Nail disorders are a result of infections, cutaneous diseases, neoplasms, systemic diseases, or may be self-induced. Physical appearance and prognosis correlates with etiology. Onychomycosis (fungal infection) is the most common, representing 30% to 40 % of all nail disorders. The toenails are involved in 80% of cases of onychomycosis, and all can be categorized as distal subungual, lateral, proximal, or white superficial.

Infections:

• Dermatophyte (tinea unguium)—fungi (Trichophyton rubrum, T. interdigitale, T. mentagrophytes) 
• Molds—Scopulariopsis brevicaulis, Aspergillus, Fusarium 
• Bacteria—Staphylococcus aureus or Pseudomonas 
• Yeast—Candida albicans 
• Paronychia—from excessive manicuring or trauma, then infection with C. albicans 
• Warts—human papilloma virus 
• Adrenal compromise 

• Cutaneous diseases—psoriasis, lichen planus, alopecia areata
• Systemic diseases—nail changes diagnostic for underlying disorders (e.g., cardiopulmonary disease or gastrointestinal disorders associated with nail clubbing; nail fold telangiectases associated with lupus erythematosus)
• Lesions—melanoma, squamous cell carcinoma, benign
• Self-induced—habit tic, poor grooming or overgrooming, trauma (e.g., ingrown nail, pincer nail)

• Infections—genetic; trauma; heat and humidity; excessive exposure to water; tight-fitting or rubber shoes; chemical damage
• Peripheral vascular disease
• Diabetes mellitus
• Cutaneous diseases
• Neoplasms—history of trauma
• Trauma and microtrauma—predispose to infection
• Overmanicuring
• Habit-tic deformity—picking the proximal nailfold of the thumb
• Soil contamination
• Human immunodeficiency virus (HIV)
• Peripheral vascular disease
• Overt or subtle compromised immunity

Infections:

• Onychomycosis—yellow or yellow-brown discoloration; nail bed hyperkeratosis
• Pachyonychia—painful, red swelling of nail fold; thickening of the subungual keratin/nails; cuticle separates from nail plate; disintegration of the nail plate
• Candida Onychomycosis—nail folds and bed, usually fingernails
• Paronychia—inflammation of nail folds

Cutaneous diseases:

• Psoriasis— yellow discoloration; salmon-colored spots; nail bed hyperkeratosis; pitting; onycholysis; splinter hemorrhage; other cutaneous signs of psoriasis
• Lichen planus—longitudinal ridges, scarring, matrix destruction and subsequent pterygium formation (nail fold adheres to nail bed where nail no longer grows)

Lesions:

• Longitudinal lesion with pigmented band or yellowish thickening in the nail plate that widens even into nail fold—matrix tumor
• Onycholysis, subungual hyperkeratosis, or circumscribed discoloration—nail bed tumor
• Longitudinal melanonychia (brown–black band) that suddenly appears or becomes wider—melanoma
• Pain—for basal or squamous cell carcinoma
• Usually thumb or great toe

Self-induced:

• Habit tic—horizontal and parallel grooves on nail plate
• Ingrown nail— edema, redness, pain, infection
• Pincer nail—transverse overcurvature, pain

• Type of nail disorder must be confirmed before treatment.
• Eczema

In some cases, diagnosis cannot be made by visual examination alone as appearance may be misleading (e.g., psoriasis closely resembles fungal infection). A complementary diagnosis of culture, biopsy, and radiographic studies allows a correct diagnosis and avoids unjustified treatments.

• Potassium hydroxide (KOH) fungal preparation or culture—identifies various fungi and differentiates from other disease such as psoriasis
• Bacterial culture
• Biopsy (punch or scalpel)—of pigment or lesion, for neoplasms; with PAS stain
• Histologic examination of keratin

• Various specific microbials found in nail keratin
• Malignant neoplasms

Radiographic studies are performed with suspected neoplasms.

The infected portion of the nail is removed with nail clippers or by chemical or surgical avulsion. Topical or oral treatment appropriate to the type of nail disorder then follows. Combination oral/topical treatments tend to enhance therapeutic results and reduce relapse rates. Total surgical removal of nail sometimes is indicated.

• Paste of 40% urea mixed with a 1% bifonazole causes onycholysis in one to three weeks
• Itraconazole—for dermatophytes, yeast, and some molds; has high affinity for keratin tissue; must be given after a meal; continuous therapy, 200 mg/day for 90 days; pulse therapy, 400 mg/day one week a month for four months; side effects: gastrointestinal, headache, skin rash; drug interactions
• Terbinafine—for dermatophytes, especially T. rubrum; continuous therapy, 250 mg/d for 90 days; pulse therapy, 200 mg/bid one week a month for three months; side effects: gastrointestinal, headache, skin rash, altered sense of taste; perform CBC and liver function tests with use
• Fluconazole—for dermatophytes, Candida (e.g., paronychia), some molds, possibly onychomycosis; 150 to 300 mg once weekly until clear; side effects: gastrointestinal, headache, skin rash, hepatotoxicity; drug interactions
• 1% iodinate, Whitfield's ointment, silver nitrate, glutaraldehyde, and imidazole derivatives—for molds
• 12% urea with 0.03% retinoic acid—with weekly abrasion, for warts
• 3% thymol in 70% ethanol—for paronychia; bid to tid until clear
• Antibiotics—topical (povidone–iodine) for ingrown nails or paronychia; systemic (broad spectrum antimycotics) for infections such as paronychia
• Amorolfine 5% or ciclopirox 8%—therapeutic nail polish for fungal infections
• Topical steroids (e.g., clobetasol propionate)—under nail fold; for psoriasis, lichen planus
• Systemic steroids—for severe lichen planus; prednisolone 0.5 mg/kg/d for three weeks
• Intramatrix injection of dexamethasone acetate—for lichen planus; 2.5 to 5 mg/mL per finger
• Intralesional steroid injections (e.g., triamcinolone acetonide 3 mg/mL)—for psoriasis
• Psoralen plus ultraviolet A (PUVA)—for psoriasis

Paronychia lesions should be incised and drained. For acute trauma, hematomas may be drained with a heated lance or by successive nail removal with a scalpel. Wide excision, surgical avulsion, and sometimes Mohs surgery is performed for malignant lesions. In severe cases of ingrown or pincer nails, the nail is surgically removed.

May be beneficial in addressing the underlying cause and providing optimal nutrition for nail health.

For general nail health include adequate protein and minerals. Increase nuts, seeds, whole grains, legumes, fresh vegetables, sea vegetables, and cold-water fish. Avoid sugars, alcohol, caffeine, and refined foods.

Common nutrient deficiencies in nail disorders include the following.

• Vitamin A (10,000 IU/day)
• Zinc (15 to 30 mg/day)
• Essential fatty acids (flax, borage, or evening primrose oil) 1,000 to 1,500 mg bid
• Iron (ferrous glycinate 100 mg/day)
• Vitamin B₁₂ (1,000 mcg/day)

Consider digestive enzymes and/or free-form amino acids for compromised digestion or malabsorption.

For infectious etiology and systemic or cutaneous disease, include immune-supporting nutrients:

Vitamin C (1,000 mg tid), vitamin A (10,000 to 20,000 IU/day), zinc (30 mg/day), vitamin E (400 to 800 IU/day), EFAs (1,500 mg bid), and acidophilus (1 capsule bid to tid).

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

With nutritional deficiencies:

The following herbs stimulate circulation and are rich in minerals. Take 15 to 20 drops tincture tid or drink two to three cups tea daily. Ginger (Zingiber officinalis), nettles (Urtica urens), dandelion herb (Taraxecum officinalis), horsetail (Equisetum arvense), spearmint (Mentha spicata), and hawthorn (Crataegus monogyna) in equal parts.

With bacterial or viral infection:

Combine equal parts of coneflower (Echinacea purpurea) and goldenseal (Hydrastis canadensis) with one-half part of ginger. Take 20 drops tincture qid.

With fungi, molds, or yeast infection:

Combine equal parts of coneflower, oregano (Origanum vulgare), spilanthes (Spilanthes acmella), usnea (Usnea barbata), Oregon grape root (Mahonia nervosa), and myrrh (Commiphora molmol). Take 20 drops tincture qid.

Apply undiluted grapefruit seed extract or tea tree oil to affected nail. Do not allow contact with skin.

An experienced homeopath would consider the individual's constitution. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Calcarea carbonica for distorted, brittle nails, especially with muscle cramps and arthritis
• Graphites for thickened, hard nails, especially with arthritis or skin eruptions
• Sulfur for thick, distorted nails, especially on the feet

May be helpful in enhancing immune function, normalizing digestion, and addressing systemic disorders.

Can aid in stimulating peripheral circulation to facilitate the transport of nutrients to the nail bed.

Monitoring occurs as needed for drug side effects or interactions.

• Avoid risks such as habitually wetting hands or occlusive footwear.
• Wear cotton socks.

• Cellulitis
• Onychomycosis may lead to osteomyelitis.
• Emotional and social disruption from unsightly nail appearance

• Fingernail—regeneration takes 4 to 6 months
• Toenail—regeneration takes 8 to 12 months
• Damage to matrix—more likely to result in permanent damage (e.g., split nail); possible with numerous conditions such as psoriasis, lichen planus, warts
• Damage to nail plate or bed—good prognosis for normal regrowth
• Relapses more common with multiple nail involvement

Delay treatment with certain drugs until after pregnancy if possible.

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