Toenail infection

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 from your doctor that can help even if you have had the problem for years.

Causes of thickened toenails

Physical damage to your toenail may cause it to be thick until the damaged area grows out. This is why thickening of the big toenails is common in young men, particularly football players. Old people also often have thickened, hard toenails, probably because of the damage they have sustained over the years, and because their nails grow more slowly, it takes longer to repair the damage.

Fungal infection can make your nails thick. The commonest infection is with Trichophyton rubrum, the same fungus that causes athlete’s foot. Occasionally, other types of fungus, such as yeasts, are responsible, and people who have been abroad may have some quite exotic fungi.

Psoriasis, a skin condition, can make nails thick, with tiny pits on their surface.

How a fungal infection occurs

It is easy to pick up fungi – they are particularly common on the floors of communal showers and changing rooms – and many of us probably already have fungi on our skin. They cause problems only when conditions are ripe for them to thrive, which means warmth and moisture. When human beings started wearing enclosed shoes, which trap sweat and heat, we created ideal conditions for fungi. This why only 1% of people in Zaire, Africa, have fungal toenails compared with 10% of people in the UK. It is not surprising that fungal toenail infections (and also athlete’s foot) are five times as common in people who have to wear work boots for long periods in wet conditions.

The fungi shelter under the tip of the nail and start to get a hold. This is particularly likely to happen if:

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.

Sometimes the infection starts at the base of the nail, giving a whitish area near the half moon, or it may just affect the surface of the middle of the nail, where it will appear as a white patch.

What you can do

Be patient. For any treatment to be successful, one of the most important elements is patience. You will have to use the treatment for at least 3 months, and some treatments take even longer to work. Nails grow from the base to the tip, as anyone who has used nail varnish knows. Because it can take 18 months for a nail to be replaced completely by a new one, it may be a long time before you see a result.

Try benzalkonium chloride (ClearZalBac), which you can buy from pharmacies. It is applied twice daily for 2–4 months for fingernails or 4–8 months for toenails. It is an antiseptic that kills some bacteria and fungi.

Try tea tree oil. The antifungal treatments that you can buy from the chemist, designed for thrush or for athlete’s foot, do not penetrate nails and are not worth trying. However, if you really do not want to go to your doctor, you could try tea tree oil, which is available from health shops and chemists. It has some natural antifungal properties and one study found that it improved or cured 60% of cases of toenail infection. Apply it generously twice a day with a cotton-wool bud, wiping it under the tip of the nail and on the surrounding skin. Because it is an oil, it may discolour leather shoes. At night, soak a small piece of cotton wool with the oil, and tape it to the end of your toe.

Is tea tree oil safe?

Recently, 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.
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.

Treat athlete’s foot promptly. If you ever develop athlete’s foot in the future, treat it so it does not spread to the nails.

How a chiropodist can help

For any problem with your feet, particularly the toenails, it is well worth seeing a state-registered chiropodist – in the UK, a qualified chiropodist will be registered with the Health Professions Council (see useful contacts). The chiropodist will be able to advise you on foot care, and will be able to tell you if your thickened toenail is likely to be a fungal infection or due to some other cause. The chiropodist can also thin down the thickened nail so that other treatments such as paints or tablets will be more effective. Chiropodists cannot prescribe antifungal tablets or the most effective antifungal paints – you will have to see your family doctor for these.

How your doctor can help

There are now some quite effective treatments for fungal nail infections. The downside is that they have to be taken for a long time, can have side effects and do not work for all types of fungi. So before starting treatment, your doctor will usually take a sample by scraping under the nail (this may be slightly uncomfortable but not painful) and sending it to the laboratory to identify your particular fungus. It can take over 3 weeks for the laboratory to grow and identify the fungus.

Antifungal nail paints. If only the end of the nail is affected, and the nail is not too thick, and the cause is a Trichophyton fungus, your doctor may prescribe a nail paint. There are various types of nail paint.

28% tioconazole is applied twice a day for 6 months.
Amorolfine is applied once a week for 9–12 months.
Ciclopirox is used in the USA, but is not available in the UK.

You need a doctor’s prescription for these nail paints – you cannot buy them over the counter. They are inconvenient and it is important to use them continually because if you stop, even for a short period, the new nail that has grown will become infected by the fungus, and you are back to square one. These antifungal paints are not suitable if you are pregnant. Success rates are not very high – about 22% for tioconazole, possibly 40% for amorolfine and about 12% for ciclopirox. However, 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.

Medications that you swallow. Your doctor may prescribe terbinafine, fluconazole or itraconazole for certain types of suitable fungus shown on the laboratory test.

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 Dermatology 2005;53:578–84).
Fluconazole is taken once a week until the abnormal nail has grown out (6–9 months for fingernails and 9–12 months for toenails).

The treatment does not have an immediate effect. The drug stays in the nail and continues to act for long afterwards, and the result shows when the new, healthy nail grows.

Experts are arguing about how effective these drugs are. Some claim that they have an 80–95% likelihood of cure, but the true figure may be lower – probably about 25–40% for itraconazole and 35–50% for terbinafine (Archives of Dermatology 1998;134:1551–4).

Like any drug, these medications can have unwanted side effects. There have been rare cases of severe reactions, and each of these drugs can affect the liver. You should not take itraconazole if you are taking erythromycin (an antibiotic), or if you are taking calcium-channel blocking drugs (for angina or blood pressure). Also, itraconazole may weaken the force of the heart’s contractions, so you should not take it if you have a heart problem (see Useful contacts).

Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Last updated: Thursday, March 25th 2010

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Comments on this article

Posted by Optional on 14/07/2010 at 01:41:33 pm

if ur toenail is black then it may fall off in a while

Posted by Optional on 14/07/2010 at 01:38:28 pm

when i cut my toenails it hurts because of this whitehead thing is in the way

Posted by Optional on 26/06/2010 at 03:23:58 am

my big toe nail is lifting up from my toe and is discoloured any suggestions

Posted by angelina on 16/06/2010 at 11:51:40 pm

well on my both big toe nails a big patch has apeared on the corners. it is white and brownish what cuold the problem be?

Posted by razzaefc on 16/06/2010 at 10:18:49 am

i have a nail infection,or so my doctor told me,a chiropodist told me it was just a thick nail,my doctor gave me PYTEX PAINT,and told me it does work, i hope so.as i go traveling in october and want it to be gone,has anyone use it before

Posted by Optional on 26/05/2010 at 08:35:17 pm

Large Toenails thickening - I have hepatic encellopaophy

Posted by Optional on 22/05/2010 at 03:27:01 pm

Hello. I have had problems with my two big toe nails for years now, but I find it too embarrassing to go to the doctors about. I have scoured the internet and found that the problem most resembles "Distal Subungual Onychomycosis" from photographs I have seen. The nails are thick, have yellow/white build up around the edges and are sort of curved. They are brittle and uneven and just generally not pleasant. Can you offer any advice please? I was wondering if I should use Curanail, or ClearZal Bac? I can't bear to go to the doctors but would really like to be able to wear sandals again and my nails are very noticeable as they are so thick, please help!! :)

Posted by Optional on 22/05/2010 at 08:31:47 am

Try using distilled malt vinegar

Posted by Deni on 21/05/2010 at 10:20:24 am

It seems to have alot of treatments.Mine was treated with Cicropirox and did not help at all. Now I have this fungus for 1 year and is getting worst.

Posted by Optional on 14/05/2010 at 04:05:29 am

Hi I have a problem with my big toe nail it is thick and blue underneath looks awful but not painful at all and I did not knowck it - what is this ? a fungus ? must I go and see a doctor ?

Posted by Anonymous on 27/04/2010 at 11:15:21 pm

toenail is thick with white under toenail hard to cut and very deep the infection

Posted by Optional on 10/04/2010 at 10:46:48 am

Both my feet are badly infected. It started with my feet, hard skin, foot infection then my toes, but as I always wear varnish and instead of taking it off I used to always apply it and thus for this reason never so the extent of the infection. Only two of my toes are ok, the rest look really white and the ends are flaky. One of my toes has now gone thick (the way it grows. I never show my feet to anyone and its horribly embarrassing. I have plucked up the courage to go to the doctors. I'm just worried that I will end up with amputation?

Posted by Jose on 05/04/2010 at 11:52:22 pm

I liked the consise and very informative, easy read and organized website.Top site in my book,will use again and again.

Posted by bfore on 05/04/2010 at 09:07:57 pm

My problem is bruised toenails two middle toes on my left foot. Have had this problem for about two years or more don't remember bumping it.They are really black nails. They don't hurt nor will they fall off. Is there anyway I can turn them natural again?

Posted by Optional on 13/03/2010 at 12:13:39 am

Soak your feet in Listerine. It takes a half dozen soaks about 2 weeks apart but it DOES work.

Posted by kimberly on 10/03/2010 at 09:04:49 am

Have had this problem since I can remember, but have been too embarrassed to talk to anyone about it. I just try to hide it, but I really want to get rid if it. So I am risking not wearing an artificial nail or polish for a while. I am using wart freeze treatment wich I heard works miracles together with vinegar wash and tea tree oil. See wat happens

Posted by Lisa on 16/01/2010 at 03:07:00 pm

After years of nail painting, both my husband and I have found a solution - good old Vicks vapourub! It works a treat - we only tried it because I kept reading on the internet how well it works on toenail fungal infections. Apply it everyday to the affected area and we both saw an improvement after few weeks! In fact 3 months on and the nails on our feet are totally clear!

Posted by Anonymous on 20/10/2009 at 12:01:00 pm

my two small toes on each foot are brown and always grown darjer than my other toenails. I imagine its from all the bad fitting shoes I sued to wear when I was younger. does anyone have a suggestion how to bring these toes back to the same colour as the others.

Posted by MalcH on 15/09/2009 at 01:28:00 pm

After several years of using expensive commercial treatments and home remedies without any real success I noticed after swimming in a salt water pool for several days while on holiday the nail appeared to improve. Once home I made up a strong solution of salty water and poured this on and under the nail and applied this three times per day - after 2 weeks there was a noticable improvement and after 4 weeks the infection has disappeared and the original damage to the nail is now disappearing as the nail grows.

Posted by joanne on 30/07/2009 at 12:03:00 pm

i have a fungal infection on my big toe which now has spread to my other toes on the same foot. the nails grow but become hard with a build up of white flaky tissue behind which if removes crumbles away. what can you prescribe for me

Posted by Anonymous on 07/07/2009 at 09:15:00 am

have had fungal nails for years,interestingly not had athletes foot for sometime.FOR ME ;Tea-tree oil did not work;topical nail lacquer(loceryl)used for year didnot work;both Terbinafine and the PULSE treatment worked ok,but eat yogurt with these as they also depleat good bacteria so thrush can take a hold

Posted by Daniel on 23/04/2009 at 09:03:00 pm

I was Completely oblivious to my infection, I was to busy doing things I have always worn socks at home. But now I have to keep them free mmmm well that sucks sometimes technology advances are'nt really hellping anyone.

Posted by Anonymous on 14/04/2009 at 06:11:00 pm

larfe toenail became infected and now the has raised itself about a quarter of and inch causing it to be uncomfortable wearing a shoe . nail is very hard

Posted by Dr Fred Connor on 13/03/2009 at 01:00:00 pm

I came across Curanail a year ago while I was on a training course. I used to write scripts for Loceryl (a fungal nail infection treatment) but realised that there is an over-the-counter version of it, called Curanail. The product is perfect, treats the fungal nail infection quite well by penetrating the nail. It's much beter than cheap cosmetic alternatives.

Posted by kelley on 11/03/2009 at 03:48:00 pm

i have discolouring and i also have bloodblister's under my 2 big toe nail's and i'v started useing clear-zac! so i was wondering if you no of any thing els that could help? also my mum has discolouring toe nail's and they are getting thicker and pushing her toe nail up away from the skin? she is in a lot of plan soo please help!

Posted by Mariyn on 09/03/2009 at 05:02:00 pm

I have a lot of discolour on all my toe nails on the right foot and can see tiny discolour coming on left toe nails have bought PHYTEX paint and am going to use it twice a day to see what happens i dont really want to use any thing else at the moment keep you posted

Posted by Anonymous on 01/03/2009 at 04:35:00 pm

Both of my big toe toenails bruised from boots. Both nails partially lifted and I cut them off. Will the rest come off and will the nail smooth up again?

Posted by Anonymous on 27/01/2009 at 11:57:00 am

I have a problem only on my one big toe. Its badly discoloured and looks almost as if it has red fibrous veins running through it. Nail also splits and is very bumpy and seems to have holes underneath. Please help!!!!!!!!!

Posted by Jassmin on 24/01/2009 at 01:23:00 am

what abt blackening if toenails??? my mum is recently having a blackened toenails,which is embarassing and makin it hard 4 her to wear open shoewear.nd her dr. prescribed her some toe paints but it's useless..so dr.phill plzz tell me wat she can do abt it?? can it be permanent?