Pyogenic Granuloma on Toenail: Causes & Treatment

Pyogenic granuloma on toenail represents a localized, benign vascular proliferation that commonly affects the nail folds, often arising from minor trauma or injury to the area. The condition, while not cancerous, can cause discomfort and aesthetic concerns, prompting individuals to seek medical advice from healthcare professionals like dermatologists specializing in nail disorders. Understanding the etiology of pyogenic granuloma on toenail involves recognizing that factors such as Staphylococcus aureus infections can sometimes contribute to its development. Treatment strategies for pyogenic granuloma on toenail typically range from conservative measures, including topical medications, to more interventional approaches like surgical excision, tailored to the size and location of the lesion, as well as patient-specific needs.

Understanding Pyogenic Granuloma of the Toenail

Pyogenic granuloma (PG) affecting the toenail, while relatively uncommon, presents a unique clinical challenge. This introduction sets the stage for a comprehensive understanding of this condition, focusing on its defining characteristics, specific implications when it occurs on the toenail, and the critical need for accurate diagnosis and appropriate management.

Defining Pyogenic Granuloma

A pyogenic granuloma is not a granuloma in the true pathological sense, nor is it caused by a pyogenic (pus-producing) infection. Rather, it is a benign, rapidly developing vascular lesion. It's characterized by its propensity for exuberant growth and rich blood vessel proliferation.

These lesions typically appear as small, raised nodules that can bleed easily, even with minor trauma. While PGs can occur on various parts of the body, their presentation on the toenail necessitates a specific understanding of the underlying causes and appropriate treatment strategies.

Pyogenic Granuloma on the Toenail: A Location-Specific Perspective

The occurrence of a PG on the toenail introduces unique considerations. The anatomy of the nail unit – comprising the nail plate, nail bed, nail matrix, and surrounding skin folds – significantly influences the development and management of these lesions.

For example, a PG arising near the nail matrix (the area responsible for nail growth) may affect nail formation, potentially leading to nail deformities if left untreated or improperly managed. Similarly, the limited space and constant friction within footwear can exacerbate the symptoms of a PG on the toenail, increasing the risk of bleeding and discomfort.

The Significance of Early Recognition and Management

Prompt and accurate diagnosis of a toenail PG is paramount for several reasons. Firstly, it allows for the differentiation of the lesion from other, potentially more serious conditions, such as melanoma or squamous cell carcinoma.

Secondly, early intervention can prevent the lesion from growing larger, thereby minimizing discomfort and reducing the likelihood of complications, such as secondary infections.

Finally, appropriate management, tailored to the specific characteristics of the PG and the individual patient, can effectively resolve the lesion and prevent recurrence, ensuring optimal outcomes and improved quality of life. Therefore, a thorough understanding of the causes, clinical presentation, and treatment options for toenail PGs is essential for all healthcare practitioners involved in foot and nail care.

Unraveling the Causes: Etiology and Pathogenesis of Toenail PG

Understanding the etiology and pathogenesis of pyogenic granulomas (PGs) on the toenail is crucial for effective prevention and treatment. While the precise mechanisms remain an area of ongoing research, a combination of factors, including trauma, inflammation, and angiogenesis, are known to play significant roles in their development.

This section will explore these factors in detail, providing insights into the underlying processes that lead to the formation of these lesions.

The Role of Trauma as an Initiating Factor

Physical trauma is frequently implicated as the initiating factor in the development of PGs on the toenail. Even seemingly minor injuries can disrupt the integrity of the skin and underlying tissues, setting off a cascade of events that can ultimately lead to PG formation.

These injuries can range from acute, obvious trauma, such as stubbing the toe, to chronic, repetitive micro-trauma from ill-fitting footwear or activities that place excessive pressure on the toes.

The location of the trauma is also important. Injuries to the nail bed, matrix, or nail folds are particularly likely to trigger PG development due to the rich vascularity and regenerative potential of these tissues.

Underlying Mechanisms in PG Formation

Following initial trauma, a complex interplay of inflammatory and vascular processes drives the formation of a PG. Key mechanisms include inflammation, angiogenesis, and the development of granulation tissue.

Inflammation: The Initial Response

The initial response to trauma is inflammation. Inflammatory cells, such as neutrophils and macrophages, migrate to the site of injury, releasing a variety of mediators that promote vasodilation and increased vascular permeability.

This inflammatory response is a normal part of the healing process, but in some cases, it can become dysregulated, leading to excessive inflammation and contributing to the development of a PG.

Angiogenesis: Proliferation of New Blood Vessels

Angiogenesis, the formation of new blood vessels, is a critical component of PG development. The inflammatory mediators released at the site of injury stimulate the proliferation of endothelial cells, the cells that line blood vessels.

This results in the formation of a dense network of new capillaries, which contribute to the characteristic vascular appearance of a PG. Vascular endothelial growth factor (VEGF) is a key player in this process, promoting endothelial cell proliferation, migration, and survival.

Granulation Tissue: The Characteristic Tissue Mass

Granulation tissue is a type of connective tissue that forms during wound healing. It is characterized by its rich vascularity and the presence of fibroblasts, which produce collagen and other extracellular matrix components.

In the case of PGs, the excessive proliferation of new blood vessels and fibroblasts leads to the formation of a characteristic tissue mass that is prone to bleeding.

Predisposing Factors for Toenail PG

While trauma is often the initiating factor, certain predisposing factors can increase the likelihood of developing a PG on the toenail. These factors include injuries to specific parts of the nail unit and the presence of other nail conditions.

Injury to the Nail Bed (Matrix) or Nail Fold (Lateral and Proximal)

Injuries to the nail bed or nail matrix, the area responsible for nail growth, can disrupt normal nail formation and increase the risk of PG development. Similarly, injuries to the nail folds, the skin folds surrounding the nail plate, can create an environment conducive to PG formation.

Association with Ingrown Toenail (Onychocryptosis) and Paronychia

Conditions like ingrown toenails (onychocryptosis) and paronychia (infection of the nail fold) are frequently associated with the development of PGs on the toenail. The chronic inflammation and irritation associated with these conditions can promote angiogenesis and granulation tissue formation, increasing the risk of PG development.

The presence of a foreign body, such as a nail spicule in the case of an ingrown toenail, can also act as a persistent irritant, further exacerbating the inflammatory response and contributing to PG formation.

Identifying the Signs: Clinical Presentation of Toenail PG

Recognizing the clinical presentation of pyogenic granulomas (PGs) on the toenail is paramount for early detection and appropriate management. These lesions exhibit a distinct set of characteristics that, while sometimes mimicking other conditions, allow for a relatively straightforward diagnosis upon careful examination.

This section will guide you through the typical appearance, associated symptoms, and common locations of toenail PGs, equipping you with the knowledge to identify these lesions effectively.

Characteristic Appearance: More Than Just a Red Bump

The hallmark of a toenail PG is its rapid growth.

These lesions typically emerge quickly, often over a period of just a few days to a couple of weeks.

They present as small, raised nodules, generally ranging in size from a few millimeters to a centimeter in diameter.

The color is also distinctive, typically ranging from bright red to a deeper purplish hue, reflecting the lesion’s highly vascular nature.

The surface of a PG can vary. It may appear smooth and glistening in its early stages.

However, it often develops a lobulated or cauliflower-like appearance as it matures.

This irregular surface is prone to ulceration and crusting, particularly if subjected to repeated trauma.

Common Symptoms: Bleeding and Tenderness

While the appearance of a toenail PG is quite telling, the associated symptoms further aid in identification.

Bleeding is perhaps the most common and often the most alarming symptom.

Due to the abundance of blood vessels within the lesion, even minor trauma, such as bumping the toe or simply putting on shoes, can trigger profuse bleeding.

This bleeding can be a significant nuisance and a source of considerable anxiety for patients.

Pain or tenderness is another frequently reported symptom.

The degree of discomfort can vary from mild tenderness upon palpation to more significant pain, especially when pressure is applied to the lesion.

The presence of secondary infection can exacerbate the pain and tenderness.

Location Matters: Where Toenail PGs Typically Arise

Toenail PGs exhibit a predilection for the nail folds, the skin surrounding the nail plate.

The lateral nail folds, located on the sides of the toenail, are particularly common sites.

However, PGs can also develop on the proximal nail fold, the skin at the base of the nail.

In some cases, PGs may arise from the adjacent skin, particularly if there has been trauma or irritation in that area.

Understanding these common locations can help narrow down the possibilities when evaluating a suspicious lesion on the toenail.

Being observant of these features allows you to differentiate PG from other possible conditions affecting the toenails.

Reaching a Diagnosis: Confirming Toenail PG

While the clinical presentation of a suspected pyogenic granuloma (PG) on the toenail can be highly suggestive, definitive diagnosis requires a systematic approach. This involves a thorough clinical examination complemented, in most cases, by a biopsy to confirm the nature of the lesion and exclude other, potentially more serious, conditions.

This section will detail the critical steps in reaching a diagnosis of toenail PG, emphasizing the importance of both clinical acumen and histopathological confirmation.

The Power of Observation: Clinical Examination Techniques

The diagnostic process begins with a meticulous clinical examination, relying heavily on the power of observation and careful palpation.

Visual Inspection: Identifying Key Characteristics

Visual inspection is paramount. The examiner will carefully assess the lesion's size, shape, color, and surface characteristics.

Note the rapid growth pattern, the characteristic red or purplish hue indicative of vascular proliferation, and the presence of any surface irregularities, ulcerations, or crusting.

Also, carefully note its location, noting whether it arises from the nail fold, nail bed or surrounding skin.

Palpation: Assessing Texture and Tenderness

Palpation provides additional information. Gently feeling the lesion allows the examiner to assess its texture – whether it is firm, soft, or fluctuant.

Palpation also helps to determine the degree of tenderness or pain associated with the lesion.

Increased tenderness may indicate inflammation or secondary infection.

The Gold Standard: The Role of Biopsy and Histopathology

While clinical examination provides valuable clues, a biopsy is often considered the gold standard for confirming the diagnosis of toenail PG and, crucially, ruling out other potential conditions, including malignancy.

Indications for Biopsy: When to Take the Next Step

A biopsy is generally indicated when the diagnosis is uncertain, when the lesion exhibits atypical features, or when there is a concern for malignancy.

Atypical features can include rapid growth, unusual coloration, or the presence of satellite lesions. Any suspicion of malignancy warrants prompt biopsy.

Histopathology: Unveiling the Microscopic Details

The biopsied tissue sample is then sent to a pathologist for histopathological examination.

Under the microscope, the pathologist can identify the characteristic features of a PG, including:

• A proliferation of small blood vessels (angiogenesis).
• The presence of granulation tissue.
• An inflammatory infiltrate.

Furthermore, histopathology allows the pathologist to rule out other conditions that may mimic PG, such as squamous cell carcinoma, melanoma, or Kaposi's sarcoma.

The histopathological findings are crucial for confirming the diagnosis and guiding subsequent management.

Ruling Out Other Possibilities: Differential Diagnosis of Toenail PG

Accurate diagnosis is paramount in managing toenail lesions. While the clinical presentation of a pyogenic granuloma (PG) can be quite distinctive, it's crucial to consider and exclude other conditions that may mimic its appearance. This process, known as differential diagnosis, ensures that patients receive the most appropriate treatment.

Failing to consider other possibilities can lead to misdiagnosis, delayed treatment, and potentially adverse outcomes. This section will explore several conditions that should be considered in the differential diagnosis of toenail PG.

The Importance of a Broad Perspective

The initial assessment of a toenail lesion should involve a broad perspective, considering all potential etiologies.

A rush to judgment based solely on superficial appearance can be misleading. A methodical approach, incorporating thorough examination and, when necessary, biopsy, is vital.

This approach ensures the patient receives the right diagnosis and treatment plan.

Common Mimics of Toenail PG

Several lesions can present with similar characteristics to a pyogenic granuloma on the toenail, necessitating careful differentiation.

Squamous Cell Carcinoma (SCC)

Squamous cell carcinoma is a malignant tumor arising from keratinocytes.

While less common, SCC can sometimes present as a rapidly growing nodule, similar to a PG.

Unlike a PG, SCC may exhibit features such as induration, ulceration, or a crusted surface that bleeds easily.

A biopsy is crucial to rule out SCC, especially in older patients or those with a history of sun exposure or HPV infection.

Melanoma

Melanoma, a malignant tumor of melanocytes, can also occur in the nail matrix or nail bed (subungual melanoma) and may be mistaken for a PG, especially in its early stages.

Key distinguishing features to look for include pigmentation changes (melanonychia), nail dystrophy, and the Hutchinson sign (pigment extension onto the proximal nail fold).

Any suspicion of melanoma warrants immediate biopsy and dermatological evaluation.

Glomus Tumor

Glomus tumors are benign, but often painful, tumors arising from glomus bodies, which are specialized arteriovenous anastomoses involved in thermoregulation.

These tumors are typically located under the nail and can cause localized pain and tenderness.

While usually not as rapidly growing as a PG, a glomus tumor can sometimes present as a reddish or bluish nodule, mimicking its appearance.

Provocative maneuvers such as cold sensitivity testing, along with imaging, can aid in differentiating a glomus tumor.

Kaposi's Sarcoma

Kaposi's sarcoma, a vascular tumor associated with human herpesvirus 8 (HHV-8), can present as reddish-purple nodules on the skin and, less commonly, on the nail.

In immunocompromised individuals, especially those with HIV/AIDS, Kaposi's sarcoma should be considered in the differential diagnosis of a PG.

Typically, Kaposi's sarcoma lesions are slower growing, and other cutaneous lesions may be present elsewhere on the body.

Wart (Verruca)

Warts, caused by human papillomavirus (HPV), are common skin lesions that can occur around the nail.

While typically having a rough, cauliflower-like surface, a wart can sometimes present as a smooth nodule that may be mistaken for a PG.

Close examination may reveal thrombosed capillaries (black dots) within the wart, a feature not usually seen in PGs.

Foreign Body Granuloma

Trauma to the nail area can introduce foreign material, leading to an inflammatory reaction and the formation of a granuloma.

These granulomas can sometimes mimic the appearance of a PG.

A careful history and examination, looking for signs of previous trauma or embedded foreign bodies, are crucial.

The Decisive Role of Histopathology

In many cases, the clinical features alone are insufficient to definitively differentiate a PG from other conditions. In such instances, a biopsy followed by histopathological examination becomes essential.

Histopathology allows for the detailed microscopic analysis of the tissue, enabling the pathologist to identify characteristic features of a PG and rule out other potential diagnoses, including malignancy.

This step is paramount in ensuring accurate diagnosis and guiding appropriate treatment.

Treatment Strategies: Managing Toenail PG

Once a pyogenic granuloma (PG) on the toenail has been accurately diagnosed, the next critical step involves selecting the most appropriate treatment strategy.

A multifaceted approach is often necessary, taking into consideration the lesion's size, location, symptoms, and the patient's overall health.

This section will explore the range of available treatment options, from conservative measures to advanced surgical techniques, while also addressing pain management and the potential for secondary infections.

Conservative Management: A Prudent First Step

In some instances, particularly with small or early-stage lesions, a conservative approach may be sufficient.

This involves meticulous wound care, ensuring the affected area is kept clean and protected from further trauma.

Regular cleansing with mild soap and water, followed by the application of a sterile bandage, can help prevent secondary infection and promote natural healing.

However, conservative management alone is often not enough to resolve a PG, especially if it is well-established or causing significant symptoms.

Chemical Cauterization: Targeting Vascularity

Chemical cauterization involves the application of a chemical agent to the PG with the goal of reducing its vascularity and promoting tissue necrosis.

Silver nitrate is a commonly used agent for this purpose.

It works by cauterizing the blood vessels within the lesion, leading to its gradual shrinkage and eventual resolution.

The application of silver nitrate requires precision and should be performed by a qualified healthcare professional to avoid damage to the surrounding healthy tissue.

While relatively simple and non-invasive, chemical cauterization may require multiple treatments to achieve complete resolution.

Surgical Intervention: Definitive Removal

Surgical intervention offers a more definitive approach to managing toenail PGs, particularly in cases where conservative measures or chemical cauterization have failed.

Several surgical techniques can be employed, depending on the size and location of the lesion.

Excision and Curettage

Excision involves the complete surgical removal of the PG, typically with the use of a scalpel.

Curettage, on the other hand, involves scraping away the PG tissue with a specialized instrument called a curette.

Both techniques are often performed under local anesthesia and may require sutures to close the wound.

Nail Avulsion: Addressing Underlying Causes

In some cases, the PG may be associated with an underlying nail condition, such as an ingrown toenail (onychocryptosis) or chronic paronychia.

In such instances, nail avulsion, either partial or complete removal of the nail, may be necessary to access the PG and address the underlying cause.

This allows for more complete removal of the lesion and reduces the risk of recurrence.

Other Modalities: Advanced Techniques

In addition to the abovementioned approaches, other modalities, such as cryotherapy and laser therapy, can also be used to treat toenail PGs.

Cryotherapy

Cryotherapy involves freezing the lesion with liquid nitrogen, causing cell death and eventual sloughing off of the PG tissue.

This technique is relatively quick and can be performed in an outpatient setting.

Laser Therapy

Laser therapy utilizes focused beams of light to selectively destroy the blood vessels within the PG, leading to its shrinkage and resolution.

Different types of lasers can be used, depending on the specific characteristics of the lesion.

Pain Management: Ensuring Patient Comfort

Regardless of the treatment modality chosen, pain management is an important consideration.

A digital block, involving the injection of a local anesthetic near the base of the toe, can effectively numb the area and minimize discomfort during the procedure.

Post-operative pain can be managed with over-the-counter pain relievers or, in some cases, prescription analgesics.

Addressing Secondary Infections: A Proactive Approach

Secondary infections are a potential complication of toenail PGs, particularly if the lesion is ulcerated or bleeding.

A proactive approach to preventing and managing infections is crucial.

Topical antibiotics, such as mupirocin or bacitracin, can be applied to the affected area to prevent or treat localized infections.

In cases of more severe or systemic infections, oral antibiotics may be necessary.

The choice of antibiotic should be guided by culture and sensitivity testing, if possible, to ensure that the organism causing the infection is susceptible to the chosen medication.

Seeking Expert Advice: The Role of Medical Professionals in Toenail PG Care

The effective management of a pyogenic granuloma (PG) on the toenail often necessitates the involvement of qualified medical professionals.

While some cases may resolve with simple conservative measures, the expertise of a physician is crucial for accurate diagnosis, appropriate treatment selection, and the prevention of complications.

This section will detail the specific roles of general practitioners, dermatologists, and podiatrists in providing comprehensive care for patients with toenail PGs.

General Practitioners: The First Point of Contact

General practitioners (GPs) frequently serve as the initial point of contact for individuals experiencing toenail problems.

Their broad medical knowledge allows them to conduct an initial assessment of the lesion, evaluate the patient's overall health, and determine the necessity for specialized care.

The GP's role is crucial in differentiating a PG from other potential causes of similar symptoms, such as infections, tumors, or other dermatological conditions.

Furthermore, GPs can offer initial advice on basic wound care and pain management while arranging for referral to a specialist.

Prompt and appropriate referral is vital to ensure patients receive the most effective and targeted treatment for their specific condition.

Dermatologists: Skin Experts in PG Management

Dermatologists possess specialized expertise in the diagnosis and treatment of skin conditions, including pyogenic granulomas.

Their in-depth knowledge of skin pathology enables them to accurately diagnose PGs through clinical examination and, if necessary, biopsy.

Dermatologists are well-versed in a variety of treatment modalities, including chemical cauterization, cryotherapy, laser therapy, and surgical excision.

They can tailor the treatment plan to the individual patient's needs, considering the size, location, and characteristics of the PG, as well as the patient's overall health and preferences.

Dermatologists are particularly valuable in cases where the diagnosis is uncertain or when more advanced treatment options are required.

Podiatrists: Specialists in Foot and Toenail Health

Podiatrists specialize in the care of the foot and ankle, including conditions affecting the toenails.

Their expertise in biomechanics, nail pathology, and surgical techniques makes them uniquely qualified to manage toenail PGs, especially those associated with underlying foot or nail disorders.

Podiatrists can perform nail avulsion procedures to access the PG and address underlying causes, such as ingrown toenails or chronic paronychia.

They can also provide comprehensive foot care, including orthotics and shoe recommendations, to prevent recurrence and promote overall foot health.

Podiatrists play a critical role in managing PGs that are complicated by underlying foot or nail deformities.

Collaboration for Optimal Patient Outcomes

In some cases, a collaborative approach involving multiple medical professionals may be necessary to achieve optimal patient outcomes.

For example, a GP may refer a patient to a dermatologist for diagnosis and initial treatment, and then to a podiatrist for management of an associated ingrown toenail.

Effective communication and coordination among these specialists are essential to ensure that the patient receives comprehensive and well-integrated care.

By working together, medical professionals can provide patients with the best possible chance of resolving their toenail PG and preventing future complications.

Long-Term Management: Patient Education and Follow-Up for Toenail PG

Successful resolution of a pyogenic granuloma (PG) on the toenail extends beyond the initial treatment phase. Long-term management necessitates a proactive approach, emphasizing patient education and diligent follow-up care.

These measures are crucial to ensure sustained healing, minimize the risk of recurrence, and empower patients to actively participate in their recovery. This section will explore the key aspects of long-term PG management, highlighting the importance of adherence, recurrence awareness, and proper wound care.

The Cornerstone of Success: Adherence to Treatment Plans

Adherence to the prescribed treatment plan is paramount for achieving optimal outcomes in toenail PG management.

This involves diligently following all instructions provided by the healthcare provider, including medication regimens, wound care protocols, and activity modifications.

Failure to adhere to the treatment plan can impede healing, increase the risk of complications, and potentially lead to recurrence.

It is crucial for patients to understand the rationale behind each aspect of the treatment and to communicate any difficulties or concerns they may have to their healthcare provider.

Open communication fosters a collaborative environment and allows for adjustments to the treatment plan as needed to maximize adherence and effectiveness.

Addressing the Specter of Recurrence

One of the most significant challenges in managing toenail PGs is the potential for recurrence. While treatment may successfully eliminate the initial lesion, certain factors can predispose individuals to developing new PGs in the future.

These factors may include persistent trauma to the nail bed or surrounding tissue, underlying nail deformities, or systemic conditions that affect wound healing.

Patients must be educated about the risk factors for recurrence and strategies to minimize their exposure.

This may involve wearing properly fitting footwear to avoid pressure and friction on the toes, practicing meticulous foot hygiene to prevent infections, and addressing any underlying nail or foot problems promptly.

Regular self-examination of the toenails is also recommended to detect any early signs of recurrence.

Prompt identification and treatment of recurrent PGs can prevent them from becoming larger and more problematic.

Mastering Wound Care: A Pathway to Healing

Proper wound care is an essential component of long-term management following any treatment for a toenail PG, especially after surgical interventions like excision or nail avulsion.

Meticulous wound care promotes healing, reduces the risk of infection, and minimizes scarring.

Patients should be provided with clear and concise instructions on how to clean and dress the wound.

Generally, this involves gently cleansing the area with mild soap and water, applying a thin layer of antibiotic ointment, and covering the wound with a sterile bandage.

Dressings should be changed regularly, as directed by the healthcare provider, and the wound should be monitored for signs of infection, such as increased pain, redness, swelling, or pus.

Patients should also be advised to avoid activities that may traumatize the wound, such as wearing tight shoes or participating in high-impact sports, until it is fully healed.

Empowering Patients Through Education

Patient education is the linchpin of effective long-term management for toenail PG. Empowering patients with knowledge about their condition, treatment options, and self-care strategies promotes active participation and improves outcomes.

Educational materials should be tailored to the individual patient's needs and literacy level, and should cover topics such as:

• The nature of pyogenic granulomas and their causes.
• The importance of adherence to treatment plans.
• Risk factors for recurrence and strategies for prevention.
• Proper wound care techniques.
• Signs and symptoms of infection.
• The importance of regular follow-up appointments.

Providing patients with a comprehensive understanding of their condition enables them to make informed decisions about their care and to take proactive steps to maintain their toenail health.

The Value of Follow-Up Appointments

Regular follow-up appointments with a healthcare provider are crucial for monitoring healing, detecting recurrence, and addressing any complications that may arise.

The frequency of follow-up appointments will vary depending on the individual patient's needs and the nature of the treatment they received.

During follow-up appointments, the healthcare provider will examine the treated area, assess the patient's progress, and address any concerns they may have.

These appointments also provide an opportunity to reinforce patient education and to ensure that they are adhering to the treatment plan.

In some cases, additional treatment may be necessary to address persistent symptoms or recurrence.

Consistent follow-up care allows for early intervention and helps to ensure that patients achieve the best possible long-term outcomes.

Dealing with a pyogenic granuloma on your toenail can be a bit of a nuisance, but remember, it's usually treatable. Don't hesitate to reach out to your doctor or a dermatologist if you suspect you have one, and they'll help you get it sorted out so you can get back to feeling your best – and showing off those toes!