Thickened, ugly nails are common – up to 10% of the population have infected toenails – but can be very upsetting. Fortunately, there are now some fairly effective treatments available that can help even if you have had the problem for years.
Causes of thickened toenails
How a fungal infection occurs
- the end of the nail has been damaged (for example, by ill-fitting shoes) and is already slightly separated from its toe
- you are taking long-term tetracycline medication and then expose your toenails to sunlight – this is called photo-onycholysis
- you have a condition such as diabetes or an immune deficiency
- you are elderly
- the fungus is already multiplying between the toes (athlete’s foot).
The fungus very gradually spreads towards the base of the nail and down the sides, loosening the nail from the underlying toe and filling the separated area with crumbly, yellowish-white gunk. The nail itself becomes thicker and yellowish brown in colour. This can take months or years.
What you can do
Try amorolfine (Curanail; Loceryl), an antifungal nail paint that you can buy from pharmacies. It is usually applied once or twice a week after filing and cleaning the nails. Treatment should continue until the infection has cleared, which can take about 6 months for fingernails and up to 12 months for toenails. See ‘What your doctor can do’ below for further general information on nail paints.
- There have been concerns about the safety of tea tree oil, especially if undiluted.
- The EU’s Scientific Committee on Consumer Products says the undiluted oil is a ‘severe irritant’ to the skin. And the risky chemicals become even stronger if the oil is stored at room temperature and exposed to light and air. Some experts advise using a concentration of only 1%.
- Another study warns that using very dilute tea tree oil (perhaps less than 4%) can make skin bacteria resistant to antibiotics – ‘superbugs’ (Journal of Antimicrobial Chemotherapy 2007;59:125–7).
Care for your feet sensibly by following these rules.
- Give your feet plenty of air, because warmth and sweat encourage the fungi; so follow the advice given for sweaty feet. When you are at home, go barefoot whenever possible, and if you don’t want to expose your toenails search for some strappy sandals that cover the toes.
- Choose shoes that give your toes plenty of room. As well as making sure your shoes are long enough, so your toes are not touching the end, check there is plenty of depth in the toe area. You don’t want shoes that compress your toenails. Hold the shoes up and look at them sideways, and when you are trying them on wiggle your toes upwards to check there is room.
- Dry your feet very thoroughly after washing, using a tissue to dab underneath the end of the nail to make it as dry as possible.
- It is tempting to use nail varnish to disguise the nail, but nails need to breathe so use it for short periods only, removing it as soon as possible.
How a chiropodist can help
What your doctor can do
- 28% tioconazole, which is applied twice a day for 6 months.
- Ciclopirox, which is used in the USA but is not available in the UK.
It is important to use nail paints continually because if you stop, even for a short period, the new nail that has grown will become infected by the fungus, and you will be back to square one. Antifungal paints are not suitable if you are pregnant. Success rates are not very high – possibly 40% for amorolfine, about 22% for tioconazole and about 12% for ciclopirox. Although inconvenient, they do have an important plus point; you apply the drug only to the part of the body where it is needed, rather than taking a tablet that could have side effects.
- Itraconazole is taken twice daily for a week, followed by a 3-week medication-free period. The treatment saturates the nail, and continues to work in the medication-free period. This treatment cycle is repeated two more times.
- Terbinafine is taken every day for about 3 months, or in a higher dose for 1 week each month for 3 months. The continuous treatment is probably more effective (Journal of the American Academy of Dermatology 2005;53:578–84).
Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Last updated: Wednesday, May 1st 2013
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Nails are made of keratin, the same protein as horses' hooves
It takes 12-18 months for a toenail to grow from root to tip
If you are right-handed, the nails on your right hand grow faster than on your left, but toenails grow at the same rate on each foot
Nails grow faster in summer than winter
Toenail problems have strange medical words. Onychogryphosis (on-ee-co-gry-foe-sis) is the thickened, hard toenails that old people often have: onychomycosis (on-ee-co-my-co-sis) means fungal nail infection
In the UK, the NHS spends more than £15 million a year on treatments for fungal nail infection
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