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Care of the Skin and Nails of the Neuropathic Foot

Joan Conlan, LVN, CPed

THE SKIN

Healthy skin is soft and flexible and slightly moist and acidic. It is the largest organ of the body, covering 3,000 square inches on the average adult. It weighs approximately six pounds (almost twice the weight of the brain and liver). The skin receives about one third of all circulating blood of the body. Its two main parts, the epidermis and the corneum (the dermis), serve as a protective barrier against microorganisms. It insulates against heat and cold, helps eliminate body wastes in the form of perspiration, and its sense receptors enable the body to feel pain, cold, heat, touch, and pressure. The epidermis is thickest on the palms and soles of the feet and becomes thinner over the surface of the trunk.

THE NAIL

Nails are composed of hard keratin, a modification of the horny epidermal cells of the skin. The white crescent shape of the lunula at the proximal end of each nail is caused by air mixed in the keratin matrix. The nail plate originates from the proximal nail fold and attaches to the nail bed. It grows about 1 mm per week unless inhibited by disease. Regeneration of a lost toenail occurs in 6 to 8 months.

FACTS ABOUT NAILS1

  • Nails grow approximately 0.1 mm per day or 3 mm per month.

  • Nails grow faster in daytime and summer.

  • Fever and serious illness slow growth rates.

  • Pregnancy enhances growth.

  • Nails grow more rapidly in men and younger people than in women and the elderly.

  • Toenails grow 1/2 to 1/3 the rate of fingernails.

SKIN AND NAIL CARE

Before starting skin and nail care, thoroughly inspect feet and ankles for breaks in the skin. Have a mirror available to examine the heels. Look for ulcers, heel fissures, maceration between the toes, or embedded objects. When nails are neglected and grow too long, they can break the skin of the neighboring toe. Abnormal nails that are not given routine care can accumulate excess keratin and debris under the nails and in the nail folds, creating an ideal environment for bacteria to grow.2 Poor hygiene necessitates routine foot care.

The procedure for basic foot care is as follows:

  1. Wash hands.

  2. Submerge patient's feet into warm water (not more than 95°F).

  3. While wearing gloves, make a paste of baby shampoo (or any mild soap) and baking soda in the palm of your hand and gently massage over the entire foot. (You can also use water that is three parts water and one part vinegar to clean the feet. Vinegar softens the skin and nails.3)

  4. Rinse and wrap feet individually.

  5. Expose toes and apply cuticle remover.

  6. Using a curette, gently remove dead skin and loose cuticle from the toes.

  7. Rinse.

  8. Using nail clippers, cut nail straight across. Don't cut what you can't see. Always have good lighting.

  9. Thinner, more fragile nails can be cut using smaller cuticle nippers.

  10. Ingrown toenails are a puncture wound. To prevent them, use an ingrown nail file to smooth sharp corners that can dig into the skin.

  11. Smooth rough edges of nails with emery board. Patient may take the emery board home for self-care.

  12. Massage emollient into feet but not between toes. Avoid lotions with fragrance because of drying, alcohol content. Vaseline, lanolin, or even Crisco may be used. Pat excess off with paper towel. Remind patient to use caution when using emollient to prevent slipping and falling. Removing excess and wearing socks help minimize the hazard.

  13. Educate patient regarding appropriate footwear.

There are nails that are difficult to trim. The safest way to trim the pincer type nail is to file it straight across, rather than risk cutting the skin. Some nails have grown into a "tent" shape, usually formed by being squeezed into tight pointed shoes for years. When trimming this type nail be aware of the skin under the nail at the apex. A condition called onycholysis (separation of the nail plate from the nail bed) can be caused by nail traumas and disorders. If onycholysis has been present for a long time (6 months or more) the structure of the nail bed can change and the nail plate will no longer attach to the nail bed. At this point, the condition becomes permanent. Keep the patient's nails short to prevent the nail from catching on something and tearing off.4

HELPFUL FOOT AIDS

  • Tube foam is ideal for protecting bunion deformities, soft corns, and maceration between the toes.

  • Lamb's wool aids in protection between the toes from maceration and provides cushioning.

  • Toe socks help with overlapping toes and controlling maceration in interdigit spaces.

  • Socks that are designed to wick moisture away from the skin are desirable, especially in a foot that sweats excessively. Avoid socks with tight elastic tops.

CARE OF THE HYPERTROPHIC NAIL

A hypertrophic nail may be caused by damage to the matrix, fungal infection, age, or circulation problems.

Hypertrophic nails that have been neglected for a long period need to be thinned to make shoe fit possible and to help prevent secondary infection if the prominent nail is traumatized.

The most effective and expedient way to thin the nail is to use a cordless rotary Dremel tool (Dremel, Racine, WI) with an abrasive disc. These discs are easily interchangeable and should be discarded between patients.

It is important to protect yourself and the patient from airborne dust by wearing a mask and, preferably, hair covering. Using a government-rated high efficiency particulate arrestance (HEPA) air filter device would give added protection to limit the amount of dust in the air.

PROCEDURE FOR REDUCING HYPERTROPHIC NAILS

  1. Begin by washing your hands and donning gloves.

  2. Examine the skin around the nail for any damage.

  3. If there are no signs of broken skin or infection, secure toe to be worked on with the thumb and index finger and move other toes out of the way.

  4. Turn Dremel on and move sander in a proximal to distal direction in even strokes until nail is thinned. Caution must be exercised when thinning these nails because of unanticipated raised nail beds.

  5. Wash and dry thinned nail with water or water/vinegar solution (three parts water/one part vinegar) and apply an antifungal cream such as Tineacide (Blaine Labs, Inc., Santa Fe Springs, CA). Use of this, or a similar product, will allow consecutive nail care to be more effective by keeping the nail and surrounding skin conditioned.

Correspondence to: Joan Conlan, LVN, CPed, 706 Glen Mar Drive, Mt. Shasta, CA 96067; e-mail: .


JOAN CONLAN, LVN, CPed, is the owner of Theraped, Mt. Shasta, CA.

References:

  1. Kechiijian P. How do nails grow? Nails. May 1993:78–79.
  2. O'Neal LW. Surgical pathways of the foot and clinical pathological conditions. In: Bowker JH, Pfeifer MA, eds. The Diabetic Foot, ed 6. St. Louis: CV Mosby; 2000:501–506.
  3. Ruscin C, Cunningham G, Blaylock A. Foot care protocol for the older client. Geriatric Nursing. July/August 1993: 210–212.
  4. Scher RK. The nail doctor. Nails. December 1997:93–95.