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Nail alterations, also called onychodystrophies, are a very frequent problem. They can cause discomfort but are mainly a cosmetic problem.

For some reason, there is a tendency in society to blame fungi for all nail diseases. But the truth is that most of the times onychodystrophies or nail alterations are due to many other reasons.

There are numerous exogenous and endogenous factors that can affect our nails.

Trauma or continuous microtrauma, products that we apply such as nail polish, nail polish remover, washing our hands a lot, irritants, tics, cuticle manipulation, nail biting, etc. can produce different types of nail alterations.

Sometimes, onychodystrophy may be the first manifestation of a skin disease or accompany it.

On the other hand, the nails transmit a lot of information about what is happening or has happened to the organism. They may reflect some systemic diseases, such as respiratory, hepatic and renal diseases, having passed a general infection a few months ago, taking drugs such as chemotherapy or a vitamin deficiency.

Infections mainly due to fungi and bacteria can also produce alterations in the nail structure.

As we have explained, not all nail disorders are fungal, although this is the first thing that is usually thought of when a nail appears altered.

A careful examination of the nails and skin should be carried out and the necessary tests should be ordered according to the clinical suspicion. In case of suspicion of mycosis (fungal infection) or diagnostic doubts, it is advisable to perform a fungal culture.

I am going to talk about the most frequent onicopathies that we see in the office on a daily basis.

A very frequent cause of consultation is the traumatic onychodystrophy. It is generally secondary to chronic trauma or microtrauma with shoes, favored by the use of tight shoes with narrow toes and heels, certain shoes used in the workplace and the practice of some sports such as running, walking or playing tennis.

Nails damaged by chronic trauma can become whitish, yellowish and even thickened. Sometimes small subungual hematomas (blood under the nail) appear. The nails of the first toe of both feet are especially prone to alteration, often symmetrically.

Nail mycosis or onychomycosis. It is mainly due to nail infection by fungi of the dermatophyte type. There are usually predisposing factors such as humidity, athletes, previously altered nails, general diseases that create predisposition to fungal infections (immunosuppression, diabetes mellitus…).

It appears mainly on the toenails. Thickened nails with yellowish-white areas usually appear. The nails are not usually affected symmetrically, unlike traumatic nail disease. It tends to appear in the distal and lateral area of the nail and then spreads throughout the nail and even affects adjacent nails if left untreated.

Some skin diseases also affect the nails, especially psoriasis, causing the typical “oil stains”, thickening of the fingernails and toenails, as well as pitting on the nail plate. The typical “oil spots”, thickening of the fingernails and toenails as well as “pitting” or stippling on the nail plate appear. Lichen planus also frequently affects the nails with distal onycholysis (nail breakage) and severe nail striation.

In many occasions these entities are difficult to differentiate even for us dermatologists and it is necessary to perform a fungal culture or request an imaging test such as ultrasound, MRI or X-ray.

Rarely, but more serious, it may be due to the presence of a subungual tumor such as squamous cell carcinoma or acral melanoma.

Treatment of nail disorders (fungus and other causes)

In case of mild onychomycosis (when less than one third of the nail is affected), topical treatment should be carried out, generally in the form of a lacquer with ciclopiroxolamine or amorolfine for several months.

In case of greater nail involvement, oral treatment is recommended, usually terbinafine or itraconazole for 4-6 months. Sometimes it is necessary to perform combined treatments.

For other types of onychodystrophy or nail disorders, urea creams or lacquers at different concentrations can be used.

It can take up to a year for the nail to recover, so it is sometimes necessary to take vitamin complexes to help the body recover the original nail.

Dr. Elena Vera