Nail Problems: Symptoms, Causes & Treatment Guide

What Are Common Nail Problems?

Common nail problems include ingrown toenails, nail bed infections (paronychia), and fungal nail infections (onychomycosis). These conditions affect approximately 10% of the general population and can cause pain, discoloration, and nail deformity if left untreated.

Nail problems are among the most frequently encountered dermatological conditions, affecting people of all ages. The nails, which are composed of keratin protein, serve protective functions for the fingertips and toes while also providing important diagnostic clues about overall health. Understanding the different types of nail disorders, their underlying causes, and appropriate treatment approaches is essential for maintaining nail health and preventing complications.

The nail unit consists of several components including the nail plate (the visible hard part), the nail bed (the skin beneath the nail), the nail matrix (where nail growth originates), the cuticle (the skin at the base of the nail), and the nail folds (the skin surrounding the nail). Problems can occur in any of these structures, leading to various symptoms and conditions that range from mild cosmetic concerns to painful infections requiring medical intervention.

Most nail problems develop gradually and are often preventable through proper nail care and hygiene practices. However, some conditions require professional treatment, particularly when infection is present or when underlying health conditions such as diabetes or peripheral vascular disease increase the risk of complications. Recognizing the early signs of nail problems and understanding when to seek medical care can help prevent minor issues from becoming serious health concerns.

Types of Nail Problems

Nail disorders can be broadly categorized into infectious conditions (bacterial, fungal, or viral), traumatic injuries, inflammatory conditions, and changes related to systemic diseases. The most common problems encountered in clinical practice include ingrown toenails, which occur when the nail edge grows into the surrounding skin; paronychia, an infection of the nail fold; and onychomycosis, a fungal infection that causes nail thickening and discoloration. Each of these conditions has distinct characteristics and treatment approaches.

Beyond these primary conditions, nails can develop various abnormalities including brittleness, splitting, ridging, pitting, color changes, and separation from the nail bed (onycholysis). While some of these changes are simply cosmetic concerns related to aging or minor trauma, others may indicate underlying health problems such as thyroid disease, psoriasis, or nutritional deficiencies that warrant further medical evaluation.

What Causes Ingrown Toenails?

Ingrown toenails develop when the nail edge grows into the surrounding skin, most commonly due to improper nail cutting, tight-fitting shoes, or toe injury. The big toe is most frequently affected, and the condition can lead to pain, swelling, and infection if not properly treated.

An ingrown toenail, medically known as onychocryptosis, occurs when the lateral edge of the toenail penetrates into the adjacent soft tissue of the nail fold. This creates a wound that causes pain, inflammation, and can become infected if bacteria enter the break in the skin. The condition affects approximately 2.5-5% of the population and is particularly common in adolescents and young adults, though it can occur at any age.

The development of an ingrown toenail typically involves a combination of factors rather than a single cause. The shape of the nail plate, the anatomy of the nail fold, and external pressure from footwear all play important roles. Understanding these contributing factors is essential for both treatment and prevention of recurrence, which is a common problem with this condition.

While ingrown toenails can occur on any toe, the big toe is by far the most commonly affected, accounting for approximately 80% of cases. This is partly due to the greater forces applied to the big toe during walking and the tendency for this nail to have a more curved shape. The condition can affect one or both sides of the nail and may involve one or multiple toes.

Primary Causes and Risk Factors

The most common cause of ingrown toenails is improper nail cutting technique. When toenails are cut too short or rounded at the corners rather than cut straight across, the nail edge can more easily penetrate the surrounding skin as the nail grows. This is why proper nail cutting technique is considered the most important preventive measure for this condition.

Footwear plays a significant role in ingrown toenail development. Shoes that are too tight, too narrow, or have pointed toe boxes create pressure that pushes the nail fold against the nail edge. High heels exacerbate this problem by forcing the foot forward into the narrow toe area. Athletic shoes that are too small or worn during activities involving repetitive toe trauma also increase risk.

• Improper cutting: Cutting nails too short or rounding the corners
• Tight footwear: Shoes that compress the toes together
• Toe trauma: Injury from stubbing, dropping objects, or repetitive impact
• Nail shape: Naturally curved or thick nails are more prone
• Sweaty feet: Moisture softens skin, making penetration easier
• Poor circulation: Impairs healing and increases infection risk

Symptoms of Ingrown Toenails

The earliest symptom of an ingrown toenail is usually mild pain and tenderness along the nail edge, particularly when pressure is applied. As the condition progresses, the affected area becomes red and swollen, and the pain intensifies. The skin next to the nail may appear puffy and start to grow over the nail edge as the body attempts to heal the wound.

If infection develops, additional symptoms appear including increased warmth around the affected area, pus drainage, and possibly fever in severe cases. The tissue may become increasingly red and may develop a condition called proud flesh or hypergranulation tissue, where excessive healing tissue grows over the nail. Without treatment, the infection can spread to the underlying bone (osteomyelitis) in rare but serious cases.

What Are Nail Bed Infections (Paronychia)?

Paronychia is an infection of the nail fold, the skin surrounding the nail. Acute paronychia is usually caused by bacteria entering through a break in the skin and develops rapidly with pain, swelling, and pus. Chronic paronychia develops gradually and is often associated with moisture exposure or fungal infection.

Nail bed infections, technically called paronychia, are among the most common hand infections encountered in clinical practice. The term refers specifically to infection of the perionychium, the soft tissue surrounding and supporting the nail. This area is particularly vulnerable to infection because the tight attachment of skin to the underlying nail plate creates potential spaces where bacteria and fungi can become trapped and multiply.

Paronychia is classified as either acute or chronic based on the duration and underlying cause. Acute paronychia develops rapidly, usually over 1-5 days, and is typically caused by bacteria, most commonly Staphylococcus aureus. Chronic paronychia develops slowly over weeks to months and often involves a combination of factors including repeated moisture exposure, fungal infection, and bacterial colonization.

Understanding the distinction between acute and chronic paronychia is important because the treatment approaches differ significantly. Acute bacterial infections may require antibiotics and surgical drainage, while chronic paronychia typically requires addressing underlying causes such as moisture exposure and may need antifungal treatment.

Causes of Acute Paronychia

Acute paronychia develops when bacteria, most commonly Staphylococcus aureus, enter the tissue surrounding the nail through a break in the skin. Common entry points include hangnails (small tears in the cuticle), nail biting, aggressive manicuring, picking at the cuticle, and minor trauma. Once bacteria enter, they multiply rapidly in the warm, moist environment, causing inflammation and pus formation.

Certain activities and occupations increase the risk of acute paronychia. Healthcare workers who frequently wash their hands are at higher risk due to skin breakdown from repeated wetting and drying. Similarly, food handlers, bartenders, and others whose hands are frequently wet are more susceptible. Nail biting is a particularly common cause in children and adolescents.

Causes of Chronic Paronychia

Chronic paronychia typically results from repeated exposure to moisture and mild irritants that damage the cuticle and allow colonization by Candida (yeast) and bacteria. Unlike acute paronychia, chronic paronychia is not primarily an infection but rather an inflammatory condition that creates an environment favorable for opportunistic organisms. The cuticle becomes damaged, allowing water and irritants to penetrate beneath the nail fold.

Occupations with frequent water exposure are strongly associated with chronic paronychia. Dishwashers, bartenders, cleaners, healthcare workers, and those in food preparation have significantly higher rates of this condition. Contact with irritants such as detergents, cleaning chemicals, and certain foods (particularly citrus fruits) can also contribute to chronic paronychia development.

What Causes Fungal Nail Infections?

Fungal nail infections (onychomycosis) are caused by dermatophyte fungi, yeasts, or molds that invade the nail. Risk factors include aging, diabetes, poor circulation, athlete's foot, and exposure to warm, moist environments. The condition causes nail thickening, discoloration, and crumbling.

Onychomycosis, commonly called fungal nail infection or nail fungus, is one of the most prevalent nail disorders, affecting approximately 10-12% of the adult population. The prevalence increases significantly with age, reaching up to 50% in people over 70 years old. While the condition is often considered primarily cosmetic, it can cause significant discomfort, affect quality of life, and in certain populations, lead to serious complications.

The fungi that cause onychomycosis are the same organisms responsible for athlete's foot (tinea pedis) and ringworm. In fact, the most common route of infection is spread from athlete's foot to the toenails. The warm, dark, moist environment inside shoes provides ideal conditions for fungal growth, which is why toenails are affected much more frequently than fingernails.

Fungal nail infections typically begin at the edge or base of the nail and slowly spread throughout the nail plate over months to years. The fungus breaks down the keratin protein that makes up the nail, causing characteristic changes in nail appearance. Without treatment, the infection can spread to other nails and to close contacts who share living spaces.

Risk Factors for Fungal Nails

Several factors increase susceptibility to fungal nail infections. Age is the strongest risk factor, as nails grow more slowly with age and become thicker and more brittle, creating cracks through which fungi can enter. Reduced blood circulation associated with aging and certain medical conditions also impairs the body's ability to recognize and fight fungal infections in the nail.

Diabetes mellitus significantly increases the risk of onychomycosis and its complications. People with diabetes have impaired immune function and often have reduced sensation in their feet, meaning they may not notice early signs of infection. Additionally, the higher glucose levels in skin and nails of diabetics may promote fungal growth. For these reasons, nail problems in diabetic patients always warrant professional medical attention.

• Aging: Risk increases significantly after age 60
• Diabetes: 2-3 times higher risk than general population
• Athlete's foot: Fungus spreads from skin to nails
• Peripheral vascular disease: Reduced blood flow impairs immunity
• Immunosuppression: HIV, cancer treatment, or immunosuppressive medications
• Nail trauma: Creates entry points for fungal invasion
• Swimming pools and gyms: Exposure to fungi in wet environments

Signs and Symptoms

Fungal nail infection typically begins subtly with a small white or yellow spot under the tip of the nail. Over time, this area expands and the nail undergoes characteristic changes. The nail becomes thickened, often becoming difficult to trim, and develops a yellow, brown, or whitish discoloration. The nail surface may become rough, and the nail may become brittle and crumble at the edges.

As the infection progresses, the nail may separate from the underlying nail bed (onycholysis), creating a gap that can accumulate debris and develop an unpleasant odor. In advanced cases, the nail may become significantly distorted in shape and cause discomfort when wearing shoes. The surrounding skin may also become infected, leading to athlete's foot symptoms including itching, scaling, and cracking between the toes.

How Can I Treat Nail Problems at Home?

Mild nail problems can often be treated at home with warm water soaks, proper nail care, over-the-counter antibiotic ointments, and wearing appropriate footwear. Home treatment is most effective for early-stage ingrown toenails without signs of infection and for preventing mild conditions from worsening.

Many nail problems, particularly mild ingrown toenails and minor nail fold irritation, respond well to home treatment when addressed early. The goals of home treatment are to reduce inflammation, prevent infection, promote healing, and address underlying causes to prevent recurrence. However, it is important to recognize the limitations of home treatment and know when professional medical care is needed.

Successful home treatment requires consistency and patience. Most mild nail problems improve within 1-2 weeks of proper care, but fungal infections and some chronic conditions require much longer treatment periods. Understanding what to expect and following treatment protocols consistently is key to achieving good outcomes.

Treating Mild Ingrown Toenails

For mild ingrown toenails without signs of infection, warm water soaks are the cornerstone of home treatment. Soak the affected foot in warm (not hot) water for 15-20 minutes, 3-4 times daily. This softens the nail and surrounding tissue, reduces inflammation, and promotes drainage if any pus is present. Adding Epsom salt (magnesium sulfate) to the water may provide additional soothing effects, though scientific evidence for this is limited.

After soaking, gently lift the edge of the ingrown nail and place a small piece of clean cotton or waxed dental floss underneath. This helps guide the nail to grow above the skin edge rather than into it. Change this packing daily after soaking. Apply an over-the-counter antibiotic ointment such as bacitracin or polymyxin B and cover with a clean bandage. Wear open-toed shoes or sandals whenever possible to reduce pressure on the affected toe.

Treating Minor Nail Fold Irritation

For minor irritation around the nail fold that has not developed into a full infection, keeping the area clean and dry is essential. Wash hands frequently but briefly, and dry thoroughly afterward, paying attention to the areas around the nails. Avoid picking at cuticles or hangnails, as this creates entry points for bacteria.

Protect hands from moisture and irritants by wearing waterproof gloves when washing dishes, cleaning, or working with chemicals. Cotton glove liners worn underneath provide additional protection by absorbing sweat. Moisturize hands regularly but avoid getting moisturizer in the nail folds, as this can promote fungal growth.

Over-the-Counter Treatments for Fungal Nails

Several over-the-counter antifungal treatments are available for fungal nail infections, including products containing tolnaftate, undecylenic acid, or tea tree oil. While these products are generally safe, their effectiveness for established nail infections is limited because they have difficulty penetrating the nail plate to reach the fungus underneath.

Over-the-counter treatments work best for very early or superficial fungal nail infections and for preventing recurrence after successful treatment with prescription medications. They should be applied daily according to package directions, typically for many months. If no improvement is seen after 3-6 months, prescription treatment is likely needed.

When Should You See a Doctor for Nail Problems?

See a doctor if you have diabetes or circulation problems and develop any nail issue, if there are signs of spreading infection (increasing redness, warmth, pus, fever), if home treatment fails after 1-2 weeks, for recurrent ingrown toenails, or for unexplained nail color changes or dark streaks under the nail.

While many nail problems can be successfully managed at home, certain situations require professional medical evaluation and treatment. Recognizing when to seek care is important because delayed treatment of nail infections can lead to serious complications including cellulitis (spreading skin infection), osteomyelitis (bone infection), and in severe cases, sepsis.

The threshold for seeking medical care should be lower for people with conditions that impair healing or immunity. Diabetes is particularly important because it affects both immune function and sensation, meaning infections can progress significantly before being noticed. Similarly, people with peripheral vascular disease, HIV, cancer, or those taking immunosuppressive medications should seek medical attention early for any nail problem.

Medical Treatment for Ingrown Toenails

When home treatment fails or infection is present, several medical procedures can effectively treat ingrown toenails. The simplest is partial nail avulsion, where the ingrown portion of the nail is removed under local anesthesia. This provides immediate relief and allows the infection to drain. The procedure can be performed in a doctor's office and typically takes only 15-20 minutes.

For recurrent ingrown toenails, more definitive treatment may be recommended. Partial nail avulsion with matrixectomy involves removing the ingrown nail portion and destroying the nail matrix (growth center) in that area using a chemical (phenol) or electrical cautery. This permanently narrows the nail and prevents regrowth of the problematic edge, with success rates exceeding 95%.

Medical Treatment for Paronychia

Acute bacterial paronychia with significant pus accumulation usually requires incision and drainage. This simple procedure, performed under local anesthesia, involves making a small incision to release the pus and relieve pressure. Oral antibiotics are often prescribed in addition, particularly if cellulitis (spreading redness) is present. Most patients experience rapid improvement within 24-48 hours after drainage.

Chronic paronychia treatment focuses on avoiding precipitating factors, keeping the area dry, and treating any underlying fungal or bacterial colonization. Topical treatments may include antifungal creams, steroid ointments to reduce inflammation, or combination products. Oral antifungal medications are sometimes needed for resistant cases. Treatment typically requires several months of consistent care.

Medical Treatment for Fungal Nail Infections

Prescription antifungal medications are the most effective treatment for onychomycosis. Oral medications such as terbinafine and itraconazole achieve cure rates of 60-80% for toenail infections. Terbinafine is typically taken daily for 12 weeks for toenails, while itraconazole may be given in pulse dosing regimens. These medications can have side effects and require monitoring with blood tests.

Topical prescription antifungals including efinaconazole and tavaborole have been developed specifically for nail infections and can penetrate the nail plate more effectively than over-the-counter products. However, cure rates with topical treatment alone are generally lower than with oral medications, typically around 35-55%. Topical treatments may be used alone for mild infections or in combination with oral medications for more severe cases.

How Can You Prevent Nail Problems?

Prevent nail problems by cutting nails straight across at appropriate length, wearing properly fitting shoes with adequate toe room, keeping feet clean and dry, treating athlete's foot promptly, and avoiding trauma to the nails. Good nail hygiene and regular inspection can catch problems early.

Prevention is the most effective approach to nail problems because many conditions, once established, can be difficult and time-consuming to treat. Understanding the causes of common nail problems allows you to take specific preventive measures. Most prevention strategies focus on proper nail care technique, appropriate footwear, and reducing exposure to environments that promote infection.

Regular nail inspection is an important preventive practice, particularly for people at higher risk of complications. Taking a few moments weekly to examine your nails can help identify early signs of problems when they are easiest to address. Look for changes in nail color, shape, texture, or the surrounding skin, and address any concerns promptly.

Proper Nail Cutting Technique

The way you cut your nails significantly affects your risk of ingrown toenails. Toenails should be cut straight across rather than curved to follow the shape of the toe. Leave the nails at a length where the corners are visible and extend just slightly beyond the skin edge, roughly level with the tip of the toe. Cutting too short leaves the nail edges more likely to grow into the skin.

Use proper nail cutting tools, keeping them clean and sharp. Dull clippers can crush or tear the nail rather than cutting cleanly, creating rough edges that can irritate surrounding skin. For thick nails that are difficult to cut, soaking feet in warm water for 10-15 minutes first softens the nail and makes cutting easier. Filing rough edges after cutting can help prevent snagging on socks.

Footwear Recommendations

Wearing properly fitting footwear is essential for preventing ingrown toenails and creating conditions that discourage fungal growth. Shoes should have adequate space in the toe box, allowing you to wiggle your toes freely. When trying on shoes, stand up and ensure there is about a thumb's width of space between your longest toe and the end of the shoe.

Choose shoes made of breathable materials such as leather or canvas rather than synthetic materials that trap moisture. Alternate between different pairs of shoes to allow each pair to dry completely between wearings. In warm weather or during exercise, moisture-wicking socks help keep feet dry. Change socks daily or more frequently if feet become sweaty.

• Cut straight across: Avoid rounding the corners of toenails
• Don't cut too short: Leave nails level with toe tip
• Wear proper shoes: Ensure adequate toe room
• Keep feet dry: Change socks when damp, use antifungal powder
• Protect in public: Wear sandals in locker rooms and pools
• Treat athlete's foot: Prevent spread to nails
• Don't share: Avoid sharing nail tools, shoes, or towels

Reducing Fungal Infection Risk

To reduce the risk of fungal nail infections, keep feet clean and dry. Wash feet daily with soap and water, and dry thoroughly, particularly between the toes. Apply antifungal powder to feet and inside shoes if you are prone to excessive sweating or have had fungal infections before.

In public areas where fungal infections are commonly spread, such as swimming pools, gyms, and locker rooms, wear protective footwear such as flip-flops or shower shoes. If you have athlete's foot, treat it promptly to prevent spread to the nails. Avoid sharing shoes, socks, towels, or nail care tools with others.