Kenneth Beer, M.D. is a board-certified dermatologist and dermatopathologist in Palm Beach, Fla., and the director of, an online skincare company. He is also the director of The Cosmetic Bootcamp, which trains physicians in best practices for cosmetic medicine. Dr. Beer is an instructor in dermatology at the University of Miami, and he is an A.B. Duke Scholar at Duke University. He obtained his medical degree from the University of Pennsylvania School of Medicine, and received his dermatology and dermatophathology training at the University of Chicago. Visit Dr. Beer's office at

Fix Your Nail Problem

Wednesday, 26 September 2012 08:04 AM

Unfortunately many patients with nail problems get treated incorrectly because neither they nor their physician recognize the many reasons nails become damaged.
Frequently, the patient will be treated with antifungal products (either orally or topically). However, the actual reason for the nail problem may be more complex than this.
While fungal infections are common, other causes include psoriasis, bacterial infections, eczema, allergic reactions, and, less commonly, cancers. Recognizing these differences is essential to providing the correct treatment.

Fungal infections of the nails are usually characterized by thick, yellow, or brownish nails. The skin of the surrounding areas may also be infected, and this skin typically is red and scaly.
Treating fungal nail infections is usually done with oral medications such as Lamisil. Topical medications are also available, but they are less effective because they don’t penetrate the nail plate to a similar degree.
In my practice, I diagnose nail fungus or yeast by documenting the infection with a nail culture. This requires sending a sample of the nail to a lab where it is grown and typed. Once classified, I can determine whether it is in fact fungal, and if so, which drug is likely to help.

Skin Cancer
Another diagnosis that should be considered is skin cancer involving the nail. This can only be determined by a biopsy. A nail biopsy is a relatively simple procedure that can be performed by most surgical dermatologists in the office.
Obviously, diagnosis of a nail cancer is best caught early and the delays seen in some patients can be problematic. Treatment for a nail cancer may involve Mohs skin cancer surgery with reconstruction using a flap or graft or, when it is advanced, may involve removing part of the finger.
Melanomas of the nail are uncommon but may appear as black or brown streaks on the nail. Typically, they involve the cuticle of the nail and cause discoloring. As with other suspicious nail lesions, a biopsy is essential to the diagnosis of this disease. Surgery is required to treat nail melanomas.

When psoriasis affects the nails, the nail plate can become yellow and thick and pitted with small dents. Nail psoriasis may be misdiagnosed and treated as fungus for a long time before the correct diagnosis is made.
Since the two entities are treated very differently, it is important to distinguish between them and a biopsy or referral to a nail specialist may be helpful.

Bacterial infections tend to occur more rapidly than fungal ones and they are usually more painful because they fill the tight space around the nail in a rapid manner. Depending on the type of bacteria involved, antibiotic treatments can help.
However, in some cases the swelling is so dramatic and painful that a dermatologist will need to drain the area. This is a simple, in-office procedure that requires local anesthetic. Once the pressure around the nail is released, the pain is reduced almost instantly.
A special type of bacterial infection called pseudomonas deserves special attention. It is a frequent problem for people who have occupations that require them to have their hands in water. This bacteria produces a pigment that can stain the nail with a greenish tinge.
Because it is mistaken for fungus by those not familiar with it, this infection can be treated with the wrong medication for months. The proper treatment is a simple topical antibiotic drop under the nail and an attempt to dry out the nail plate after it gets wet.

Allergic reactions can affect the skin around the nail to such a degree that the nail becomes gnarled. Products used for artificial nails may cause allergic reactions resulting in red, itchy skin around the nail. Treatment typically involves topical steroid creams and removal of the offending product. The nail will recover in fairly short order.
As with any disease of the nail, fixing the problem will not result in any instant change. Nail growth is slow and it can take between six to nine months for a fingernail to grow out and about a year for a toenail to grow. This means that once the problem gets fixed, it could be a while before you see a healthy nail replace the deformed one.

Normal aging frequently causes nails to become thin and brittle. After about age 60, nails can begin to splinter as the layers of the nail plate no longer adhere as well as they used to. The plate becomes thin and nails are very soft for many people.
In some instances, the supplement biotin can help this. In others, the nail problems may be a sign of thyroid disease and it is worth checking with your physician.

Clearly, not all nail problems are caused by fungus or solved with a pill. Some nail issues require more detective work and a biopsy to determine the underlying problem and help figure out the best treatment.
If you have a nail problem, see a board-certified dermatologist. For many diseases of the nails, proper treatments that can make a difference and minimize nail damage.

To learn more about Dr. Beer, visit and

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Wednesday, 26 September 2012 08:04 AM
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