What is a Podiatrist?

What is a Podiatrist?

As a practicing podiatrist for the last 20 years, this is a question that I am frequently asked - What is a podiatrist? Along with that question is the ever-popular "how can you stand looking at feet all day?" To answer these questions, let me start by explaining what it takes to become a podiatrist.

For a person coming out of high school with dreams of becoming a podiatrist, the first step is to go to college. Your major in college is not nearly as important as some might think. You will need to take several required classes regardless of your major though, with a heavy emphasis in the sciences (chemistry, physics, and the biological sciences). Once you near the end of your undergraduate career, it's time to start the application process to one of the 8 podiatry schools. Podiatry school is a 4-year curriculum, which when examined, closely resembles that of a typical medical school. This is especially true for the first two years. It is rigorous, and will test even the brightest of students. The further along students get into podiatry school, the more emphasis is placed on clinical training - as in actually seeing and treating patients. It would be a mistake, though, to think that today's podiatrist only learns about feet. To the contrary, the training is quite broad. In real life, it is impossible to treat foot problems without knowledge of what is going on with the rest of the body. For example, if a patient comes into my office with sudden onset of pain in his foot at the base of the big toe, I would include in my list of possible causes of the pain the diagnosis gout (see http://www.concordfootdr.com/library/1860/Gout.html). Treatment for this systemic disease that presents itself in the foot usually requires oral medication. Medication cannot be prescribed without knowledge of what other medication the patient is taking and how they all interact. Because of this, podiatrists have become experts in treating diseases, injuries and abnormalities of the foot and ankle, but are also able to tailor treatment plans that take the whole patient's situation into consideration.

Following the completion of podiatry school, the training is not yet complete. Podiatrists today must complete residency training that lasts up to 3 years. During this time, further training is received in the many areas podiatrists see in daily practice, including surgery, wound care, biomechanics, podiatric medicine, etc.

On a typical day in my office, I may see and treat any number of following conditions:
Ingrown toenails
Diabetic ulcers
Heel pain
Flat feet
Bunions
Hammertoes
Arthritis
Neuromas
Fungal toenails
Sprains
Fractures
Athlete's foot
Gout
Poor circulation
Neuropathy
Corns and calluses
And the list goes on and on.

So, the next time you think of your podiatrist, be grateful that such trained individuals are there to take care of all your foot care needs.

Oh, and as to the second question, how can I stand looking at feet all day? I look at it this way. If I can have a person come into my office with pain, and leave painfree, there is nothing I would rather do. I brings a great deal of satisfaction to get people back to normal activities... back to being able to walk, run, and work. In short, healthy feet go a long ways to making lives more fulfilling and productive. It's great to be play a part in improving the lives of my patients!