Onychogryphosis (ram's horn nail)

What are the causes of onychogryphosis? 

Toenails and fingernails are primarily composed of a protein called keratin. Usually, nails grow one layer at a time in a symmetrical order. Nail changes and abnormalities may provide warning signs when your body is malfunctioning.

Medical causes of nail changes can include:

• Brittle nails can signal iron deficiency or thyroid disease.
• Psoriasis can cause cracks in your nails.
• White lines in the nails can indicate kidney disease.
• Dark lines in the nails can indicate skin cancer (melanoma).

Keeping a close eye on your nails and looking for unusual changes or growths is essential. Onychogryphosis doesn’t just develop overnight; some cases result from years of inadequate personal care.

There have, however, been instances of congenital onychogryphosis

Who is most at risk of developing onychogryphosis?

Although nail disorders can occur at any stage of life, older adults are particularly susceptible. Older people can sometimes be forgetful, making them less vigilant about trimming their nails. Trimming nails can also become difficult due to arthritis or difficulties bending over and reaching the toes.

Onychogryphosis is common in people who have (or had):

• Poor circulation
• Type 2 diabetes
• Bunions (hallux valgus)
• Gout
• Ichthyosis
• Peripheral vascular disease (PVD)
• Syphilis
• Family background or genetic predisposition
• Pemphigus
• Paronychia

In addition, repeatedly hurting your feet can damage the toes and nail plates, eventually leading to onychogryphosis.

Does toenail fungal infection cause onychogryphosis? 

Toenail fungus is more than a visual problem. This common infection may lead to severe complications if left untreated — including onychogryphosis.

As many as 50% of patients with onychogryphosis say they had toenail fungus for years before their onychogryphosis developed. Even if toenail fungus wasn’t the primary cause, there’s likely a correlation between the two.

What is the differential diagnosis for onychogryphosis? 

Other diseases have some of the same symptoms as onychogryphosis. Our University Foot and Ankle Institute (UFAI) podiatrists look at all your symptoms and perform in-house diagnostic testing. By accurately diagnosing your toenail problem, we can provide accurate medical advice and come up with a treatment plan.

It's important to consult with our podiatrists because many onychogryphosis symptoms can overlap with other conditions, such as:

• Congenital misalignment of the toenails.
• Pachyonychia congenita (a congenital condition that can result in abnormally shaped or thickened nails).
• Onychomycosis (toenail fungus)

What is the treatment for onychogryphosis?

UFAI podiatrists’ goal is to minimize pain and recovery time when treating foot problems. Depending on the cause and symptoms (for example, some patients experience lesions), onychogryphosis can be treated conservatively or with surgery.

Whenever possible, we aim to keep your feet healthy and functional with non-invasive treatment options.

Conservative treatment of onychogryphosis may include:

• Mechanical debridement with a nail clipper to shorten the nail and remove subungual hyperkeratosis (thickening of skin under the nail).
• Cryotherapy before debridement softens the nail, making it easier to cut.
• Blunt dissection with a nail clipper after medical nail avulsion (removal)
• Cauterizing the matrix with phenol acid
• If the cause of the ram’s horn is tight shoes and microtrauma to the nail bed, changing to well-fitted shoes can reduce further damage and give the nail time to heal.

What are surgical treatments for onychogryphosis? 

If conservative treatment fails, surgical or chemical nail avulsion may be needed.

This procedure includes surgically removing the nail to allow the nail bed a chance to repair the damage as a new nail grows.

We may follow up nail removal with a matricectomy — surgically or chemically removing the proximal nail matrix at the base of the nail. We have multiple potential methods for excision of the nail matrix, but all will result in the nail no longer growing.

When all else fails, this is the sure-fire way of treating your ram’s horn nail and making sure it doesn’t keep growing back.

What is the outcome of onychogryphosis treatment?

Onychogryphosis typically reappears after conservative treatment. Treatment, however, can be repeated to keep the nail bed short and prevent secondary complications. Use proper footwear to avoid excessive nail pressure on the nail bed.

A matricectomy will prevent the nail from growing and stop onychogryphosis from recurring.

Can you prevent onychogryphosis? 

You can do several things to minimize the risk of onychogryphosis and maintain good nail health. Prevention involves keeping your feet safe from injuries and fungal infections that can impact nail growth.

Make sure to:

• Wash your feet with soap and water regularly. Dry them off with a towel afterward.
• Keep your feet dry. Change your socks when they’re wet or sweaty,, wear cotton socks that remove moisture from your feet, rotate your shoes so they can dry out, and purchase shoes that breathe and don’t constrict your feet.
• Use foot powder to keep your feet dry.
• Wear shower shoes in a locker room, pool, or communal shower.
• Keep your nails well-maintained, making sure to cut your toenails straight across.
• Use disinfected tools when trimming your nails.
• Purchase new shoes after your nail fungus has been cured.

Why trust UFAI for your onychogryphosis treatment? 

It should not be a surprise that foot and ankle pain are widespread. The American Podiatric Medical Association reports that 77% of adults have experienced foot pain, which is constant for 80%. 

One of the great things about modern medicine is that our surgical team is well-versed in treating every part of the human body. Our foot and ankle specialists will keep you walking strong when it comes to the often-neglected feet. That’s where we come in.

UFAI’s surgeons are at the forefront of research, education, product design, regenerative medicine, and foot and ankle care advancements. Our non-profit foundation educates surgical fellows in advanced foot and ankle treatment and surgery, has performed dozens of clinical trials, and has educated the community for 20 years.

For a consultation please call (877) 736-6001 or make an appointment online now.

University Foot and Ankle Institute is conveniently located throughout Southern California and the Los Angeles area. Our foot and ankle surgeons are available at locations in or near Santa Monica, Beverly Hills, West Los Angeles, Sherman Oaks, the San Fernando Valley, Manhattan Beach, the South Bay, LAX, Calabasas, Agoura Hills, Westlake Village, Valencia, Santa Clarita, and Santa Barbara.

References

Kameyoshi Y, Iwasaki Y, Hide M, Yamamoto S. Congenital onychodysplasia of the index fingers in identical twins. Br J Dermatol 1998;139:1120-2.

Ko D, Lipner SR. Onychogryphosis: Case Report and Review of the Literature. Skin Appendage Disord 2018; 4:326.