Some things should not wait for the next free routine appointment. Some things should not wait for the next free routine appointment. Telephone the practice and say what is happening, or go to an emergency room, if you have a mole or a mark that has changed shape, colour or size, that has become raised or uneven, or that bleeds, itches or will not heal; a sore anywhere that has not healed in three weeks; a rash that is spreading quickly, especially with fever, blistering, or peeling skin; a painful rash in a band on one side of the body, particularly near an eye; redness that is hot, swollen, tender and spreading, which can be a deep skin infection; a new rash after starting a medicine, especially with mouth or eye involvement; or a child under three months with any widespread rash. If you have been treated here and something is worse rather than better after a procedure, telephone us rather than waiting for the review appointment. We would far rather field a call that turns out to be nothing.
Nails change slowly and they record what has happened to them, which makes them genuinely informative and genuinely slow to treat. A fingernail takes about six months to grow out completely and a toenail twelve to eighteen, so any treatment is judged over that timescale rather than in weeks — a point worth establishing before starting, because the commonest reason people abandon nail treatment is that nothing appeared to happen in month three.
The most useful thing this practice does for nails is refuse to assume. Roughly half of the thickened, discoloured toenails sent for testing turn out not to be fungal, and the alternatives — psoriasis of the nail, repeated trauma from footwear or sport, lichen planus, eczema around the nail fold — need entirely different treatment. Oral antifungal medication means several months of tablets and blood tests to monitor the liver, which is a real undertaking to go through for a nail that was never infected.
There is also one nail finding that is not a cosmetic matter at all: a dark band running lengthways down a single nail, particularly if it is widening, has irregular edges, or the pigment extends onto the skin at the base of the nail. That warrants prompt examination, because melanoma can arise in the nail unit and it is one of the sites where diagnosis is most often late — especially on darker skin, where it is proportionally more common.
What a changed nail usually turns out to be
Descriptions to bring you in, not to let you conclude anything.
Fungal infection
Usually starting at the outer edge and working inward, with yellow-brown discolouration, thickening and crumbling debris beneath. Frequently accompanied by scaling between the toes or on the soles, which is worth treating at the same time or the nail simply gets reinfected.
Nail psoriasis
Pitting like the surface of a thimble, oil-drop patches of discolouration, thickening, crumbling and lifting of the nail from its bed. Extremely commonly mistaken for fungus and treated as such for years. Nail involvement is also associated with a higher chance of psoriatic joint disease, so it is worth naming correctly.
Repeated trauma
From running, from footwear that is a half-size short, or from a single injury. Produces thickening, discolouration and sometimes complete lifting. Common in runners and dancers and easily mistaken for infection.
Lifting of the nail from its bed
Has many causes — trauma, moisture, chemicals, psoriasis, thyroid disease, some medicines. The gap under the nail then commonly colonises with bacteria or yeast, which produces a green or black discolouration that alarms people considerably and is not dangerous.
Chronic inflammation of the nail fold
Swollen, tender skin around the nail, loss of the cuticle, and ridged distorted nails, usually in people whose hands are wet repeatedly — carers, cleaners, cooks, bartenders, hairdressers. Managed chiefly by keeping the hands dry and protected, plus treating the inflammation.
Melanoma of the nail unit
Uncommon, and the reason a single dark lengthways band is examined rather than watched. The features that raise concern are a single nail rather than several, a band that is widening, irregular in colour or edge, and pigment spreading onto the surrounding skin.
Treatment, and the honest timescales
Nothing here is fast, and being told so at the start is what allows people to complete it.
Confirm it first
Clippings and subungual debris are examined and cultured. It takes a couple of weeks for a result and it prevents months of unnecessary treatment. We will not prescribe oral antifungals on appearance alone.
Topical antifungal lacquers
Applied daily for up to a year. They avoid the systemic risks entirely, they are inexpensive, and their success rate for an established toenail infection is modest — best where the infection is limited to the outer part of one or two nails.
Oral antifungal treatment
Considerably more effective, taken for several months, and requiring blood tests to monitor liver function and a check for interactions with your other medicines. Even after successful treatment the nail looks abnormal until it has grown out, which takes twelve to eighteen months for a toenail.
Treating nail psoriasis
Different entirely: topical treatment applied to the nail fold, steroid injection into the nail fold for stubborn cases, and systemic treatment where the skin or joints also warrant it. Improvement here is measured in many months.
Sorting out the footwear and the feet
For fungal nails, treating athlete's foot at the same time, drying between the toes, rotating shoes, and replacing the ones that have been worn throughout the infection. Reinfection is common and this is where it comes from.
Deciding not to treat, which is sometimes right
A single mildly thickened toenail in somebody healthy, causing no discomfort, does not have to be treated with months of tablets. If you would rather leave it, that is a reasonable choice and we will say so — as long as we know what it is.
Nail Disorders in western Queens
Thickened, discoloured, crumbling or lifting nails. About half of what is assumed to be fungus is not, which is why nails are sampled here before treatment rather than after months of it.
Every appointment here starts the same way: a proper history, an examination in good light, and a named diagnosis said out loud and written down for you to take home. If there is genuine doubt you will be told that, and told what would settle it — usually a biopsy. You leave with a plan that has a strength, a site, a frequency and a date to stop or come back on it, and, where the condition is one that relapses, what to do on the first day of the next flare. If the honest answer is that this is better left alone, or that it belongs somewhere other than here, that is what you get instead, and it costs exactly the same.
This page is not medical advice, and it is not a diagnosis. Nothing on this website is medical advice for you in particular, and it is not a diagnosis. These pages describe conditions in general terms so that you arrive knowing what the questions are — they cannot tell you which condition you have, because that requires somebody to look at your skin, feel it, ask you a hundred questions and frequently take a sample of it. Two conditions on this website can look identical in a photograph and need opposite treatments. If something on your skin is new, changing, painful or not healing, the useful next step is an appointment rather than more reading.
No before-and-after photographs, and no promised outcome. There are no before-and-after photographs on this website and there never will be. Every set you have seen somewhere else was chosen from a much larger pile, and the second picture is usually taken in different light, at a different angle, at a different point in a flare cycle. In dermatology the dishonesty is sharper than in most fields, because nearly every condition here fluctuates on its own — photograph any relapsing skin disease at its worst and again at its best and you have a persuasive pair of images that demonstrates nothing about the treatment in between. What we publish instead is what a treatment typically achieves, in how long, in what proportion of people, and how often it does not work.
The risks, plainly. Every treatment described here has side effects, and some carry real risks. Topical steroids thin skin if they are used at the wrong strength on the wrong site for too long, which is why they are prescribed with a site, a strength and a stopping point rather than handed over indefinitely. Light-based and laser treatment can burn, blister and cause pigment change that lasts months, and that risk is higher on deeper skin tones and on recently tanned skin. Any procedure that breaks the skin can bleed, become infected and leave a scar; on the chest, the shoulders and the jawline, scars are more likely to thicken. Several of the medicines used in this speciality require blood tests, and some cannot be taken during pregnancy. We tell you your own risk rather than the average one, and where the honest answer is that a condition is better left alone, that is the advice you will get.
Nothing is diagnosed from a photograph. We do not diagnose skin from photographs, and we do not answer "what is this?" by email, by message or through a form. This is not caution for its own sake. A photograph has no history attached to it, cannot be felt, cannot be stretched or pressed to see whether the colour blanches, cannot be examined under a dermatoscope, and misreports colour badly — which matters enormously on skin that is not pale. The examination that actually distinguishes a harmless growth from an early cancer involves magnification, cross-polarised light and, when there is any doubt at all, a biopsy. An application that offers to tell you whether a mole is dangerous from a picture taken on a telephone is selling reassurance, and reassurance is the one product in this field that is dangerous when it is wrong. Bring the mark to a room where somebody can look at it.
Questions
Nail Disorders — the questions we are asked most
Why do you need to test my nail? It obviously looks fungal.
Because roughly half of thickened discoloured toenails turn out not to be. Psoriasis, repeated trauma from footwear or sport, and inflammation around the nail fold all look similar and none responds to antifungals. Since oral treatment means several months of tablets and blood tests, testing first is a fortnight well spent.
How long does treatment take to work?
The medicine works faster than the nail grows, and what you see is the nail. A fingernail replaces itself in about six months and a toenail in twelve to eighteen, so even entirely successful treatment leaves an abnormal-looking nail for a year. Knowing that in advance is what allows people to finish the course.
Are the oral antifungal tablets dangerous?
They are generally well tolerated with monitoring. They can affect liver function, which is why blood tests are done, and they interact with a number of common medicines, which is why we go through your full list. For most healthy people the risk is small and manageable — but it is a real medicine and it is not worth taking for a nail that was never infected.
I have a dark line down one nail. Is that serious?
It needs examining rather than watching. Several dark bands across several nails is common and usually normal pigmentation, particularly on deeper skin tones. A single band, especially one that is widening, irregular in colour or edge, or where the pigment extends onto the skin at the base of the nail, is the pattern that warrants prompt assessment.
Can I wear nail polish over it?
Between appointments, yes, and it makes no difference to the outcome. Please remove it before an appointment about nails, and before any full skin examination — polish hides exactly the changes the examination is looking for.
Will it come back after treatment?
Fungal nail infection recurs in a substantial minority, usually because the athlete's foot was not treated alongside it or because the shoes worn throughout the infection were kept. Treating the feet as well as the nails, drying between the toes and rotating footwear meaningfully reduces that.
Related
Often seen alongside this
Hair, Nails & Sweat
Hair Loss
Around twenty different causes that look similar to a patient and quite different under magnification. The question that governs everything is whether the scalp is scarred, because scarring is permanent and the window to prevent it is while the condition is still active.
Read more
Hair, Nails & Sweat
Fungal Skin Infections
Ringworm, athlete's foot, jock itch and yeast infections in the folds. Straightforward to treat once correctly identified — and routinely made much worse by a steroid cream applied in good faith.
Read more
Hair, Nails & Sweat
Excessive Sweating
Sweating far beyond what temperature requires, enough to change what you wear and what you avoid. It is a recognised medical condition with a ladder of treatments, and it is not a sign of poor hygiene or nervousness.
Read moreA named diagnosis and a written plan you leave holding
Book an appointment
Pick a physician and a time from the calendar — it shows only the hours each of them genuinely has free. A new patient appointment is thirty minutes, a full skin examination forty-five, and you leave with a named diagnosis written down. If something on your skin has changed, telephone instead and say that word: it is triaged differently.