Apr
2014

Q&A: My daughter's toenail is growing in layers and keeps popping off. Is there anything that can help?

Ask A Doctor Question: 

My 16 year old daughter have both of her big toenails growing in layers. When it get to a certain point, the toenail pops off. I've had her tested for fungus last year by a podiatrist and it came back negative. He could not help us from that point on. Is there anything you can do for her? I was told to try a skin specialist. Thank you.

- Anna

Answer: 

Howard R. Fox, DPM, FACFS - LocateADoc.com

Hello Anna,
 
While it’s possible for a 16 year old to have a fungal infection of the toenails, it’s extremely rare, and the fact that only the two big toes are involved make it even less likely it’s a fungus, so I’m not surprised her previous fungal cultures were negative.  (Just so you know, there is a new staining technique for fungus nails that came out just this week that is more sensitive and reliable than the older staining methods.)
 
The more common cause of dystrophic (thick, discolored) toenails that involve only both big toes in younger people, especially if they’re very active, is slow, gradual repetitive trauma, like the big toes getting jammed against the tip of the shoe during athletic activities.  This is actually fairly common in people with what is referred to as a Morton’s Toe, where the big toe is the longest instead of the 2nd piggy being the longest (which is normal), making the big toe more vulnerable to repetitive tapping.
 
The treatment for this is a tongue pad, as strange as it may sound.  No, not anything for her mouth, but rather a ¼ inch piece of felt placed on the tongue of her shoes.  The idea is any jamming from the foot lunging forward in the shoe gets absorbed in the instep area by the tongue pad, not the big toes.  Also, and pardon me for even asking, make sure she’s wearing the correct size shoe, especially the sneaker she wears during any activity, since that, too, can cause the big toenails to jam.
 
Toenails, like fingernails, quills on animals and such, are specialized skin cells that grow harder.  They all tend to thicken when even small amount of pressure are applied over time, just like calluses form on skin.  It’s a protective mechanism.  With toenails undergoing this kind of repetitive stress, when the nail gets long enough (and that’s not really “long”), the repetitive trauma can break the end of the nail off.  Without seeing her foot, that’s my best “guess” as to what’s going on.
 
You can buy tongue pads in the foot isle of a good pharmacy, or get them on line.
 
Hope this helps!  Feel free to ask me any questions either by email or phone 888-552-8319.
 
Good luck!!

--Howard R. Fox, DPM, FACFS
718-987-5366
Staten Island, NY

Answer: 

Jeffrey Radack, DPM, FACFAS - LocateADoc.com

A traumatic origin should be considered first. Is she an athlete?  any form of repetitive trauma to the nail?  We will see traumatic avulsions routinely in sports involving high impact activity (i.e. running, track, soccer, volleyball).  Are her shoes too tight?  should have a fingers width distance from the end of the longest toe to the tip of the shoe.  If the answer is no to all of these questions, you might consider having the nail plate avulsed surgically and letting another nail grow out.  It may do so normally.    This can be done rather simply in clinic setting under local anesthesia. 

--Jeffrey Radack, DPM, FACFAS
Mckinney, TX

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