Medical vs. Cosmetic Toenail Conditions

Have you ever noticed a yellow spot on your toenail and tried covering it up with polish? You’re not alone! Many people do this without realizing nail polish may disguise an infection or serious health issue. How can you tell if your toenail condition is medical or cosmetic? The truth is they can appear very similar to a brown spot, thick nail, ridges, or lifting of the nail plate. In most cases, medical nail conditions indicate infection, trauma, damage to nail growth or attachment, and less commonly, disease. Applying nail polish can delay healing or make things worse.

Cosmetic nail conditions usually involve an alteration in nail appearance that can be reversed with time or discontinuation of nail products. This article will help you know the difference!

TOENAIL ANATOMY (Why Should You Care?)

The nail plate is made of compact keratin produced by the nail matrix (hidden under the proximal nail fold). Normal thickness of the nail on the great toe averages 0.5–1.0 mm; generalized persistent thickening greater than ~2 mm often indicates disease. Blood vessels in the nail bed give the nail its pink color. The cuticle, or proximal nail fold, provides a seal between the nail matrix and skin. Anything that permanently alters matrix function, such as trauma, infection, or inflammatory cells, can change the nail’s appearance as it grows out, causing changes in nail curvature, color, thickness, or continuing growth separation (onycholysis).

Although toenails grow slowly at 1 mm per month on average, growth rate is why recovery takes so long! It can take 12–18 months for your toenail to completely grow out.

MEDICAL TOENAIL CONDITIONS (Fix the Problem)

Any conditions that cause pain, progressive thickening/changing, drainage, odor, nail lifting (onycholysis) from the nail bed should be evaluated, especially if they don’t improve after applying nail polish.

COMMON MEDICAL CONDITIONS

• Onychomycosis ( fungal nail infection ): Brown/yellow discoloration, thickening nail plate, black debris under nail, crumbly nail edges. May be associated with athlete’s foot rash. Testing (KOH, culture, PAS stain, or PCR) is recommended prior to initiation of lengthy antifungal treatments.

• Ingrown toenail (onychocryptosis): Nail edge growing into skin on lateral sides of nail causes pain, inflammation, and sometimes drainage if infected. May require minor surgery to prevent recurrence.

• Paronychia: Infection of the proximal nail fold that causes swelling, redness, and drainage. Acute paronychia is usually bacterial; chronic paronychia may be due to Candida or an irritant.

• Inflammatory / systemic illness : Nail psoriasis (pitting, onycholysis), nail lichen planus (vertical ridging), vascular insufficiency (slow growth, thin brittle nails)

• RED FLAGS: Look for new dark streaks (vertical pigmentation), rapid color change in nail, bleeding or ulceration. These changes require prompt attention.

Overview of Treatment:

Depending on the diagnosis, treatment options may include topical or oral medications (anti-fungals), draining infection and/or antibiotics, minor procedures for ingrown nails, or medical management for inflammatory conditions. Simply covering the nail will prolong healing.

COSMETIC TOENAIL CONDITIONS (Cover it up!)

Cosmetic conditions of the toenail cause changes in nail appearance without pain, infection, and progressive damage to the nail. They will often resolve when the irritating product or action is discontinued.

COMMON COSMETIC PROBLEMS

• Surface staining from polish pigments or hair dye

• Superficial ridging or thin nails from aggressive buffing or frequent gel/polish/acrylic removals

• Mild onycholysis from repeated trauma or improper/too-tight footwear

• Irregular nail shape from poorly fitting shoes

Tips for Management:

Try taking a “polish vacation”, stop aggressive buffing, switch to well-fitting shoes, apply moisturizer to nail plate only, and wait it out! Most cosmetic changes will be gone after the nail has completely grown out. If you have brown spots or thickening that do not resolve in 2–3 weeks without polish, be sure to rule out infection before returning to nail cosmetics.

HOW DO HEALTHCARE PROVIDERS DIFFERENTIATE?

Evaluation begins with a careful history and examination of the color, thickness, shape, tenderness to touch, and skin around the nail unit. The physician may perform testing if the

results would change his or her treatment plan:

• KOH/culture/PAS/PCR if fungal infection is suspected

• Dermoscopy or biopsy if there is atypical pigmentation or suspicion for tumors

• Bacterial culture if there is greenish or pus-like drainage

WHEN TO SEEK MEDICAL CARE

Make an appointment to be seen if you experience any of the following:

• Persistent pain, swelling, drainage, foul odor, or bleeding

• A rapidly spreading area of discoloration or a new vertical dark band

• Separation of nail from nail bed with debris under the nail or thickening that does not improve

• Conditions that put you at risk for complications, such as diabetes, vascular disease, neuropathy, or immune suppression (You should have a lower threshold for seeking care.)

Clients typically see us at Treasure Valley Foot & Ankle when nail changes cause pain with walking or wearing shoes or if the problem does not resolve with proper nail care at home.

SAFE NAIL CARE (Good for Medical & Cosmetic Conditions)

• Trim nails straight across every 4–6 weeks. Do not cut nails too short (leave 1–2 mm edge)

• Keep your feet clean and dry. Wash daily and thoroughly dry between toes. Rotate pairs of shoes to allow time to air out.

• Wear socks made of breathable material and shoes that fit properly.

• Take a break from gels/acrylics every 2–3 months

• If you notice something changing on your nails, STOP using nail cosmetics and SEEK TESTING.

KEY POINTS TO REMEMBER

• Medical conditions cause pain, progressive deformity, drainage, odor, infection, or can be linked to another medical condition. Medical conditions require appropriate evaluation and diagnosis-directed treatment.

• Cosmetic conditions alter nail appearance without other signs of serious pathology. These conditions can often be reversed with time, proper nail care, and discontinuation of nail products.

• WHEN IN DOUBT, STOP POLISHING AND SEEK EVALUATION. Early detection can protect the health of your nail and save time!

Frequently Asked Questions

Can you cover up a fungal nail infection?

Yes, you can cover up a fungal infection with nail polish. While this might make your nail look better, it can actually make the infection worse. Keeping moisture under the nail can promote fungal growth. If you have discoloration or thickening that does not resolve in 2-3 weeks without polish, get it checked out before painting over it!

Can you get fungus under nail polish?

Yes! Paint, especially if stacked on thick, can trap moisture under the nail and create a breeding ground for fungus.

Are gel nails bad for your nails?

Gel nails are generally safe but can be harmful if there is overzealous buffing of the nail plate or poor technique in application/removal. These practices can lead to thin nails, lifting of the nail gel from the nail bed, and infections.

How long does it take for toenails to return to normal?

EVERY MONTH! Remember that toenails take approximately 12-18 months to completely grow out on the great toe. Bilateral changes usually mean something systemic!

Who needs to see a doctor for a nail problem sooner?

Those who have diabetes, vascular disease, decreased sensation in the feet (neuropathy), or weakened immune systems should see a physician if they develop any signs or symptoms of infection or have nail changes that concern them.