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Toenail Problems

There are many people with toenail problems. I wonder if toenails are the most neglected part of our anatomy. I have written about ingrown toenails and fungus infection in the nails. I feel it is time to revisit the subject.

The nails are appendages of our most versatile organ – skin. Besides nails, the skin has three other appendages – hairs, sweat glands, and sebaceous glands.

Nails protect the tips of our fingers and toes. Hairs protect and provide warmth to the skin. Sweat glands help regulate body temperature and fluid and electrolyte balance. Sebaceous glands provide oil and odour to the skin.

The nail has a free end which we trim on regular basis. The two sides of the nail are under the skin folds. The root is at the base where the growth occurs. The average rate of growth of the nail is 0.1 mm a day or 3 mm per month. About 3.6 cm a year.

Fingernails grow faster than toenails. Both grow faster in the summer than in the winter. The nails grow rapidly in “nail biters” and slowly in people confined to bed. The growth is faster in males than females. Certain illnesses can arrest the growth.

The nail can be a window for physicians to suspect other illnesses. Normally, nails are flat and light pink. They are pale in anaemia. Nails in general and big toenail in particular can be sites of many problems. Ingrown big toenail with infection and pain is a very common condition. It can lead to gangrene and amputation in patients with diabetes and circulatory problems.

Ingrown toenail of the big toe usually occurs when sweaty feet are encased in tight shoes. The situation gets worse when the nail is trimmed short and the corners are curved down. The side of the nail curls inwards and grows to form outer spikes. This causes painful infection of the overhanging nail fold.

Ingrown toenails can be prevented by keeping feet nice and clean. Wear roomy shoes and clean cotton socks. Allow the outer corners of the nail to grow over the skin margins placing small piece of cotton soaked in an antiseptic just under the outer corners of the nail. Cut the nails straight. Antibiotics will help relieve acute infection but will not cure the primary problem.

If all this fails then surgical treatment becomes necessary. Simple whole nail avulsion or wedge removal of the nail can result in more than 50 percent recurrence rate. The best results are obtained by removing the root at the same time. This is done under local anaesthetic in a doctor’s office. About 10 days of tender loving care of the big toe after the surgery usually results in satisfactory outcome. There is about 10 percent or less recurrence rate.

Fungal infection of the nails is common as well. It affects toenails more than finger nails. The nail is thickened and discolored. It is usually yellowish. The nail may grow in a twisted manner. The infection is picked up in a public place where it is transmitted from person to person. Poor feet hygiene does not help.

Fungus infection is best treated with anti-fungal therapy orally and locally for three months. Cure rate is around 80 percent. Ongoing meticulous foot care is very important to prevent recurrence.

In my view, walking bare feet is the worst thing you can do for your feet. Wash your feet at least once a day (twice if your feet sweat a lot) with soap and water. Dry them well with a soft towel. Wear good quality clean socks and proper fitting comfortable shoes.

If you love your feet then take good care of them.

Thought for the week:

“War is the unfolding of miscalculations.” – Barbara Tuchman (1912-1989)

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Heart and Stroke

On Friday June 3, the Medicine Hat branch of the Heart and Stroke Foundation had their 12th annual golf classic at Medicine Hat Golf and Country Club. I was one of the 160 golfers to participate in this fundraising event.

It is a big event. After 18 holes of golf (even the rain stopped for six hours for uninterrupted golf!), sumptuous dinner and some exciting prizes, I drove home thinking about the hard work done by people behind the scenes.

Darlene Neigum, Area Manager, Heart and Stroke Foundation of Alberta, NWT & Nunavut and her band of volunteers and sponsors work tirelessly to make this event a great success. It is an event worth waiting for each year.

Heart disease and stroke are subjects close to my heart as I have a strong family history of cardiac problems. The subject is also close to the hearts of many Canadians as heart disease is the number one killer in this country and in all the Western countries.

Heart and Stroke Foundation has a very interesting website (www.heartandstroke.ca). There is a lot of information to read and digest for a healthy heart.

Heart disease is usually a progressive disease occurring over many years. It is usually a result of bad genes and/or mismanagement of risk factors.

There are certain risk factors which we can influence in a positive way and there are some which are beyond our control. The risk factors that we can influence are:
-High blood cholesterol
-High blood pressure
-Lifestyle factors (lack of exercise, being overweight, smoking, drinking too much alcohol, stress) and
-Diabetes

The risk factors that we cannot change are:

-Age and gender (55+ for women, 45+ for men)
-Ethnic descent (African, South Asian, and First Nation populations are at higher risk)
-Family medical history – heart attack or stroke before age 65, angina, tendency to develop high blood cholesterol or blood pressure

Risk factors for stroke are very similar to heart disease. The best way to prevent heart disease and stroke is to work toward pursuing a healthy lifestyle. This includes daily exercise, eating a healthy dose of fruits and vegetables, keeping our weight within an acceptable range for our age and height, never to start smoking, drinking minimal amount of alcohol, and learning to manage stress.

Pursuing a healthy lifestyle will help control other risk factors such as diabetes, high blood pressure and high cholesterol level. It is important to see a family physician on a regular basis and have these risk factors checked.

To pursue a healthy lifestyle is not easy or cheap. It requires significant amount of sacrifice and time commitment. It is a question of making choices. Not always easy to do that.

The volunteers with the Heart and Stroke Foundation make sacrifices and time commitment to organize fundraising events so that money can be spent on research and education to help people like me who are at a high risk for heart disease and stroke. In return we owe it to ourselves and our families to make a commitment to pursue a healthy lifestyle. Summer is a good time to do that.

Thought for the week:

“Even if we can’t be happy, we must always be cheerful.” – Irving Kristol.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Inguinal Hernia

Dear Dr. B: I have a groin hernia. My doctor says it is an inguinal hernia. How did I get this and what is the best treatment for an inguinal hernia?

Answer: There are two types of hernia in the groin: inguinal and femoral. Inguinal hernia is by far the commonest hernia. Inguinal hernia can appear at any age – from birth (congenital) to old age (weak muscles).

The hernia appears through a potentially weak spot in the abdominal wall. The hernial sac may contain an organ, most often the bowel but sometimes the bladder or an ovary.

The hernia can be a source of discomfort or pain or can be totally asymptomatic.

A groin hernia presents as a bulge during straining, coughing, micturating or doing heavy lifting. The bulge will appear whenever there is increase in the intra-abdominal pressure. The bulge will usually disappear on lying down or after gentle manual reduction.

If the bulge cannot be reduced then it becomes a potentially life-threatening problem. The hernial contents trapped in the hernial sac may lose its blood supply and become gangrenous.

Treatment of hernia is surgery. If the hernia is causing no symptoms then one can elect not to have surgery. Hernia does not go away without surgical treatment. If surgical treatment is not undertaken then the hernia may remain the same, get bigger or there is a small risk of strangulation and gangrene.

If the hernia is symptomatic then surgery is the best answer. There are two surgical approaches to repair of inguinal hernia: open method (a groin incision with tension free mesh repair) and laparoscopic repair (done through small holes in the abdominal wall).

People commonly ask: Which method is superior? Answer to this question is controversial. Commonly four outcome measurements are used to measure the success of each technique: return to work, operative time, postoperative pain, and recurrence rate.

Studies have shown that patients return to work after a minimum of nine days, regardless of the type of repair. Return to work is more a function of employment status; self-employed workers go back to work earlier than patients on workers’ compensation.

Operative time depends on individual surgeons. Overall operative times are not significantly different between the two repairs although some studies have shown that laparoscopic repair takes little longer.

Some reports have suggested that post-operative pain is less for laparoscopic repair, but these studies have not adequately compared the patients who had open tension-free repair. What about the recurrence rate? Laparoscopic repair appears to have lower recurrence rate than open method but there were very few tension-free repairs in that study to make appropriate comparison.

Overall, the two repairs appear to have similar complication rates. The procedure is done as a day surgery under local, spinal or general anaesthetic. The type of anaesthetic used depends on the surgical technique used and the general condition of the patient.

Thought for the week:

“It’s easier to apologize than reform oneself.” – From Musings by Dennis van Westerborg, local artist and writer.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Hemorrhoids

My doctor says I have hemorrhoids. Can you please tell me more about this subject? What is the treatment for hemorrhoids?

Answer: We all have hemorrhoids. Hemorrhoids are vascular cushions in the anal canal. External hemorrhoids are in the margins of the anal canal. Internal hemorrhoids are at the junction of the rectum and the anal canal. There are three internal hemorrhoidal cushions at three, seven and 11 o’clock.

It is important to remember that hemorrhoids are not always symptomatic and all problems in the rectal area are not due to hemorrhoids. It is difficult to estimate the true incidence of symptomatic hemorrhoids.

The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BC by Hippocrates. It was thought that the hemorrhoidal symptoms were due to infection of the veins in the rectum due to passage of stool. Red-hot iron was used to cauterize the hemorrhoids!

Napoleon was finally defeated by the British at the Battle of Waterloo in 1815. Several accounts by those who were close to him have indicated that the battle was lost because Napoleon was too busy treating his hemorrhoids. He routinely treated his hemorrhoids with three to four leeches!

There are two main reasons why people get symptomatic hemorrhoids: there is a history of straining while having a bowel movement and the aging process makes the supporting tissues in that area lax. Increased intra-abdominal pressure (for example in pregnancy) and increased congenital internal anal sphincter pressure can give rise to symptomatic hemorrhoids.

Internal hemorrhoids are classified by the degree of prolapse:
-First-degree hemorrhoids do not prolapse with straining, but can be associated with bleeding.
-Second degree hemorrhoids protrude during straining but will spontaneously retract.
-Third degree hemorrhoids protrude outside the anal canal with straining and require manual reduction.
-Fourth degree hemorrhoids remain prolapsed independent of straining and are irreducible.

Patients with hemorrhoids have no symptoms or present with variety of symptoms such as bleeding, prolapse, feeling of incomplete evacuation, soiling, irritation and itching. Severe pain in the rectal area is due to thrombosed hemorrhoid, fissure or cancer.

The diagnosis of symptomatic hemorrhoids is usually made with digital rectal examination and direct visualization with an instrument. If patient presents with rectal bleeding then other causes of bleeding should be ruled out by endoscopy.

Treatment of hemorrhoids includes dietary and lifestyle changes, rubber band ligation of hemorrhoids and surgery.

High fiber diet and fiber supplement reduces the bleeding and discomfort from hemorrhoids. Fiber causes bloating and flatulence so it should be increased gradually. Avoid straining at the time of defecation. Use hemorrhoidal ointment to lubricate the anal canal before and after bowel movement.

Hot baths help relax the internal sphincter and ease discomfort in the anal area. In 1963, Barron described rubber band ligation for second and third degree hemorrhoids. After the procedure the patient may experience a feeling of pressure or rectal fullness for a period of 24 to 48 hours. There are other complications but they are rare and occur in less than three to four per cent of people.

For fourth degree hemorrhoids, surgical excision is the best option for relief of symptoms. Likely post-operative complications are pain, bleeding and urinary retention. But these treatment options are better than using leeches or red-hot iron rod!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!