42 CLINICAL
Toenail presentations in primary care
Nail problems can range from the mundane to the life threatening . Can you identify the causes of these toe troubles ? Answers can be found at the foot of the page .
1
A 45-year-old woman is concerned about this black line that has appeared under her big toenail . Can you reassure her about the cause ?
Fungal nail infection Melanoma Subungual haematoma Ingrowing toenail
2
A 63-year-old man is worried that this pigmentation under his nail might be cancer . What do you tell him ?
Fungal nail infection Melanoma Subungual haematoma Ingrowing toenail
3
A 23-year-old woman wants to know what you are going to do about her ‘ manky toenail ’ as it is summer and she feels she can ’ t wear sandals . What is the possible diagnosis ?
Fungal nail infection Melanoma Subungual haematoma Ingrowing toenail
4
An 18-year-old is concerned about his toe , which has been like this for months . What is your opinion of the problem ?
Fungal nail infection Melanoma Subungual haematoma Ingrowing toenail
Answers 1 Melanoma Any new or changing pigmented band under the toenail should prompt concern about a subungual melanoma , particularly if the pigment extends under the nail fold ( known as Hutchinson ’ s sign ). 2 Subungual haematoma This does not look like a melanoma – reassuring features include the growth of normal nail proximally to the haematoma . The history may reveal trauma , or vigorous activity such as running that is unusual for the patient . 3 Fungal nail infection Onychomycosis , or fungal nail infection , usually causes yellow discolouration that starts distally and progresses towards the nail bed . Diagnosis should be made with nail clippings and it is managed with either topical paint or oral antifungals . If it is not bothering the patient , it need not be treated . 4 Ingrowing toenail Infected ingrowing toenails should be treated with antibiotics . Home management includes cutting the nail straight across , rather than a curved cut , and not cutting too short . If this does not work then referral to podiatry for wedge excision may be needed .
SCIENCE PHOTO LIBRARY X3 / PCDS nursinginpractice . com Autumn 2021