Onycholysis: why a nail lifts from the nail bed, treatment and regrowth

Treatment depends on the cause. DermNet’s general measures are to clip the affected portion and keep the nails short with frequent trimming, minimise activities that traumatise the nail and nail bed, and avoid irritants such as nail enamel, enamel remover, solvents and detergents. It suggests wearing gloves, including light cotton gloves under vinyl gloves for wet work, taping the nail to the finger, and using antimicrobial soaks such as dilute vinegar to reduce the risk of secondary infection.

The NHS’s general nail care advice is consistent: wear rubber gloves if your hands are often in water, clean nails with a soft nailbrush, apply hand cream, trim regularly and cut injured, loose nails back to where they are still attached so they do not bend or catch. Do not clean under nails with sharp objects, bite or pick them, or ignore fungal infections on your skin.

Specific treatment may mean stopping or changing a medicine (only after speaking to the prescriber), treating a nail infection, or managing an associated skin or systemic condition.

The nail plate is the hard part of the nail you can see. It normally sits firmly on the nail bed beneath. In onycholysis the plate lifts away, usually starting at the free edge, and air under the lifted part makes it look white and opaque rather than pink. DermNet explains that the border between the pink attached nail and the white lifted nail is typically sharp and irregular.

One nail or several can be affected, on the fingers or toes. It can affect all ages, though DermNet notes it is most frequently seen in adult women. It is usually painless, but can be painful if it comes on suddenly or is inflamed.

The nail surface itself may look normal, or may be pitted, indented or crumbly depending on the underlying cause. Thickened skin can build up under the detached nail.

The NHS says most nail problems are caused by injuries or biting your nails, staining, not trimming regularly or cutting at an angle, hands often being in water or cleaning products, and fungal nail infection. It also says nails can become loose and eventually fall off after an injury. DermNet gives a longer list of possible causes of onycholysis specifically, shown in the table below.

Not necessarily, but a fungal infection is one possible cause. The NHS says a fungal nail infection usually affects toenails, starts at the edge of the nail and can spread to all of it, making it thicker and turning it white or yellow. It says the nail may become brittle and crumbly and the whole nail can sometimes lift off. Onycholysis from injury or wet work does not need antifungal treatment, which is why finding the cause matters.

If a fungal infection is suspected, the NHS says a pharmacist can suggest an antifungal nail medicine to brush onto the nail, used daily or weekly for 6 to 12 months, and that a GP can prescribe antifungal tablets if pharmacy treatments have not worked, after possibly taking a sample of the nail. The NHS says to see a GP if the infection is severe and treatment has not worked, has spread to other nails, or if you have diabetes or a weakened immune system.

Psoriasis can affect the fingernails. The NHS psoriasis page says the surface of the nails can have dents and pits, and the NHS nail problems page says small dents or pits can be a sign of nail psoriasis, eczema or alopecia. The NHS lists psoriasis among the conditions that can cause nail problems, along with iron deficiency anaemia, an underactive or overactive thyroid, diabetes and heart, lung or liver disease.

If a nail is lifting and there are skin changes elsewhere, mention both to your GP. Some medicines can also cause nail problems, and the NHS suggests checking the side effects of any medicine you are taking, rather than stopping it without advice.

The NHS advises seeing a GP if a nail has changed shape, changed colour or fallen off and you do not know why, or if the skin around your nails has become sore, red, swollen and warm, which can be a sign of infection. A podiatrist can help if nails are too tough to cut or you cannot reach them, and the NHS says you may be able to refer yourself directly to a podiatrist in some areas.

DermNet lists subungual squamous cell carcinoma and melanoma of the nail unit among the reasons onycholysis may persist or progress, so a nail that keeps lifting without an obvious cause should be examined. A dark streak, a nail that keeps lifting with no clear trigger, or a nail change that spreads or bleeds is worth showing to a doctor rather than waiting.

DermNet says onycholysis is a clinical diagnosis, meaning the doctor recognises it by looking, and the cause is often obvious from the history and examination. If the cause is not clear, investigations may include nail clippings or scrapings for bacterial or fungal culture and blood tests for systemic causes of nail disease, such as thyroid function tests.

A doctor will usually ask about injuries, manicures and nail products, water exposure at work, medicines, skin conditions such as psoriasis and other symptoms. Onycholysis should be distinguished from white nail (leukonychia), where the nail stays attached but appears white.

DermNet says onycholysis of short duration and known origin can recover with appropriate treatment. The longer it persists, the less likely new nail growth will reattach, because of permanent damage to the underlying nail bed. It can also predispose to secondary infection under the nail, most commonly with Candida albicans or Pseudomonas, which can discolour the nail.

Because the nail takes months to grow out, improvement is slow. Keeping to the protective measures during that time matters more than any single product.

The NHS gives a general guide for nails lost after injury: fingernails that fall off after an injury should grow back within 6 months, and toenails can take up to 18 months. DermNet gives a similar picture for nail regrowth, with fingernails taking 4 to 6 months to regrow fully and toenails around twice as long. That is why a lifted nail can look unchanged for weeks even when the cause has been dealt with.

Most nail problems are looked at in primary care by a GP, and many areas offer NHS podiatry with self-referral. If a skin condition such as psoriasis or lichen planus is behind the nail change, a GP may refer to dermatology.

Some people use private podiatrists or dermatologists for faster appointments or nail procedures. The NHS notes you can pay to see a podiatrist privately. The main differences are access and cost rather than the underlying approach, which still relies on finding and treating the cause.