Nail Care

• Nail care refers to the proper maintenance of the fingernails and toenails. Nail care is important because it helps prevent nail problems, such as fungal nail infections and ingrown toenails. However, in some cases, nail problems are symptoms of an underlying medical condition, such as an infection throughout the body.
• The fingernails and toenails help protect the fingers and toes. The nails are made up of several different parts. The nail plate is the largest and most visible part of the nail. It is the hard part that covers the tips of the fingers. The nail bed is the skin that is beneath the nail plate. The nail folds are the skin that surrounds the three sides of each nail. The cuticle is the thin u-shaped tissue that overlaps the nail plate at the base of the nail. It protects new nail as it grows from the nail bed. The lunula is the white-colored half-moon shape at the base of the nail beneath the nail plate.
• The nails start growing underneath the cuticle, in what is called the matrix. As new cells grow, older cells harden and are pushed out to become part of the nail plate. On average, nails grow about 0.1 millimeters a day. In other words, if a nail falls off, it takes about four to six months for it to completely grow back.
• Nails are considered healthy if they are smooth and uniform in color and consistency. Healthy nails do not have ridges or grooves, and they do not have spots or discoloration.
• In order to maintain healthy nails, it is recommended that individuals keep the nails clean, trimmed, and moisturized. Moisturizing the nails helps prevent the nails from becoming brittle and breaking or cracking. Although nail biting does not usually cause nail problems, it is not recommended. In some cases, nail biting may worsen a nail condition, such as an infection around the nail bed.

• Oral antifungals: Patients with fungal nail infections typically take antifungals by mouth. These medications, such as terbinafine (Lamisil®), fluconazole (Diflucan®), or itraconazole (Sporanox®), kill the fungus and allow a new nail to grow that is not infected with the fungus. Treatment generally lasts about six to 12 weeks. However, results will not be apparent until the new nail has completely replaced the old, infected nail. Treatment does not cause the infected toenail to fall off. This may take anywhere from four to six months. Once treatment is over, individuals should try not to expose the nails to warm, moist environments because this may cause the infection to return.
• Some antifungal medications that are taken by mouth may cause liver damage. This is because they are strong medications that must be broken down by liver before they can be absorbed into the body. Ketoconazole (Nizoral®) and amphotericin B (Fungizone®, Abelcet®, AmBisome®, or Amphotec®) are the most likely to cause liver damage. Therefore, blood tests should be performed regularly during treatment to monitor liver function. Patients who experience nausea, vomiting, weakness, fatigue, abdominal pain (especially near the liver), dark urine, or jaundice (yellowing of the skin and eyes) should consult their healthcare providers immediately. These are all signs of liver damage.
• According to the U.S. Food and Drug Administration (FDA), two oral antifungals, called itraconazole (Sporanox®) and terbinafine (Lamisil tablets®), have been associated with rare cases of liver failure and death. Itraconazole that is taken by mouth may weaken the heart and should not be prescribed for long-term use if a patient has a history of heart disease or heart failure.
• Antifungal lacquer: Rather than taking oral antifungals, some individuals who have mild to moderate fungal nail infections may be treated with an antifungal lacquer, such as ciclopirox (Penlac®). Once a day the lacquer is painted onto the nails like nail polish. After seven days, all of the lacquer is wiped off with alcohol. The treatment is then repeated. However, this treatment may be less effective than oral antifungals. According to human studies, daily use of Penlac® cured fungal nail infections in 10-30% of patients. Therefore, some doctors may prescribe an antifungal lacquer in combination with an oral antifungal.
• Topical antifungals: Topical antifungals may be used in combination with oral antifungals. Unlike antifungal lacquers, topical antifungals are applied to the nails as well as the surrounding skin. Topical antifungals usually do not cure fungal nail infections on their own, which is why they are usually used in combination with oral antifungals. Patients may be asked to use topical antifungals in combination with other creams that contain urea. The urea-containing creams may help speed up the absorption of the medication.
• Soaking the foot: Individuals who have minor ingrown toenails are encouraged to soak the foot in warm water for 15-20 minutes. Then, a dry cotton ball should be placed under the ingrown corner of the nail. This may help the nail start to grow above the skin. Signs that an ingrown toenail is not healing include increased pain, swelling, and drainage of pus or blood from the affected area.
• Individuals who have bacterial paronychia should soak the infected nails in warm water and antibacterial soup three to four times a day for 15 minutes. This should be continued until signs and symptoms are gone. If the condition does not improve in a few days, patients should visit their healthcare providers.
• Non-steroidal anti-inflammatory drugs (NSAIDs): Patients with mild ingrown toenails may also take over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin® or Advil®) or naproxen (Aleve®) to help reduce pain and inflammation. If pain is severe or worsens, patients should visit their healthcare providers because this may be a sign of an infection.
• The frequency and severity of side effects vary. The most common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include kidney failure, liver failure, ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers in the stomach or duodenum.
• Minor surgery: If an ingrown toenail does not improve with the treatment mentioned above, minor surgery may be necessary. A doctor first numbs the affected toe with an anesthetic. Next, the toenail that is growing into the skin is cut and pulled out of the skin.
• In some cases, a liquid solution or small electrical charge may be applied to the nail bed. This non-permanent procedure, called ablation, helps prevent the nail from growing back into the skin. A permanent procedure, called nail matrix ablation, can be performed to prevent the nail from growing back at all. This procedure is usually only performed in patients who experience frequent ingrown toenail or in individuals who have a high risk of experiencing complications (such as diabetics).
• After surgery, patients are typically advised to soak the foot in warm water each day. An antibiotic ointment may be prescribed to help prevent an infection. Nail treatments, including painting the nail with nail polish, are not recommended during the healing process.
• Patients who experience frequent ingrown toenails may have part of the toenail and nail bed removed in order to prevent that part of the nail from growing back.
• Individuals who have fungal or bacterial paronychia may have to have abscesses drained. In serious cases, the entire nail may need to be removed.
• Antibiotics: If an ingrown toenail causes an infection, antibiotics are prescribed. These medications kill the bacteria that are causing the infection.
• Most cases of bacterial paronychia do not require antibiotics. These medications are used when there is extreme swelling and pain that does not respond to other treatments.
• Nail hardeners: Nail hardeners may be applied to nails in patients who have weak or brittle nails that are caused by nail dehydration. Nail hardeners typically contain acetates, toluene, nitrocellulose, acrylic, and polyamide resins. Some products, called fibered nail hardeners, contain 1% nylon fibers. Other additives may include glycerin, hydrolyzed proteins, modified vegetable extracts, propylene glycol, and metal salts.
• Patients should avoid products that are made with formaldehyde or sulfonamide because they may irritate the skin. Nail hardeners should not be used if a nail infection is suspected.
• Limit use of nail polish remover: Individuals who have naturally weak or brittle nails should limit their use of nail polish remover. In general, individuals should not use nail polish remover more than twice a month. Many nail polish removers contain harsh solvents, such as acetone, alcohol, ethyl acetate, or butyl acetate. Individuals should avoid nail polish removers that contain acetone because this product dries up nails, making them even weaker and more brittle. Individuals can purchase acetone-free nail polish at local drug stores.

C Unclear or conflicting scientific evidence

• Biotin : Biotin is an essential water-soluble B vitamin. Biotin has been suggested as a treatment for brittle fingernails, particularly in women. There is not sufficient scientific evidence to form a clear conclusion.
• Avoid if hypersensitive to constituents of biotin supplements.
• Bitter orange : Limited available human study found promising results using the oil of bitter orange for treatment of fungal infections. However, due to methodological weakness of this research, further evidence is needed to confirm these results.
• Avoid if allergic or hypersensitive to bitter orange or any members of the Rutaceae family. Avoid with heart disease, narrow-angel glaucoma, intestinal colic, or long QT interval syndrome. Avoid if taking anti-adrenergic agents, beta-blockers, QT-interval prolonging drugs, monoamine oxidase inhibitors (MAOIs), stimulants, or honey. Use cautiously with headache, hyperthyroidism (overactive thyroid), or if fair-skinned. Avoid if pregnant or breastfeeding.
• Cranberry : Limited laboratory research has examined the antifungal activity of cranberry. Reliable human studies supporting the use of cranberry for fungal infections are currently lacking. Further research is warranted in this area.
• Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Pregnant and breastfeeding women should avoid cranberry in higher amounts than what is typically found in foods.
• Garlic : Garlic is used both medicinally and as a food spice. Several studies describe the use of garlic as a topical antifungal to treat fungal infections of the skin, including yeast infections. More research is needed in this area.
• Use cautiously as garlic can cause severe burns and rash when applied to the skin of sensitive individuals. Avoid if allergic or hypersensitive to garlic or other members of the Lilaceae (lily) family (e.g. hyacinth, tulip, onion, leek, or chive). Avoid with a history of bleeding problems, asthma, diabetes, low blood pressure, or thyroid disorders. Stop using supplemental garlic two weeks before and immediately after dental/surgical/diagnostic procedures with bleeding risks. Avoid in supplemental doses if pregnant or breastfeeding.
• Lavender : Early laboratory studies suggest that lavender oils may have topical antibiotic activity. However, this has not been well tested in human studies.
• Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (such as anorexia or bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
• Propolis : Propolis is a natural resin created by bees to make their hives. Propolis is made from the buds of conifer and poplar trees and combined with beeswax and other bee secretions. Animal and laboratory studies suggest that propolis may be a beneficial treatment for various types of bacterial infections. Additional research is needed to confirm these findings.
• Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, or Balsam of Peru. Severe allergic reactions have been reported. There has been one report of kidney failure with the ingestion of propolis that improved upon discontinuing therapy and deteriorated with re-exposure. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.
• Seaweed, kelp, bladderwrack : Bladderwrack (Fucus vesiculosus) is a brown seaweed found along the northern coasts of the Atlantic and Pacific oceans and North and Baltic seas. Another seaweed that grows alongside bladderwrack is Ascophyllum nodosum, and it is often combined with bladderwrack in kelp preparations. Laboratory research suggests that bladderwrack may have antifungal activity. However, reliable human studies to support this use are currently lacking in the available literature.
• Avoid if allergic or hypersensitive to Fucus vesiculosus or iodine. Avoid with a history of thyroid disease, bleeding, acne, kidney disease, blood clots, nerve disorders, high blood pressure, stroke, or diabetes. Avoid if pregnant or breastfeeding.
• Tea tree oil : Although tea tree oil has been found to have antifungal activity against several fungus species in laboratory study, there is currently insufficient human evidence to determine if it is an effective topical treatment for this indication. Additional study is needed in this area.
• Tea tree oil may be toxic when taken by mouth and therefore, should not be swallowed. Avoid if allergic to tea tree oil or plants of the Myrtle (Myrtaceae) family, Balsam of Peru, or benzoin. Use cautiously with a history of eczema. Avoid if pregnant or breastfeeding.
• Thyme : Thyme has been used medicinally for thousands of years. Beyond its common culinary application, it has been recommended for many indications based on proposed antimicrobial, antitussive, spasmolytic, and antioxidant activity. Thyme essential oil and thymol have been shown to have antifungal effects. Topical thymol has been used traditionally to treat paronychia (skin infection around a finger or toenail) and onycholysis (fungal nail infection). Currently, there is insufficient reliable human evidence to recommend for or against the use of thyme or thymol as a treatment for fungal infections.
• Avoid if allergic or hypersensitive to thyme, members of the Lamiaceae (mint) family, any component of thyme, or rosemary (Rosmarinus officinalis). Avoid oral ingestion or non-diluted topical application of thyme oil due to potential toxicity. Avoid topical preparations in areas of skin breakdown or injury or in atopic patients due to multiple reports of contact dermatitis. Use cautiously with gastrointestinal irritation or peptic ulcer disease due to anecdotal reports of gastrointestinal irritation. Use cautiously with thyroid disorders due to observed anti-thyrotropic effects in animal research of the related species Thymus serpyllum. Avoid if pregnant or breastfeeding.

• In order to maintain healthy nails, it is recommended that individuals keep the nails clean, trimmed, and moisturized.
• Trim the nails and toenails regularly. Do not cut the nails, especially the toenails, too short. This may cause the nail to grow into the tissue.
• Most experts do not recommend cutting or pushing back the cuticles because it may damage the nail beds and increase the risk of infection.
• Diabetics or individuals who have poor circulation should visit their podiatrists regularly in order to prevent complications, such as infected ingrown toenails, from developing. These individuals should also consider having their nails professionally trimmed.
• Individuals should wear shoes that fit properly. If there is too much pressure on the toes, the nails may end up growing into the skin.
• Individuals should wear protective footwear, such as steel-toed boots, if they are at risk of injuring their toes at work.
• Wear gloves when performing activities that may damage nails, such as gardening. It is also recommended that individuals wear cotton-lined rubber gloves when handling harsh chemicals or soaps for extended periods of times. This is because soaps and chemicals may weaken the nails, making them susceptible to breakage.
• Avoid application of polish or other nail treatments to nails suspected of infection. Such areas may appear red, discolored, or swollen.
• Individuals should not use nail polish remover more than twice a month. Avoid nail polish removers that contain acetone. This product dries up nails, making them even weaker and more brittle. Individuals can purchase acetone-free nail polish at local drug stores.