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How did I get these black nails?
There are 3 common causes for black nails. One of them is a killer.
That is going to leave a mark
The most common cause is trauma- big or small.
Dropping a bowling ball, can of soup, phone, or frozen turkey on a toe will cause bleeding under the nail. After you are done seeing stars you will notice a blue or purple color in the nail bed. Bleeding under the skin is a hematoma. If it develops under a nail it is called a Sub Ungual hematoma. That is the bonus word for the day.
Acute bleeding under the nail is strapped and has nowhere to go. After an injury the bleeding builds up pressure and this can be surprisingly painful. It may take 2 – 24 hours before the fireworks start. Unfortunately, people wait 3-4 days to seek treatment. By this time the toe is starting to resorb the fluid and they start to feel better. Sadly these 4 days of torture could be avoided. It the nail is treated in the early stages, comfort can be immediate.
As fluid accumulates under the nail it is separated from the nail bed. A nail can survive a little separation but if it is more than 50% the nail is doomed. A new nail will start growing with the growth center re boots. The new nail will eventually push or lift the old nail off the bed. Early treatment has other benefits. If the nail separation can be reduced it will also reduce the chance the nail will fall off.
The Gift That Keeps On Giving
After you get through the initial pain there is the surprise and shock of losing a nail. It may take 6 months to a year to replace the entire nail. The big toenail takes 4 times longer than the little piggy nail. The big toe is also the most likely to get injured.
Long after you forgot about the original injury the new nail will start to look different. The yellow or brown color will show up at the end of the nail. There may be some dark streaking or white patches around the edges. This is the beginning of a nail fungus (Onychomycosis). This is where the suspenseful music starts and panic sets in. Trauma is the #1 cause of fungal nails. Nail changes are typically noticed long after the original trauma. The history of the injury doesn’t even show up in a person’s short term memory banks …at first. The majority of my patients will eventually have an Ah-Ha moment and remember. Again, this is unfortunate because early treatment could have eliminated the 2+ year head start the fungus has in its quest to take over the nail.
And there is more!
If the nail matrix is damaged the nail can become wider. The surrounding skin will not tolerate a size 9 nail in a size 6 nail bed. An ingrown nail can become a problem on its own. Add a fungus in the mix and there is a tough one-two punch.
The runner’s badge of honor
It is hard to call yourself a dedicated runner if you never had a black toenail. It is almost a requirement for this activity. This type of nail damage occurs from repetitive microtrauma. A shoe that is too large, too loose, or too small will damage nails. The most common problems are with the hallux or second nail. The difference between the big bang and the microtrauma theory is that the latter produces minimal discomfort. That is the good news. There is still a good chance the nail will eventually fall off. A black nail from activity will follow the same timeline as an acute injury. Microtrauma can also occur in an aggressive dress shoe, ski boot (water or snow), and reinforced steel-toed boot.
The Queen said off with their heads
The old damaged nail may spontaneously fall off. You could get a surprise in your bed like Jack Woltz in The Godfather. Or it may be less dramatic and happen while putting on your socks or taking a bath. This will not occur right after the original injury. It will take months for the nail to plan its escape. The old nail becomes loose after the separation from the nail bed. It may take 2-3 months for the new nail to lift off the old nail. This can be a repeating affair every 2-3 years with a thick fungus nail.
What Else Can Go Wrong?
The second most common cause of dark or black nails is a result of fungus involvement. It seems like any discussion of nail problems ends up with fungus. When the nail gets thick it will look darker. When the nail gets extremely thick, it will push on the nail bed and create damage and bleeding. This will provide the same appearance with runners- mentioned in the paragraph above. Only the nail will be 4-10 time thicker than normal
So what came first, the injury or the thickening?
- A) A nail injury creates bleeding, looks black, and eventually gets thick. B) A thickened nail can create subungual bleeding and eventually look black. Either way, the end result is a bad nail. The treatment options are also the same. The success rate of getting a normal nail depends on how long the problem has been present.
It is a hope and a prayer that the nail will return to normal without treatment. And even with treatment the chance of a normal nail dramatically lowers with each year that goes by. It is so easy to treat a recently injured nail and prevent it from becoming the dreaded thick nail.
Pain is a good motivator.
Injured people in pain make my job easier. These people become patients right away. Early treatment means better results. It is the minimal or non-painful problems that never set off the “get help “alarm. I get to see these patients 5- 10 years later.
What is the scariest movie you have ever seen?
The third way to get a black nail is through melanin deposits. Well, that does not sound so scary. Melanin is what gives our skin pigmentation. The more melanin the darker the skin. The pucker moment is that focal darkening and streaking can also be a melanoma. You CAN get cancer in your feet and in the nails. This will make your favorite scary movie seem pedestrian.
The red flag changes appear as dark streaks that extend toward the end of the nail. There can also be dark streaks in the nail that are normal pigments. Now that is the REAL scary part of our story! How do we tell the difference?
These are important: How long have the streaks been present? How many streaks and how many toes are affected? Is there a history of skin cancer?
An additional examination with a special instrument called a dermatascope is important. It will enlarge more than a magnifying glass. Specific cell patterns help tell the difference between the good guys (normal melanin deposits) and the bad guys (malignant melanoma). A small punch biopsy will provide a definitive diagnosis. I cannot stress how important it is to catch this problem early.
Black nails are like the old western movie: The Good, The Painful, and the Deadly.