What Do Damaged, Fungal Nails Look Like? - Jeffrie C. Leibovitz, DPM

What Do Damaged, Fungal Nails Look Like?

Jan 17, 2023

Most people can recognize a thick discolored nail from long-term fungus involvement. It is hard to miss. But what does it look like when it starts? And how and why does it start? 

The majority of the time I see this problem at the end stage change. If I was able to treat this in the early stages there would be a jump in success rate. I guess we need a 5K walk to bring awareness to it.

Nail damage allows entry of a fungus. Unfortunately, people do not seek treatment when the initial symptoms develop. A delay of several years allows the nail to become thick and discolored. Click here to see a neglected nail.

Let’s Start at the Beginning

The most common cause of a thick discolored nail is trauma.  Injury can be from 3 sources. 

  1. Macro trauma (dropping something heavy on a toe).  If there is bleeding under the nail there will be a blueish–black appearance.  The bleeding is trapped under the nail and builds up pressure. This can produce a lot of pain. Early treatment can provide immediate relief. If the trauma is significant there can also be a fracture of the phalanx.
  2. Repetitive micro-trauma can be from wearing a shoe that is just a little too small or too big. The nail can turn dark just like a big hit. The pressure or pain does not develop until much later.
  3. Chronic use of nail polish or faux nails trap and encourage fungal growth. If you have not looked at your naked nails for 5 years, you probably have a fungus. 

If you are using polish to cover discolored nails… you have a fungus. 

If you use the communal bottle of polish at the salon and if any of the people before have fungus … then you have a fungus. 

Salon tip – Bring our own polish. It is better not to share!

Case Study 1 (Dr. L!)

The right hallux nail had a single hard collision with a large rock while mountain biking at Brown County State Park. Yeah boy, it hurt. Initially, I thought I broke my toe but the x-rays were negative – I was lucky.

The left hallux nail damage is from a long hike with too thick of a sock in a hiking boot – about 4000 individual impacts/steps. I did not have any discomfort during the hike. There was some mild tenderness immediately afterward. My discomfort did not appear until later that night.

1 week after treament

1st Week

The bleeding under the nails (subungual hematoma) is obvious in both toes. 

The right damage is confined to the base of the nail at the point of impact. 

The larger area on the left is from an accumulation of fluid that has separated the nail from the nail bed. Fortunately, there was minimal bleeding and little discomfort.

No big deal – right?  99.9% of people make this mistake. This is the easiest time to prevent fungal involvement – before it starts. 

We want to keep the fungus from invading the nail.  That is where topical medications shine. Once a fungus is in the nail it is a tough battle to clear the nail.  The topical meds have a 5% chance of success after the nail is invaded. 

NOTE: The topical meds I am referring to have an antifungal component – TolfinateTerbinafine, or Clotrimazole. Beware of the super duper secret oil extracts that list undecylenic acid, “All Natural Stuff”, or “Key Ingredients” (my favorite).

There is a limited time, several weeks, that using topical medications as the only treatment will be effective. I started treatment right away. ONLY TOPICAL MEDS were used.

1 Month

The left nail is still attached, at this point. All the sub ungula (under the nail) bleeding or fluid has escaped. The dotted outlined marks the separated nail vs attached nail.

KEY POINT: Notice the brownish debris that is present after the loose nail has been removed.  THIS IS FUNFGAL DEBRIS aka smutz (medical term) that has made its home under the nail. It is made of dead skin cells and remanence of blood – a food source for a fungal colony.  This is a petri dish for bad things. The area is hidden and protected when the nail is left intact. It is an un-chaperoned party for fungus. I consider it a miracle if fungus does not take over the nail in this scenario.

A nail can respond in several ways to an injury. If fluid accumulation, nail separation occurs.

  1. The nail can go dormant for a few weeks and then continue to grow. You may see a district line across the nail where it changed growth patterns. This may take several months to see.
  2. The growth center (matrix) will reboot and start a new nail. The old will be lifted up by the new nail. It may take 1 – 2 months but the old nail will become detached. This can be a problem when the old nail catches on a pant leg, bed sheets, or sock. The remaining attached nail can be torn off producing more nail trauma.

The right nail has shown migration/drifting of the sub-ungula bleeding. There was not enough bleeding to separate the nail. The color is trapped in the nail.  Normal nail is visible at the base. There is 3-4 mm of growth in the last month (time of injury). This nail is not expected to fall off.

It is a good sign IF there is a clear nail between the damaged area and the base of the skin margin. This is the last call to use topical meds as the primary treatment. The topical medications are fungal static. That means they limit the growth of the fungus and do not kill it.

 12 Long WEEKS – the Virtue of patience

Nail growth is very s-l-o-w even for a healthy non damaged nail. Medications will not change a nail that has been damaged. We can only protect new nail as it grows.

You should be able to see changes in the nail after 3-6 months if the topical med is going to be helpful.

A clear, pink, and thin nail should be visible at the proximal (bottom) skin border. The old nail will be thicker than the new nail. It will feel like a miniature speed bump.

There should be affirming nail changes after 3-6 months of using topical meds. If no,  it is time to consider additional options. 

The latest generation of oral meds try to clear the fungus at the growth center. But these meds carry a small chance of irritating the liver. This is why blood tests are performed before taking the medication and again in 1 ½ months. The medicine will imbed in the nail as it grows. This should create a clear zone at the base of the nail. This is like returning to your own hair color after highlights. Another requirement to use oral meds is a great vascular supply. If there is no delivery system then limited medicine can be delivered.

An additional option is laser therapy. Like topical meds, laser therapy is not a standalone remedy. It is part of the trinity of fungal nail treatments. There are no allergies or liver irritation with laser. It is an out-of-pocket expense (not covered by insurance).

toenail after 6 months of treatment

6 Months

The goal is a “clear” zone at the base of the nail. It should be well defined at 3-6 months. It is now a race – a very slow race. How fast can the nail grow vs how fast the fungus can take over the nail? The fast rate of nail growth is important for good results.

Factors that slow down nail (and hair) growth:  

Diminished blood supply. Toes are the farthest point from the heart. A small decrease in flow will have a significant effect on blood flow in your toes.

Cold temps. Nails grow slower in the winter. The body shuts down peripheral circulation in cold temps.

Poor dietWere the nails brittle and thin before the injury? This could indicate a nutritional deficit.

Nail polish. A damaged nail does not look great. It is common to hide nail changes with polish. This is the worst thing you can do!! Covering the nail hides and protects the fungus and provides a great environment for them to thrive. Chronic use of nail polish is the second most common cause of fungal nails. If you are trying to get rid of the fungus, polish makes it impossible to clear the nail.

Age. This is a combination of all the above.  The 50-year age group has a 50% incidence of fungus… 60% at 60 years old and 80% at 80 years old. It appears that if you make it to 100 there is a 100% chance you will have fungus.

9 Months

Don’t you love it when a plan comes together? It looks like the topical med has protected the new nail growth.  But the final results are not in yet. It will be a year to 1.5 years before I will celebrate. I will be looking for any return of discoloration at the end of the nail. If an irregular pattern in the nail develops, it could be from previous damage or a return of fungus.

Both toes look clear. The follow-up is not over yet. I recommend using the topical 3 months after the nail looks clear. Unfortunately, it is rare that treatment is started so early. This patient was really motivated to follow the treatment to completion. 

There have been no studies using PO meds for initial trauma to a normal nail. This one-off trial sways my opinion that early treatment is optimal to protect the nail.

Stay Tuned

I just injured another nail. This time I will add Laser therapy with the topical for the treatment plan. I will try not to get any more injuries that we can study. It’s going to take a while so hang on to the edge of your seat…

A single treatment option is not very successful with established or chronic onychomycosis. Topical medication is a reasonable option in the early stages or as a preventive measure. Stay tuned…

What About a Tie?

Another option after a year of treatment would be a nail with minor color changes but no thickening of the nail. Everyone would like to return to a normal nail. If we can prevent a massive thickening of the nails it may be considered a victory. An ounce of prevention may be worth a pound of … thick ugly nails. Using topical meds as a maintenance treatment may be a value. Sure… treatment with topicals is boring. Yes, it is time-consuming. If you are the type of person that is living fast and furious you may not have the time or patience for this.

Let Us Help With Fungal Nails or Other Foot Conditions!

To sum up, it’s important to always come in whenever a foot, ankle, or nail concern comes up. So if you have anything you are worried about with your podiatric care, hop on the phone to schedule an appointment with us! Give us a call at (317) 545-0505 or use our form to contact us through our website.