Isla Bennett
Toenails growing in layers could be a result of retronychia, a condition caused by repetitive injury to the nail, often from wearing tight shoes. In the acute stage, retronychia causes inflammation, discoloration, and growth of connective tissue. In the chronic stage, inflammation resolves, but the nail plate thickens and separates from the nail bed, resulting in layers of stacked nail plates. Other possible causes of toenail abnormalities include onychogryphosis, a thickening of the nails due to injury or infection; nail patella syndrome (NPS), a rare genetic disorder; and koilonychia, characterized by thin and fragile nails that resemble a spoon. Additionally, fungal infections, such as mycotic nails, can cause nail discolouration and separation.
| Characteristics | Values |
|---|---|
| Condition | Retronychia |
| Cause | Repetitive injury to the nail, often from wearing tight shoes |
| Appearance | Layers of nail plate, missing cuticle, inflammation, yellow or white discoloration, thickened nail plate, nail separated from nail bed |
| Treatment | Corticosteroids applied or injected into the nail; in chronic cases, the nail is removed |
| Prevention | Avoid activities that injure the nail, wear shoes with more space around the toes |
| Nail Composition | Protein-rich tissue called keratin |
| Nail Growth Process | Keratinization – cells multiply at the base of the nail, layer on top of each other, and harden |
| Nail Matrix | The root of the nail; located in a small pocket under the skin |
| Nail Bed | The area under the nail plate where the nail grows |
| Lunula | The small, white crescent shape at the base of the nail plate; part of the nail matrix |
| Other Possible Causes of Nail Separation | Fungi, fungal infections, yeast onychomycosis, nail injuries, chemical reactions, fungal melanonychia |
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Nail injuries
A nail injury occurs when any part of the nail, including the nail bed, cuticle, or surrounding skin, sustains damage. This can be caused by a variety of factors, such as blunt trauma, nail biting, or fungal infections.
Causes of Nail Injuries
- Blunt trauma: Injuries caused by a blow to the nail, such as slamming a finger or toe in a door, or hitting it with a hammer or heavy object.
- Compression: When the finger or toe gets caught between two objects, crushing the nail and underlying nail bed.
- Lacerations: Cuts to the nail or nail bed caused by sharp objects like knives or saws.
- Avulsions: Occurs when the nail and part of the nail bed are forcefully pulled away from the finger or toe.
- Infections: Fungal infections can occur when fungi get between the nail and nail bed, causing thickening, discolouration, and lifting of the nail.
- Repetitive injury: Repeated trauma to the toenails, often due to wearing tight shoes, can lead to nail deformities and conditions like onychogryphosis (thickening and curving of the nails).
- Habits: Nail biting and cuticle biting can cause trauma to the nails and increase the risk of infections.
Treatment for Nail Injuries
The treatment for nail injuries depends on the type and severity of the injury:
- Minor injuries: For minor injuries, trim the nail to prevent further snagging and injury. If the nail has lifted off the nail bed, it can be temporarily replaced and secured with a bandage.
- Bleeding: If there is bleeding, apply pressure to stop the bleeding. Remove any jewellery, such as rings, to prevent swelling.
- Bruising: For small bruises under the nail (subungual hematoma), a heated needle can be used to create a small hole for blood and fluid drainage, relieving pressure and pain.
- Infections: Fungal infections may require oral or topical antifungal medications.
- Severe injuries: For more severe injuries, seek medical attention at an urgent care centre or emergency room. Treatment may include numbing the area, draining blood and fluid, stitching cuts, reattaching the nail with glue or stitches, or removing the nail if it cannot be saved. Antibiotics may be prescribed to prevent infection.
It is important to note that nail injuries can take a significant amount of time to heal, with fingernails taking about two months and toenails taking up to four months to regrow completely. During this time, proper nail care and hygiene are crucial to prevent further complications.
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Onychomycosis
The condition is often preceded by an asymptomatic, dry hyperkeratotic tinea pedis. The warm, moist environment inside shoes, combined with micro-traumatic pressure on the nail unit, creates favourable conditions for the growth of dermatophytes, which can then infect the nail bed. Risk factors for onychomycosis include aging, diabetes, tinea pedis, psoriasis, immunodeficiency, and close contact with individuals who have the condition. Hotel carpets, public showers, and pool decks can also harbour the causative organisms.
Treatment options for onychomycosis include oral and topical antifungal medications. Oral antifungal medications, such as terbinafine, itraconazole, and fluconazole, are taken as liquid medicines, pills, or tablets. Topical antifungal medications come in the form of creams, ointments, or gels that are applied directly to the affected nails. In addition to medical treatments, maintaining good foot and toenail hygiene is important for preventing and managing onychomycosis. This includes keeping toenails trimmed, washing and drying the feet thoroughly, and inspecting the toenails regularly for any changes or signs of infection.
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Onychogryphosis
The exact cause of onychogryphosis is not completely known. However, it is believed to be caused by injury or infection. Peripheral vascular disease, also called peripheral artery disease (PAD), can also lead to onychogryphosis. PAD causes the arteries in the legs to build up with plaque, reducing blood flow to the legs and feet. Smoking is a main risk factor for developing PAD. Other causes of onychogryphosis include tuberous sclerosis complex (TSC), a rare genetic disease that causes benign tumours to grow throughout the body, and ichthyosis, a rare skin condition that prohibits the body from shedding dead skin cells.
Treatment for onychogryphosis includes conservative management by limiting pressure on the nail bed and using mechanical debridement. Definitive treatment is nail avulsion followed by matricectomy or surgical resection of the nail matrix. Surgery is the only treatment option for onychogryphosis, and the type and frequency of surgery are based on the cause of the condition. If the condition is genetic, the nails may grow back, and surgery may need to be repeated. To permanently solve the problem, a doctor may suggest removing the affected nail plate.
To promote nail health and prevent onychogryphosis, it is important to maintain good foot and toenail hygiene. This includes inspecting your toenails at least once per week, carefully removing any dirt under your nails, and washing and drying your feet thoroughly. It is also important to keep your nails trimmed short to prevent them from catching on objects and pulling off your nail beds. Additionally, wearing proper footwear that does not exert excessive pressure on the nail bed can help prevent onychogryphosis.
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Natural growth patterns
Toenails grow through a process called keratinization, where cells multiply at the base of each nail, layer on top of each other, harden, and are pushed forward. The nail matrix, or the root of the nail, is responsible for this process, constantly making new cells that force the old ones to bunch up and emerge through the skin. The nail plate, or the visible part of the nail, sits on top of the nail bed. The lunula, a small white crescent shape sometimes visible at the base of the nail plate, is the only visible part of the nail matrix. The cuticle, lateral nail fold, proximal nail fold, and the nail itself also make up the nail's overall structure.
The growth pattern of toenails can vary from person to person. While nails typically curl under as they grow longer, it is not uncommon for toenails to grow upward, a condition called vertical nail. This could be the natural growth pattern of your toenails, influenced by factors such as shoe pressure on the toenail tips or profuse foot sweating.
However, upward-growing toenails can also indicate more complex medical issues. Onychogryphosis, for example, is a condition where the nails thicken and curve due to injury or infection, resembling a ram's horn or claw. It primarily affects the big toes. Nail patella syndrome (NPS) is another rare genetic disorder that often results in nail abnormalities, though it is more commonly observed in fingernails than toenails.
Additionally, toenails that appear concave or "scooped out" may be a sign of koilonychia, which can be hereditary or linked to iron deficiency anemia, malnutrition, celiac disease, heart disease, hypothyroidism, or hemochromatosis. Certain illnesses, such as COVID-19, pneumonia, or a heart attack, can also interrupt nail growth, leading to Beau's lines (horizontal ridges) or slow nail growth.
It is important to note that toenails grow slower than fingernails, taking 12 to 18 months to grow back completely. To maintain healthy toenails, it is recommended to trim them straight across, leaving them a little long to prevent ingrowth. Regular inspection, cleaning, and moisturizing are also crucial to prevent infections and maintain good foot hygiene.
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Genetic factors
The growth of toenails is influenced by genetic factors, and the speed and thickness of nail growth are often hereditary traits. Unusual nail growth, such as toenails growing upward, could also be a result of genetic predispositions.
Nail patella syndrome (NPS) is a genetic disorder that occurs in approximately one in 50,000 people. It is characterised by thin and fragile nails that resemble a spoon, a shape known as koilonychia. NPS affects almost all individuals with the disorder, and fingernails are more commonly impacted than toenails. In addition to nail abnormalities, NPS is associated with skeletal issues involving the knees, elbows, and hips, and affected individuals are at a higher risk of developing kidney disease.
Another condition that may be influenced by genetic factors is onychogryphosis, also known as ram's horn nails. While it can develop at any age, older adults are more susceptible. Onychogryphosis causes the nails to thicken and curve, resembling the shape of a ram's horn or claw. It is often associated with toenail fungus, and proper care is necessary to prevent further complications.
While toenails growing in layers may have various causes, including injuries, infections, and skin conditions, it is important to consider genetic factors as well. Consulting with a healthcare professional is advisable to determine the specific causes and appropriate treatments for toenail abnormalities.
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Frequently asked questions
Toenails typically grow in layers as a result of a condition called retronychia, which is caused by repetitive injury to the nail. This could be from wearing tight shoes, or activities that cause toenail injuries.
If you have retronychia, you should avoid activities that injure the nail and wear shoes with more space around the toes to relieve pressure on the affected toenail. In the acute stage, treatment options include corticosteroids applied to or injected into the nail. In the chronic stage, the nail is removed.
Unusual toenail growth could be hereditary. It could also be caused by a fungal infection, yeast onychomycosis, nail matrix damage, or a serious illness.
