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When The Toenail Goes Bad

Gertrude (names changed to protect the . . . health information – google HIPPA) came into the office and I noticed right away that she was very distressed and wringing her hands.  When I see a patient for the first time, we go through their medical history.  This includes any current medical information, medications, allergies, past surgeries and just overall how they are feeling.  What Gerty (for short) had is one of the few things that I just have to look at once and I immediately know what is going on.  There is perhaps nothing that disrupts the serenity and beauty of a foot more than an ugly blackened toenail. (Well, there may be a few more disruptive things, but black toenails are pretty icky, all the same.) Dark discolorations in the toenail don’t always have to be black, either. They may also look purplish or brown, two other colors that don’t go very well with the foot’s natural décor.  As soon as she saw me Gerty threw up her hands pointing at her left big toe nail saying, “I just woke up with this and I don’t know how it got there.”

The cause of these discolorations is usually pretty straightforward—generally they’re from a blood clot or bruising under the toenail, most likely caused by that time you dropped your toolbox on your foot, or possibly the way you keep jamming your toes during football practice.

However, occasionally the cause could be something more severe, such as melanoma (or skin cancer) that’s growing under the nail. In this case, you likely see the discoloration as a brown or black streak under the nail. This type of melanoma is more likely to occur in people with dark skin (it accounts for about 30-40% of melanomas in the non-white population), although it strikes both men and women fairly equally.

Black toenails may also occur because of fungal infections, really bad ingrown toenails (often when they’re recurring), or other health concerns, although these tend to be more rare.

These are fairly easy to pick up just clinical examination and Gerty had none of these.  Obviously, the main symptom of a black toenail is…well…a black toenail. Gerty’s discoloration was caused by bruising under the nail, the bleeding caused some pain with pressure to the area, since the blood has no easy escape route.  Gerty just about jumped through the false ceiling of my treatment room when I applied the lightest touch.

Gerty, much to her credit, had become very suspicious what was happening because she couldn’t remember injuring the toe in any way.  Melanomas will tend to show up as a streak under the nail, usually dark but occasionally white.  Because they can show up in any form, it’s usually a good idea to treat any nail discoloration with suspicion—checking with me was a good idea.

If I had suspected melanoma I would have obtained a biopsy of the tissue.  This is really the only way to find out for sure if the tissue is cancerous. Melanoma is certainly no fun, but early detection makes treatment that much easier, and often more successful.

Knowing Gerty had developed some trauma to the area (and likely within the past day) it was just a matter of going through her itinerary of the day before.  Gerty had gone dancing the night before.  She pulled out the dancing shoes from 10 years before.  “It had been awhile, I know,” she said. “And they felt a little tight but I just had to use them,” she said with a wistful smile suggesting more of a nostalgic rather than functional motive for subjecting her tootsies to these shoes of bygone days.  She also mentioned that during the course of the evening she frequented the bar at the club and by the end of the evening required the help of her husband to get back home.  She could not, for the life of her recall how she got from the venue to her bed.

I explained to her that her feet had enlarged over the years and as her right foot was a little smaller (and likely always had been) than her her left that the right great toe did not get as much pressure.  I had to numb up Gerty’s left great toe and remove the nail to make sure no additional damage was done to the nail bed and to relieve the pressure from the bleeding under it.

If I suspected that Gerty had a melanoma this would have required more aggressive treatment. If the disease is caught early enough, I can just cut out the melanoma (again with the toe numb of course). However, in more advanced stages, it may be necessary to amputate the affected toe. Removing nearby lymph nodes may be needed to prevent the spread of the cancer, and treatment may also involve other cancer-fighting methods, such as chemotherapy.

After much reassuring and a followup visit Gerty was relieved to know we did not have to call the toe truck.