Thick nails (Onychauxis)

Painful toenails can make it challenging to wear shoes and socks comfortably, while interfering with a person’s gait given the pressure that moves through the toes during walking and pushing off the ground to take the next step. Having damaged or infected toenails also makes many people feel self-conscious about their nail appearance, choosing to keep their feet hidden beneath shoes and socks even in the scorching summer months. 

Our podiatrists understand the effects that toenail problems can have on our patients, and work to help them return to having painless and healthier-looking toenails. We take all toenail problems seriously - no concern is too small.

As the toenails can be affected in a wide range of ways, we’ve focused on six of the top causes that our podiatrists see and treat in our clinic.

1. Thickened Toenails

The medical term for thickened toenails is onychauxis, and is a process that typically develops and worsens over many months and years. Having smooth and natural toenails that turn bulky and often discoloured can make them very difficult to trim and manage, leaving many people frustrated with getting them caught on socks and hosiery. For some, the thickness can reach a point where it presses against the top of the shoe, causing notable toe pain.

Alongside the thickening of the toenail, you may notice the nail becomes more brittle with the nail flaking or splitting, there may be an unpleasant odour from the nail, there may be a build-up of dead skin and debris beneath the nail, or the nail may lift from the nail bed.

Most often, our toenails get thicker as we grow older as a simple byproduct of our natural ageing process where the rate at which our toenails grow slows due to reduced blood circulation, causing our nail cells to build up - and our nails to thicken. Men are more likely to suffer from thickening nails than women.

2. Fungal Nail Infection

Medically known as onychomycosis, fungal infections can cause nails to turn brittle, flaky, distorted or discoloured yellow or white, leaving many people unhappy with their appearance. Nail fungus is spread through direct contact with fungal spores in the environment - whether that’s sharing a bed or socks with someone with an existing infection, or from using a public shower, such as at the gym where a prior user had the infection. 

We’ve shared everything you need to know about fungal nail infections and how to treat them here.

3. Onychogryphosis

Onychogryphosis is often nicknamed “ram’s horn nail” due to its overgrown, firm, thickened and curved or distorted yellow-brown appearance. The nail can become so hard that trimming it with regular nail clippers can be impossible. Having ram's horn nails can make wearing closed-in shoes incredibly uncomfortable and painful.

We often see onychogryphosis in those whose toenails have suffered physical trauma, whether from dropping something heavy onto the big toe or wearing tight shoes that squeeze the toes and nails for a prolonged period. Some conditions like diabetes, which can lead to reduced circulation to the feet, can also put you at risk. Additionally, we also see onychogryphosis in those who cannot look after their feet themselves, whether that’s from general forgetfulness about nail care in later years, those with poor vision that may not realise their nails require any care, those with dementia, and more. Rarely, onychogryphosis is seen as a genetic problem, and in this case it is likely picked up either in early childhood years or during puberty.

4. Avulsed Nail (Nail Lifting Or Detachment)

Medically known as onycholysis, nail avulsion occurs when either the nail detaches and lifts away from the nail bed beneath it over time, or when part or all of the nail is forcefully torn away in an injury. If your nail detaches from the bed, even if it is still hanging on one side, it will not reattach, and instead a new nail will grow back over time.

There are many reasons why a nail may detach aside from an injury, including having a fungal nail infection, skin conditions including psoriasis, some illnesses and medicines - even having bruising and bleeding beneath the nail will separate the nail from the plate beneath, ultimately leading to an avulsed nail depending on how much blood accumulates beneath the nail. This is a common situation we see in skiers and snowboarders who wear tight boots during the ski season.

If your nail is partially detached, it’s important to see a podiatrist immediately as you are at risk of something catching on the nail and forcefully pulling it off, which can be extremely painful.

5. Bruised Toenail

Medically known as a subungual haematoma, this literally translates into “blood beneath the toenail” which creates a dark brown/purple bruised appearance on the nail’s surface. The reason for the bleeding is usually related to trauma - whether it’s stubbing your toe, dropping something on it, or even from pressure from tight shoes or boots - like we often see in skiers and snowboarders. Specifically, the pressure on the toe leads to small blood vessels beneath the nail breaking, which leaks blood into the space between the nail itself and the nail bed.

Nail bruising is not dangerous, though it may feel tender to touch. As the nail grows out, so will the trapped blood. Unfortunately, as the blood separates the nail plate from the nail bed, the nail may lift and also create a gap where dirt and bacteria can become trapped.

6. Psoriatic Nails

Psoriatic nails are commonly misdiagnosed as a fungal nail infection due to their similar appearance of a yellow discolouration, becoming brittle or flaky, and sometimes having the nail separate from the nail bed. Other signs of nail psoriasis include nail pitting (indents in the nail), lines and ridges through the nail, splitting nails, and red dots in the lunula (whiter half moon crescent at the base of the nail).

While the exact cause of psoriatic nails remains unclear, research indicates that it has a similar immune system mechanism that is involved in skin psoriasis, with 90% of people with psoriasis developing psoriatic nail changes. They can cause tenderness and pain when pressure is applied to the nail.

As problems with the toenail can have a wide range of causes that go far beyond the six we’ve provided today, caring for your feet at home is focused around managing your symptoms to optimise your comfort and pain levels until you can book in with your podiatrist. You may be able to try:

• Changing to open-toed shoes that do not place pressure on your toes, or alternatively choosing shoes with a wide, roomy toe box that do not buttress against the toes
• Using non-steroidal anti-inflammatories (NSAIDs) if your toes are feeling painful to help give you some relief
• Soaking your feet in warm water for up to 20 minutes, with or without Epsom salts
• Avoiding the actions that exacerbate your pain as best possible. This will likely include walking for prolonged periods, climbing stairs, high-impact exercise, standing on your tiptoes or wearing narrow or V-shaped shoes
• If you already have orthotics at home, wear them - if your foot characteristics mean that you naturally overload your big toe with every step, these may be able to help by redirecting pressure

It’s important to book in with your podiatrist at your earliest convenience as the causes of toenail pain rarely go away on their own, and your symptoms may worsen if left untreated

For toenail pain or problems, your appointment will start with a comprehensive assessment to understand what has happened with your nails, what has caused it, and why you’re experiencing the symptoms that you are. Once we know this, our podiatrists will put together an evidence-based management plan that supports you in getting the best outcome for your toenail problem. This may involve:

• Reducing your nail thickness: we use a sterile medical burr to manually reduce the thickness of your toenails and leave a smoother, thinner and often less discoloured appearance
• Nail trimming and care: we use surgical-grade nail clippers and other equipment to trim through even the toughest, longest or curviest nails. 
• Fungal nail treatment: if we identify a fungal nail infection, we’ll run through your options to help treat your fungal nail infection and help keep it gone.
• Footwear advice: we’ll help ensure your footwear is helping keep you comfortable and pain-free, and not placing undue pressure on your toenails to worsen the problem

Total nail avulsion: in extreme cases, we may recommend a total nail avulsion where we surgically remove the entire toenail under local anaesthetic. This enables the nail to regrow and set a healthier foundation for your nail. This will not work in all cases, where the nail may regrow with the same changes or disfigurations, so the suitability for this is assessed on a case-by-case basis.