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As a newly qualified and very green podiatrist, I would be very grateful for any tips and advice on treating a corn which is on the distal end of my patient's 1st nailbed. Haven't seen it for myself yet but he tells me last podiatrist added brown stuff to it! :confused

Hi Amy,

Cut the nail well back and debride the corn with a scalpel. There may well also be some subungual haematoma, due to the amount of pressure on the toe. The last podiatrist possibly used Silver Nitrate (hence the brown stuff). With a corn which is already hard and dry, this makes the area harder and dryer.

I now prefer to apply Tagetes cream to soften the skin, as patients seem to get greater relief this way. If there is any discharge from the lesion, I would use a sterile dressing.

Where there is a lot of discomfort I sometimes apply a semi compressed felt crescent surrounding the lesion to deflect pressure.

The prime objective with this sort of condition is to identify the cause and eradicate it - The majority of the time the shoes are either too short or too shallow at the toe box. Does your patient wear industrial shoes at work or has he changed footwear recently?

Best of luck

Anne

Thankyou Anne. Your help is appreciated.

Amy,
It is important to apply an aperture pad (felt with a hole cut out of the middle). The subungual corn is, from my experience , often caused by a hallux limitus or rigidus. The first metatarsal-phalangeal joint does not have adequate motion available in propusion, therefore the distal phalanx is forced to dorsiflex on the proximal phalanx. So, a subungual corn forms because of shoe pressure. It is not only pressure that causes the corn, but something like shearing and pressure together. The idea being that pressure alone causes ulceration, not a corn.

Don't just treat the symptoms! Check for hallux limitus/rigidus.

Tony Jagger DPM

Good point Anthony. Another underlying cause can be a sub-ungual exostosis.

Regards

Anne

Brown stuff could have been WP.

I think the most important thing in subungal HDs is how aggressivly you debride the nail. I use a needle burr and high speed setting on the drill. Don't be shy.

Regards
Robert

Hi Amy

Please only use this method if you have a modern spray drill !!

The friction / heat created without the cooling spray would be inappropriate.

The Hallux limitus/ rigidus is the most likely cause

"Remove the cause effect a cure" never a bad maxim:)

Brown stuff ?? post operative TBCo perhaps ??

Cheers

Derek

Another culprit can be slippers. Get them to check the inside of their slippers, as quite often the toenail has rubbed the lining away, and then the toe is hitting the upper with every step.

With experience you will be able to see the corn through the nail and know pretty much where to start debriding. The patient will tell you it is sore..... if they have normal sensation. But for those patients with compromised sensation look for the corn.

When looking at the nail plate before any treatment you can see a discolouration where the corn is, usually circular or oblong in shape. Different to a fungal look, more a couple of shades darker than the normal subungal tissue, rather than the white or brownish colour of a fungal. Sometimes there is a tiny bit of a blanched look around that darker shade, which makes sense, since there is a huge corn causing alot of pressure at that site.

If they can't feel it...Why treat ?? Because the pressure to the underlying tissue will only get worse and start to cause breakdown or an ulceration underneath the corn. This can have pus or fluid in it and will eventually develop into an oozing toe or a sinus.

With your clippers cut back as far as you can down and around the corn - more rather than less is best. The corn doesn't actually stick to the nail plate so you can cut the nail back away... but the pressure of the clippers working over the corn will hurt. So get in and do a couple of decent cuts and then tidy the nail up as you debride. Thin the nail down with the drill and debride all the corn away. A softening agent to keep the tissue soft while the nail grows back over the area will be required. But these corns invariably return....either 1 month or 1 year later depending how you can address the cause.

Then to really get you thinking, don't forget underneath the nail is also a good spot for little cancers, if something doesn't look right or isn't responding as you would expect get someone to check for skin cancers. I've picked 3 patients in 18yrs with skin cancers underneath the nail, but then living in Aust and people wearing sandals and open-toed shoes, not too surprising.

If the corn has been there for a while it may be a little touchy ( not pain ) for a couple of days until the underlying tissue calms down. Get the patient to apply emollient or antiseptic or whatever you think it requires for a couple of days. But if it isn't better after a few days it will need a quick little check. If it is still touchy or sore it generally won't get better without further help.

Happy Debriding
Trudi