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Dark Toenail Spots: Common or Cause for Concern?

by Mark K. Johnson D.P.M., D.A.B.P.S.
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There are many causes of discolored skin spots below or around the edges of toenails. While some of these are considered common and benign in nature, others may be of more concern for our patients and their foot and ankle specialists.

Dark yellow or brown or white spots or patches under toenails may be related to certain fungal or bacterial infections. These may cause discoloration of the toenail plate itself and/or from accumulation of skin debris below the nail. Raised white or pink hill -shaped area under the leading edge of the toenail causing thickening or tenting of the overlying nail may be from a subungual bone spur. These calcified projections may be caused by blunt stubbing or crunching injuries, tight or improperly fitted shoes, muscle weakness in the foot, or deformed curled toes which cause pressure below the nail bed.

Warts or verruca from the papilloma virus may show up as white or pinkish skin areas with small dark specks of dark color in them under the leading edge of the toenail. Warts are more common in teenagers and young adults. Exposure to the virus, excessive skin sweating, or minor scapes or cuts can inoculate the virus into skin and cause the wart to develop.

Dark reddish-blue or black spots below the back, middle, or front part of the nail may occur from subungual hemorrhage or bleeding under the nail plate - hematoma. Those may be the equivalent of hitting your thumbnail with a hammer on your weekend project. Heavy objects falling on the toe, jogging with shoes that are too short for the feet, or too long causing sliding may cause those spots. In addition, blood thinners such as Warfarin or Plavix or excessive downhill running may cause small capillaries under the nails to burst.

Are all dark spots under toenails easily explained? Not exactly. Black spots, patches, or streaks under-- or in the skin surrounding the edge of the nail -- may signal a more serious skin condition. In dark-skinned individuals such streaks in nails are often benign variations. Changes in their shape or color or length in a dark-skinned individual would be considered cause for concern. In light-skinned patients, dark areas under or around toenails require careful medical history-taking and clinical examination. Malignant melanoma, a form of skin cancer, may occur under toenails as dark spots or streaks. An especially ominous sign may be a dark strip extending from the toenail onto the adjacent skin. Other types of skin cancer may develop around the edges of toenails, sometimes as red raised fleshy areas associated with or resembling ingrown toenails. Although skin cancers below and around the margins of toenails are uncommon, their effects on the patient may be devastating! Prompt suspicion of these areas by the foot and ankle doctor, and skin/nail biopsy under local anesthesia is necessary to diagnose and characterize the type, extent, and long term prognosis of those pigmented spots.

foot and ankle specialist (Doctor of Podiatric Medicine) in private practice in West Plains, Missouri

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Mark K. Johnson D.P.M., D.A.B.P.S.

Mark K. Johnson D.P.M., D.A.B.P.S.'s web site

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