Question
Dr. Katz,

First, thank you so much for taking the time to look at this.  I have a very long story of explanation...

I am a healthy, early twenties female, and nearly three years ago (May 2006) I was in a moderate car accident, but thankfully experienced no major injuries (that I was aware of at the time). Several weeks later, I removed the toenail polish that I had been wearing since before the accident.  I noticed that my big toenail on my right foot was slightly discolored, a pale yellow, but I attributed that to the fact that I'd been wearing red nail polish for quite a while and assumed that I just hadn't been able to get it all off or that it had slightly stained the nail.  I repainted my nails and forgot about it.  A month or so later, I again removed my nail polish and noticed that the same nail was even darker, splotchy yellow, white and blue-grey.  

I went to the podiatrist in either November or December 2006.  He said that my car accident (I was wearing close-toed shoes and don't recall any unusual pain, but I did slam the front of my foot against the inside of my car) may have weakened my immune system and made me vulnerable to a fungal infection.  I began taking terbinafine for the infection.  I took the medicine for five months and my toenail cleared up, so I stopped taking the medication (I was supposed to take it for a full six months).  

Three to four months later, I noticed the infection returning.  I went back to the podiatrist, he prescribed terbinafine again, and I began taking the medication in the fall of 2007.  This time, I took it for a full six months (approximately), and my toenail once again cleared up.  I thought I was officially cured.  

During the summer of 2008, I noticed a white spot on the same toenail, but no other sign of a return of the infection.  I thought I'd just damaged the nail by dropping something on it and planned to wait for the spot to grow out before I drew any other conclusions.  

During the next few months, my toenail became pale yellow and white (no dark colors this time).  I decided to see a different podiatrist to get a second opinion.  I explained the history of my toenail to him, beginning with the car accident and continuing through the two treatments of terbinafine.  He said that had he not heard the whole story, he would have immediately said it was a fungal infection and prescribed terbinafine.  However, given the context, he said that it may not be a fungal infection; instead, it could be a result of trauma to my toenail.  He said that, even though it seemed to be a temporary fix, I shouldn't take any more terbinafine because of it's risks-- especially considering how much I've taken.  His advice was not to do anything.  He said that I should just wait and see whether a healthy nail would grow out or not.  That was just a few months ago, in December 2008.  

At present, the nail is only attached to my big toe at the base and is clear, yellow, and white.  It is slightly bowed outward and a darker yellow/white at one side of the nail, clear (but detached) in the middle, and opaque white in all other areas.  The front of the nail, (toward the tip of my toe)is slightly slanted downwards, very close to the skin on my foot (last summer, when my nail was "healthy," this same front part was growing downward so much that it was headed into the skin of my toe--I used a little metal file to separate the two).  Also, as of last month, there was white debris under the nail.  I scraped it out using a metal file (the kind attached to nail clippers).  It hasn't returned since then and I've been applying a topical treatment under the nail by lifting it gently and squeezing the topical between the nail and the skin.  

The pressure of my shoes (normal, well-fitting shoes) on the top of my toe when I walk (not all of the time, some periods are worse than others) is extremely painful and if I even lightly tap the front of the nail on my shoes as I'm walking or on the stairs or if any number of normal, everyday toenail "bumps" occur they are extremely and unusually painful.  Because this symptom makes even the most minor toe bump very painful, I wonder if the nail is in a cycle of trauma.  Perhaps (if the second doctor is right and it's not fungus, it's trauma) the nail's sensitivity causes it so much trauma that it can't heal...but does the debris make sense if it's trauma?

Additionally, the skin just below the nail (the matrix or eponychium?) is dark and slightly inflamed (it has been this was since my very first podiatrist visit fall/winter 2006).  

Since December's podiatrist visit, the nail is beginning to grow out and I can see what looks like the tip of a lunular just above the cuticle.  Despite this, I can't tell whether the little part of my toenail that is growing out is clear.

This continual problem has been embarrassing and frustrating for me.  In addition to terbinafine, I've applied topicals, tea tree oil, vinegar, vicks vapor rub...nearly every manor of nontraditional treatment I can find.

I am terrified of the thought that I may never have a healthy toenail again.  My concern, aside from the pain in the nail, is primarily superficial--I want to be able to wear open-toed shoes comfortably again--but it is nonetheless a valid problem.  

Do you have any idea what's going on with my nail?  Should I continue heeding the most recent podiatrist's advice and not do anything?  Could the recurrence be a sign of another issue?  Is it fungus or trauma?

If you have any thoughts about this, any suggestions or advice I would very, very much appreciate them!  Again, thank you so much for taking the time to read my saga.  

Sincerely,
Rachel  

Answer
Hi Rachel,

Did anyone take a sample of your nail for evaluation and culture by a pathologist?  If not that is the most important first step so there is no guessing.  I would not take more Lamisil.  Typically 3 months is adequate.  You've already taken too much, hopefully you had your liver enzymes tested during treatment.

You have damage to the nail and even if there is/was a fungal infection your nail may be damaged permanently.  You should give it time and let it grow all the way out without nail polish or any other chemicals.  You may be stuck with the nail.  Some podiatrists would consider removal of the nail to see if it would grow back normally.

Also, putting all of these chemicals causes irritation of the nail bed and skin so I would discontinue these irritants.

Sincerely,

Marc Katz, DPM
Tampa, FL
Advanced Podiatry
www.thetampapodiatrist.com
www.tampacryosurgery.com

DISCLAIMER:
This information is offered as free advice and as general information. It may not be applicable to the specific questioner and his/her problem.  It is not based on actual knowledge of the questioner or his/her medical history and it cannot and should not be relied upon as definitive medical opinion or advice.  Reliable medical opinion and advice can only be obtained through hands-on physical contact and exam of the patient to establish an accurate diagnosis and treatment plan.  No doctor/patient relationship is created or established here and may not be inferred through answers on this site.  The questioner and other readers must consult his/her own doctor before proceeding or implementing any suggestions contained within this document and answers on this site.  The questioner is only to act upon his/her own doctor抯 orders and recommendations. By reading this posting which follows, the reader fully understands and confirms that he/she holds harmless this writer. If this is not fully agreeable to you, the reader, and/or you have not attained the age of 18 years, you hereby are advised to read no further.