Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

A most unpleasant surprise: toenail fungus

The well-groomed foot.

Most of us are looking forward to sunny days after our long winter.  Sandals and open-toed wedges and shoes always look better when the feet and nails have been given attention.  Many women enjoy a relaxing pedicure and never imagine that a pedicure is actually a procedure.  Nail care professionals are required to complete training and must be licensed.  This reassures many clients that policies are in place in their salon that will prevent infections.  Unfortunately, this is not always true.

Many salons use Barbicide, UV light “sterilizer” boxes, or other chemical solutions to disinfect their tools—these may be legal and standard, but not effective at killing all bacteria and infectious agents. The only process that works is careful cleaning of all reusable equipment and then sterilization in an autoclave, a machine using high pressure and steam, which kills 100 percent of all infectious organisms. The person in charge of the cleaning, disinfecting, and sterilizing of instruments should be trained to follow all the necessary steps.

Often, nail files are not sterilized.  It is possible for fungal infections to be transferred through manicuring or pedicuring, especially when inserting files under the cuticle. Other items used in the performance of manicures and pedicures, such as emery boards, pumice stones, nail buffers, and foam toe separators cannot be sterilized.

Foot-baths—either attached or the smaller ones that are simply carried to a sink to be emptied and refilled between clients—may look clean and feel good, but they often harbor infectious agents that no one is aware of until there is an outbreak.  The Centers for Disease Control and Prevention follows clusters of unusual infections or infections that seem to come from similar sources.  A 2005 study documented “[in 2000] the first known outbreak of Mycobacterium fortuitum, cutaneous infections acquired from whirlpool footbaths at a nail salon in northern California.  Over ONE HUNDRED pedicure customers had prolonged boils on the lower legs that left scars when healed.” The initial investigation led to a study involving five large counties from different parts of California. “In each county, a team including the regional investigator of the California Bureau of Barbering and Cosmetology and a local public health professional visited selected nail salons.  They assessed foot spa equipment, cleaning solutions, and cleaning techniques and frequencies.  Swab samples were also collected.” The results were not reassuring: “Mycobacteria were isolated from virtually all pedicure spas surveyed, the sole exception being the foot spa that had only been in service for 11 days. Mycobacteria were recovered whether or not disinfectants were reportedly used and whether or not debris was visible behind the recirculation screen.”

There are recommendations for disinfecting foot spas between clients; these disinfecting procedure requires training, availability of appropriate disinfectants, and time for this solution to work.  These recommendations are rarely followed, because clients are booked back to back.

Skin on the heels that is cracked or callused is often shaved with a “fresh blade”.  But the blade holder may not be sterilized properly, and when this skin is “surgically” removed, small abrasions that clients are unaware of routinely occur. This removes the intact skin’s protective barrier against infectious agents.  Once this procedure has been completed, clients then put their feet back into that footbath, where there is dirt from their feet and dirt and debris from other clients’ feet.  

Some sensible steps to take to avoid an infection from any nail salon are:

1. Don’t shave your legs prior to the visit for a pedicure. Shaving causes abrasions or small nicks in the skin, increasing the opportunity for infectious agents to enter.

2.  Ask the salon manager to post the steps that are taken to prevent infections. These steps should include—
•  Hand washing before every new client.
•  A description of how all equipment is sterilized and disinfected.  Foot-bath disinfection should be described with the name of the disinfectant used and the length of time that the process takes between clients.

3.  Avoid salons that do not have simple footbaths without a motor.  The simple plastic ones can be cleaned more thoroughly since these do not have areas where debris collects that may allow infectious agents to multiply easily.

4.  Use a pumice stone after bath or shower daily with thick skin cream on those callouses and cracked heels. You can then avoid the risk of surgical removal of this skin by the nail specialist.

5.  Purchase your own nail equipment and take it with you to the salon and do not leave it there. Your equipment may be used when there is no time to clean the ones routinely used by the salon. Wash your own equipment with a bactericidal soap solution after it has soaked for fifteen minutes.  Rinse and dry thoroughly, wrap in a paper towel, and place in a small plastic bag.  Wash everything, including pumice stones.

6.  This next one will be hard for most women, but I do recommend that you take your own footbath if you have pedicures performed in a salon.

7.   Do ask your nail care specialist to wash her hands before she begins your pedicure.

Foot and toenail care are essential to comfort and good health. No one wants to have foot or toenail bacterial or fungal infections in order to have the latest polish on her toes.