Brittle toenails are one of the most common nail disorders encountered by dermatologists. It affects about 20 % of the population with women being affected twice than men. This condition is more common in aged people. Brittle nails are characterized by the increased fragility of nail plates and often associated with the roughness of nail’s surface. Those with easily breakable, unsightly-nails usually consider it as a cosmetic issue. But in certain conditions brittle nails can be painful and cause functional problems.

What are nails made up of?

Nail plate or the actual finger/toe nails are mainly made up of keratin, a hardened protein. It is produced by the root of the nail (germinal matrix), which lies beneath the skin under the nails. The part that extends from the edge of nail root to the tip contains blood vessels and nerves and is called nail bed or “sterile matrix”. As the nail grows it streams down along the bed and material which gives the thickness. The cuticle, which is situated between the skin and the nail, binds the nail to skin and provides a waterproof barrier. Matrix is the only living part of a nail. Nails protect the underlying nail bed and also enhance the sensation of the tips of our fingers/toes. Brittle toenails can be the result of damage to nail matrix causing altered production or due to damage of already keratinized nail plates. This can be caused by external or internal factors.

Types of Brittle Toenails

• Onychorrhexis: This is characterized by longitudinal ridges, which progress to longitudinal splits starting from the free end, and extends proximally.
• Single longitudinal split: It involves the entire nail plate Multiple crenellated splitting: There will be multiple splits and triangular pieces may easily be torn form the free margins.
• Onychoschizia: (Lamellar splitting) Free edge of the nail is split in to fine layers.
• Transverse splitting: Splits transversally and lateral edges break close to the margin.
• Friable nails: Brittle nails with changes seen only on the surface of the nail.

Causes Of Brittle Toenails

• Health and Strength of the toenails depend on three factors; the wear and tear rate, repair rate and genetic characteristics of nails. Nails deteriorate when the equilibrium between wear and tear and repair is affected. This happens either by slowing down of repair or by increased wear and tear. Also, genetically thin nails are more vulnerable to fragility. The causes, which affect the equilibrium leading to brittle toenails,can be divided broadly into local and systemic. Local: Chemical trauma can cause brittleness of toenails. Repeated exposure to detergents, cement, varnish, sugar or salt solutions etc. can cause damage to nails by dissolving the intercellular lipids. Low lipid content decreases the ability to retain water. When the water content is reduced below 16 percent the nails become brittle.
• Frequent washing can have adverse effects on strength of the nails because when the water evaporates it also dissolves the substances which help retain the water which in turn leads to dryness and increased fragility.
• Repetitive physical trauma as in wearing improper shoes or excessive length of nails can cause brittleness.
• Dermatological diseases like Lichen planus, Darier’s disease, Eczema, Psoriasis, Alopecia, Acanthosis nigricans etc. can involve nails. About 50% of patients with Psoriasis and 10 % of patients with lichen planus have brittle nails. Nail tumors can cause brittleness of nail plate along with longitudinal abnormalities. Fungi digest keratin and hence fungal infections can damage the nail plate causing brittleness.
• Environmental factors: less humid conditions as in winter season can dry up the nails causing brittleness.
• Systemic:Hypo & Hyperthyroidism
• Iron deficiency anemia
• Osteoporosis
• Diabetes Mellitus
• Osteomalacia
• Hypopituitarism
• Syphilis
• Tuberculosis
• Bronchiectasis
• Amyloidosis
• Sarcoidosis
• Gout
• Neuropathies
• Peripheral arterial diseases
• Pregnancy
• Raynaud’s disease
• Hemodialysis
• Vitamin and Mineral deficiencies (Iron, Zinc, Selenium, Vitamins A, B, C, D, E)
• Anorexia nervosa and Bulimia
• Drugs like antiretrovirals, pencillamine. Arsenic, gold etc.
• Aging causes drying of nails. This along with slow growth rate, which exposes the nail plate to environmental factors for an increased amount of time, can make the nails more brittle.
• Gender: females are affected more because of hormonal and lifestyle factors.

Treatment

• Treatment of brittle toenails depend on the cause. First step is to identify the causative factors. If there is an underlying systemic cause such as a disease or nutritional deficiency it should be treated. Removal of external factors, which is causing or exacerbating fragility of nails, is very important in regaining the health of the nails. Local treatment:Soaking nails in lukewarm water for 15 minutes daily
• Applying emollients especially those that contain phospholipids can improve nail hydration. Thicker the emollients better will be the results.
• Application of preparations containing urea or lactic acid twice a day
• Natural oil massages (olive oil, rice brand or jojoba oil)
• Nail polish can act as a protective covering to hold the moisture in nails
• Nail hardeners, nail strengtheners, fortifying nail builders are modified nail polishes with different solvent and resin concentrations with additives like nylon fibers, keratin, vitamins, natural oils etc.
• Nail hardeners with formaldehyde can chemically alter the structure of the nail plate making it hard. It should be used with caution as formaldehyde can cause adverse effects.
• Nail mending and wrapping: paper, silk, linen or fiberglass is used to splint the nail plate and is fixed using cyanoacrylate glue. This provides protection and camouflage.
• A new drug, Genadur, a hydrosoluble nail lacquer is said to improve the condition of the nails when once per night for 8 weeks.
• Systemic Treatment:Oral supplementation of vitamins, especially biotin may improve lipid synthesis that produces binding between nail plate keratinocytes. Recommended dose of biotin is 2.5-3 mg daily for 6 months. Pyridoxine 25-30 mg per day and ascorbic acid 2-3 g per day is also recommended.
• Oral oligo elements and amino acids may improve nail strength
• Iron supplementation might be helpful in some patients
• Evening prim rose oil capsules (2 no) when taken thrce a a day is found to be beneficial
• Well balanced diet facilitates growth of healthy nails. Egg whites are richest source of biotin. Nails are made of protein and sufficient protein intake is important in strengthening of the nails.
• Recommended measures for healthy toenailsAvoid frequent washing
• Prolonged usage of harsh detergents/soaps
• While using gloves, use cotton gloves underneath vinyl gloves
• Trim nails short and squared
• Limit use of nail polish removers, acetate is preferred over acetone
• Avoid overpedicuring
• Cuticle removal is not recommended
• Use of moisturizers is highly recommended, especially in geriatric population and in environments with low humidity
• Avoid wearing artificial nails for longer periods of time
• Avoid hand sanitizers with triclosan as it evaporates quickly taking away the water content from the nail plate along with it.
• Human nails reflect the overall health and nutritional status of the body.
• Brittle nails may be an inconvenience or can be unsightly, it can also be a visible symptom of an underlying problem. Hence it is very important to pay attention to the condition of your nails.