Fungal Nail Infections

Topic Overview

What is a fungal nail infection?

A fungal nail infection occurs when a fungus attacks a fingernail, a toenail, or the skin under the nail, called the nail bed. Fungi (plural of fungus) can attack your nails through small cuts in the skin around your nail or through the opening between your nail and nail bed.

See a picture of a fungal nail infection .

If you are healthy, a fungal nail infection probably won't cause serious problems. But it may look bad, hurt, or damage your nail or nail bed.

A fungal nail infection could lead to more serious problems if you have diabetes or a weak immune system. Talk to your doctor about the best way to treat a nail infection if you have one of these problems.

What causes a fungal nail infection?

Yeasts, molds, and different kinds of fungi can cause fungal nail infections. Most are caused by the same type of fungus that causes athlete's foot.

Fungi grow best in warm, moist places, and they can spread from person to person. You can get a fungal nail infection from walking barefoot in public showers or pools or by sharing personal items, such as towels and nail clippers. If you have athlete's foot, the fungus can spread from your skin to your nails.

You are more likely to get a nail infection if you:

• Are older than 60.
• Have diabetes or a weak immune system.
• Have a nail injury like a hangnail or an ingrown toenail.
• Wear shoes that make your feet moist or sweaty.
• Live or work in a hot, humid place.

What are the symptoms?

A nail with a fungal infection may:

• Turn yellow or white.
• Get thicker.
• Crumble and split, and it may separate from the skin.

When you have a fungal nail infection, it can be uncomfortable or even painful to wear shoes, walk, or stand for a long time. The fungus could also spread to other nails or your skin. Over time, the infection can cause permanent damage to your nail or nail bed.

How is a fungal nail infection diagnosed?

Your doctor will diagnose a fungal nail infection by looking at the nail, asking about your symptoms and past health, and possibly doing tests to look for fungi. Finding out what is causing the infection can help you get the best treatment.

How is it treated?

Whether to treat a fungal nail infection is up to you. If it is not treated, it won't go away, and it might get worse. But fungal infections can be hard to treat. If you do treat it, you could spend a lot of money, and the treatment might not work.

If you decide to treat a fungal nail infection, you can try an antifungal cream, lotion, or nail polish. You can buy some types without a prescription, or your doctor can prescribe a stronger one. You may need to use this medicine for a few weeks or for as long as a year. Even so, it may not get rid of the infection.

Antifungal pills give the best chance of curing a severe fungal nail infection, but they cost a lot and have serious side effects. You will need to see your doctor for regular testing if you take these pills. You should not take them if you have liver or heart problems.

How can you prevent a fungal nail infection?

Fungal nail infections often come back after treatment. It is important to take steps to prevent this.

• Before bed, wash and dry your feet carefully. Then apply an antifungal product, such as Lamisil or Penlac.
• Wear sandals or roomy shoes made of materials that allow moisture to escape. Let shoes dry for 24 hours before you wear them again.
• Wear cotton socks. Change them if your feet get sweaty.
• Do not share nail files or clippers, socks, towels, or other personal items.
• Wear flip-flops or shower sandals in wet public areas, such as locker rooms or showers.

Frequently Asked Questions

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	Should I take oral antifungal medication to treat a fungal nail infection?

Cause

Fungal nail infections can be caused by three different types of fungus, alone or in combination.

• Dermatophytes are a type of fungus that can grow on the skin, hair, and nails. They do not invade the deeper tissues of the body. The most common dermatophyte, Trichophyton rubrum, causes most cases of athlete's foot infection, which in turn can infect the toenails. You can get infected by contact with objects that have dermatophytes on them, such as clothing, shoes, nail clippers, nail files, shower and locker room floors, and carpet. Dermatophytes cause about 90% of fungal toenail infections.¹
• Yeasts are a type of fungus that grows on the skin and nails. They are normally present on the human body. Various factors such as illness, antibiotic or birth control pill use, and immune system problems may allow an overgrowth of yeast, leading to a yeast infection.
• Molds (often called nondermatophytes) are a type of fungus that commonly grows in soil and can grow on the skin and nails. They are not usually passed between people.

Fungal infections are classified by where they begin and what they affect. Most fungal nail infections affect the skin under the nail (nail bed) and the nail itself (nail plate).

Toenails are more likely to become infected when ingrown or injured, as from frequent nail trimming. For more information, see the topic Ingrown Toenail.

A condition called onycholysis, the separation of the nail from the skin beneath, can increase the risk of fungal nail infections.

You can get a fungal nail infection when you come in contact with the fungus and it begins to grow on or under your nail. Fungi grow best in warm, moist areas, such as the area around the toes. But you can have fungi on your skin without developing a nail infection. You have to be likely to get the infection (susceptible) for it to develop. If you are susceptible to fungal infections, they tend to return, even after successful treatment and especially if you do not take preventive steps.

It is not clear why some people are more susceptible to fungal infections than other people.

Symptoms

Symptoms of fungal nail infections vary. Your symptoms will depend on the type of infection you have. An infection can cause discomfort but is usually not painful. Athlete's foot is often present.

Distal subungual onychomycosis , the most common fungal nail infection, is caused by dermatophytes. It affects both the nail and the skin underneath the nail (nail bed). Dermatophytes cause 90% of all fungal toenail infections.¹ Symptoms include:

• Yellow streaks in the nail bed and on the underside of the nail.
• Buildup of bits and pieces of skin and nail fragments (debris) under the nail.
• A discolored and thickened nail that may separate from the skin under the nail.
• A brittle, broken, and thickened nail.

White superficial onychomycosis is a fungal infection of the nail surface. It is the second most common fungal nail infection and is also caused by dermatophytes. Symptoms include:

• White spots or streaks on the nail surface.
• Soft and powdery nail surface, as the infection gets worse.
• Damaged, crumbly, and brown or gray nail surface. But the nail does not separate from the skin underneath.

Two other types of fungal nail infections are uncommon. Candida onychomycosis is a yeast infection of the nails. Proximal subungual onychomycosis accounts for about 3% of all fungal nail infections.² But it is more common in people infected with the human immunodeficiency virus (HIV).

Conditions with similar symptoms

Only about 50% of all nail infections are fungal infections.³ Conditions with similar symptoms include:

• Eczema, a long-lasting skin disorder that may result in thickened and scaly skin. When it occurs on the hands, it may look like a fungal infection of a fingernail.
• Psoriasis, a long-lasting skin condition that causes raised red or white patches topped with silvery, scaling skin. The patches can appear on the nails. But the pitting of the nails that occurs in psoriasis does not happen in fungal nail infections.
• Reiter's syndrome, a bacterial infection that may result in changes of the nails.
• Pachyonychia (elephant nail), a very thick fingernail or toenail.
• Darier disease, an inherited skin disease in which the skin slowly hardens.
• Lichen planus, an uncommon, recurring skin disease that results in itchy, shiny, reddish purple spots on the skin.
• Norwegian scabies, a rare and severe form of scabies.

What Happens

Fungal nail infections generally progress very slowly. The rate at which a fungal infection progresses depends on:

• Your overall health and susceptibility to the infection.
• The levels of humidity and heat in your environment.
• The type of nail infected. Fungal nail infections of the toenail have more time to grow and spread because toenails grow more slowly than fingernails.

You may first notice a fungal nail infection when a nail or skin under the nail (nail bed) becomes discolored, damaged, thickened, or broken. If not treated, a fungal infection is likely to worsen and spread to other parts of the nail, the nail bed, and possibly the surrounding skin. Over time, the whole nail may become infected and damaged and may eventually fall out.

Fungal nail infections can be treated successfully, but some types are more easily treated than others. The most common type, distal subungual onychomycosis, can be a lifelong infection and hard to treat. Another type, white superficial onychomycosis, can be easily treated. Even after treatment, your nails may continue to look irregular in shape and appearance. It can take a year or longer before they return to normal.

Fungal nail infections often return. Of people successfully treated with antifungal pills, 15% to 20% develop another infection in the next year.⁴ After treatment, take steps to prevent reinfection, such as using antifungal creams and keeping your feet dry.

Sometimes, people with a fungal nail infection may have another problem that can make it hard to walk. For example, you may have decreased blood circulation in your feet and toes. This can worsen foot ulcers in people with diabetes and ulcers caused by poor circulation (venous skin ulcer).

Bacterial infection can develop as a complication of a fungal nail infection. A common bacterial infection, acute paronychia, causes inflammation and swelling of the skin and tissues near a fingernail or toenail.

Quality of life

Although a fungal nail disorder is not dangerous to your health, it can affect your quality of life. You may avoid some activities because of the appearance of your nails and fear of spreading the disease to others. Pain may limit your activities and interfere with work. You may worry about treatment, because insurance companies sometimes consider the condition a cosmetic problem and limit coverage of treatment options.

What Increases Your Risk

The risk of getting a fungal nail infection depends on your susceptibility to fungal infection.

Risk factors you cannot change

Risk factors you cannot change include:

• Susceptibility to fungal infection (which is not yet well understood) or a history of fungal infections.
• Impaired immune system (caused by certain diseases, such as AIDS, diabetes, or cancer, or certain immunosuppressive drugs, such as corticosteroids).
• Poor blood circulation (caused by disease or increasing age).
• Age. People older than 60 are more likely to have a fungal nail infection.⁵
• Being male.

Risk factors you can change

Risk factors you can change include:

• Wearing tight shoes.
• Wearing shoes that make your feet warm and sweaty.
• Wearing the same pair of moist shoes for 2 days in a row (and not letting your shoes dry out).
• Sharing personal items such as shoes, socks, nail clippers, or nail files with other people.
• Living in a hot, humid climate.
• Using public or shared showers or locker rooms without shower sandals or shower shoes.
• Injuring the nail (as in the case of frequent nail trimming).
• Having athlete's foot. For more information see the topic Athlete's Foot.
• Having a job in which your hands or feet are often wet (such as dishwashers or lifeguards).
• Smoking.
• Wearing artificial nails. An infection can develop in the gap between the artificial nail and the real nail, especially if a loose nail is glued back on without first being cleaned with rubbing alcohol. Nail manicures and certain nail products can damage the nail or cuticle, making the nail more susceptible to infection.

When To Call a Doctor

Call your doctor for an immediate appointment if a fungal nail infection develops signs of bacterial infection, such as:

• Increased pain, swelling, redness, tenderness, or heat.
• Red streaks extending from the area.
• Discharge of pus.
• Fever of 100 °F (37.78 °C) or higher with no other cause.

Call your doctor for an appointment if your symptoms are troubling you, such as when:

• A fungal infection appears to be spreading to the skin under the nail, the nail itself, or the surrounding skin.
• The infected area is painful.
• A thickened toenail causes discomfort.
• Your nail's appearance concerns you.

Your doctor can check for signs of fungal infection. If a fungal infection is not treated, it may get worse.

Watchful Waiting

Watchful waiting is a period of time during which you and your doctor observe your symptoms or condition without using medical treatment. If a nail is discolored or damaged but is not painful, you may decide not to treat the infection. Antifungal medicine does not guarantee a cure, and antifungal pills (oral medicine) can be expensive and have potentially dangerous side effects. But treatment may stop the infection from causing permanent damage to the nail and increase the chance of a cure.

Who To See

Health professionals who can diagnose and treat a fungal nail infection include:

• Nurse practitioners.
• Physician assistants.
• Family medicine doctors.
• Internal medicine doctors.
• Dermatologists.
• Podiatrists.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

To determine the cause of a nail problem and diagnose a fungal nail infection, your doctor:

• Will ask about your medical history, including any previous symptoms of nail damage or fungal nail infections.
• Will look at the skin and nails on your hands and feet.
• May take a sample of the bits of skin and nail fragments (debris) from under the infected nail. If a sample of debris cannot be taken easily, a nail sample may be taken by lightly scraping the nail near the infected area or by using a small blade to shave off a piece of nail.

Tests used to examine nail and debris samples include:

• KOH (potassium hydroxide) preparation, to determine whether the nail or skin condition is caused by fungi. This test can be done in a clinic or doctor's office.
• A fungal culture, which can determine which type of fungus is present. Since fungi generally grow slowly, it can take several weeks for a culture to produce test results.

About 90% of fungal toenail infections are caused by a type of fungus called a dermatophyte.¹ Because of this, if the KOH test shows there is a fungus present, your doctor may assume that the fungal infection is caused by a dermatophyte and prescribe treatment. But because one medicine may be more effective than another medicine against certain types of fungus, your doctor may want to do a fungal culture.

Many insurance companies now require testing to verify a fungal infection before they'll pay for medicines, which can be expensive.

Tests that are rarely done If the KOH preparation and fungal culture do not show the presence of fungi but a fungal infection is still suspected, your doctor may remove a small piece of nail and look at it under a microscope (nail biopsy).

Treatment Overview

Treatment for a fungal nail infection includes using medicines, taking steps to prevent the infection from returning, and possibly removing the affected nail. Treatment is generally successful, but treatment does not work for 20% to 25% of people with the condition.⁶

You may decide not to treat a fungal nail infection if your nail is discolored or damaged but not painful. Antifungal medicine does not guarantee a cure, and antifungal pills (oral medicine) can be expensive and have potentially dangerous side effects.

Without treatment, fungal nail infections tend to get worse, infecting more of the nail or surrounding skin. Early treatment may shorten treatment time and increase your chances of being cured.

If you have a fungal nail infection that causes quality-of-life problems, such as discomfort, pain, or embarrassment, you may decide to treat it.

If you have a condition such as diabetes that might complicate a minor foot injury or infection, your doctor may suggest treating a fungal nail infection, even if it does not bother you.

For more information on deciding whether to use oral antifungal medicine, see:

Should I take oral antifungal medicine to treat a fungal nail infection?

Standard treatment for fungal nail infection includes one or a combination of the following:

• Antifungal pills (oral medicine) offer the best chance of a cure. But they require close monitoring for dangerous side effects and are generally reserved for moderate-to-severe or difficult-to-treat fungal nail infections. Pills include terbinafine (Lamisil), itraconazole (Sporanox), and fluconazole (Diflucan).
• Antifungal topical medicine (creams, lotions, gels, and lacquers) are applied to the infected nail and surrounding areas of the skin. They may be used for mild-to-moderate infections and to help prevent an infection from returning or to prevent athlete's foot from spreading to the nails. Topical medicines include terbinafine (Lamisil) and ciclopirox (Penlac). Topical medicines may not be as effective as oral medicines.
• Removal of an infected nail is used for severe or recurring fungal nail infections. Combining nail removal with antifungal creams or pills is likely to be more effective than using one of these treatments alone. Nail removal is rarely necessary.
  • In nonsurgical nail removal, a urea ointment is put on the nail, softening and dissolving it for easy removal.
  • In surgical nail removal, the infected nail and tissue is fully removed (avulsion) or partially removed (debridement).

A topical or oral antibiotic is necessary only when a bacterial infection has developed along with the fungal infection.

Recurring infections and prevention

Even after apparently successful treatment with antifungal pills, a fungal nail infection can return, either as a new infection or as regrowth of the original fungi. Severe toenail infections, particularly those involving a big toe, are difficult to treat and tend to recur.

After treatment, be sure to take steps to keep a fungal nail infection from developing again.

• Before bed, thoroughly wash and dry your feet or hands and apply a topical antifungal medicine, such as terbinafine (Lamisil) or ciclopirox (Penlac), directly to your skin or nail. Use the topical medicine for 1 year.⁷
• Keep your feet and hands dry. Dry skin and nails are less likely to become infected. Apply powder to your dry feet or hands after you take a shower or bath.
• Wear dry cotton socks and change them 2 or 3 times a day if necessary.
• Wear sandals or dry roomy shoes made of materials that allow moisture to escape. Avoid tight, enclosed shoes. Injury to the tips of the toes because of tight shoes may be the biggest single factor that leads to recurrence of a fungal nail infection.⁷
• Wear shower sandals or shower shoes when using a public pool or shower, and let them dry between uses.
• Don't share shoes, socks, nail clippers, or nail files with others.
• Avoid injuring your nail. Cutting nails too short is a common cause of nail injury. If you decide to get artificial nails or have a manicure, go to a salon that uses sterile instruments. Nail manicure and certain nail products can damage the nail or cuticle, making the nail more susceptible to infection.
• Control chronic conditions such as diabetes.
• Stop smoking.

What To Think About

If you have a mild fungal infection or are concerned about the risks of oral antifungal medicine, consider using a topical treatment, such as Lamisil or Penlac.

Fungal nail infections can be treated successfully, but some types are more easily treated than others. One type, distal subungual onychomycosis, can be a lifelong infection and hard to treat. Another type, white superficial onychomycosis, can be easily treated.

Even after treatment, your nails may continue to look irregular in shape and appearance. It can take a year or longer before they return to normal.

Prevention

After your fungal nail infection has been successfully treated, take steps to prevent the infection from recurring.

• Before bed, thoroughly wash and dry your feet or hands and apply a topical antifungal, such as terbinafine (Lamisil) or ciclopirox (Penlac), directly to your skin or nail. Use the topical medicine for 1 year.⁷
• Keep your feet and hands dry. Dry skin and nails are less likely to become infected. Apply powder to your dry feet or hands after you take a shower or bath.
• Wear dry cotton socks and change them 2 or 3 times a day if necessary.
• Wear sandals or dry roomy shoes made of materials that allow moisture to escape. Injury to the tips of the toes because of tight shoes may be the biggest single factor that leads to a fungal nail infection returning.⁷
• Wear shower sandals or shower shoes when using a public pool or shower, and let them dry between uses.
• Don't share shoes, socks, nail clippers, or nail files with others.
• Avoid injuring your nail. Cutting nails too short is a common cause of nail injury. If you decide to get artificial nails or have a manicure, go to a salon that uses sterile instruments. Nail manicure and certain nail products can damage the nail or cuticle, making the nail more susceptible to infection.
• Control chronic conditions such as diabetes.
• Stop smoking.

Home Treatment

If you have a mild fungal nail infection or are concerned about the risks of oral antifungal medicine, try an antifungal medicine you put directly on your skin (topical medicine), such as terbinafine (Lamisil) or ciclopirox (Penlac). You can also use a topical antifungal to prevent athlete's foot, which can cause fungal nail infections. But topical medicines may not be as effective as oral medicines in treating fungal nail infections.

Some people consider tea tree oil or cream to be an effective alternative for treating and preventing athlete's foot and mild fungal nail infections. It is typically used to treat minor cuts, burns, acne, athlete's foot, mild fungal nail infections, vaginal yeast infections, and respiratory problems (added to a bath or vaporizer).⁸ There is little research on how effective tea tree oil is for fungal nail infections.

After an infection has cleared up, use daily measures to prevent reinfection.

• Before bed, thoroughly wash and dry your feet or hands and apply a topical antifungal, such as terbinafine (Lamisil) or ciclopirox (Penlac), directly to your skin or nail. Use the topical medicine for 1 year.⁷
• Keep your feet and hands dry. Dry skin and nails are less likely to become infected. Apply powder to your dry feet or hands after you take a shower or bath.
• Wear dry cotton socks and change them 2 or 3 times a day if necessary.
• Wear sandals or dry roomy shoes made of materials that allow moisture to escape. Avoid tight, enclosed shoes. Injury to the tips of the toes because of tight shoes may be the biggest single factor that leads to a fungal nail infection returning.⁷
• Wear shower sandals or shower shoes when using a public pool or shower, and let them dry between uses.
• Don't share shoes, socks, nail clippers, or nail files with others.
• Avoid injuring your nail. Cutting nails too short is a common cause of nail injury. If you decide to get artificial nails or have a manicure, go to a salon that uses sterile instruments. Nail manicure and certain nail products can damage the nail or cuticle, making the nail more susceptible to infection.
• Control chronic conditions such as diabetes.
• Stop smoking.

Medications

Antifungal medicine is standard treatment for a fungal nail infection. The goals of treatment are to have few or no side effects, provide a long-term cure, and reduce treatment time.

• Antifungal pills (oral medicine) offer the best chance of a cure. But they also require close monitoring for dangerous side effects and are generally reserved for moderate-to-severe or difficult-to-treat fungal nail infections. Pills include terbinafine (Lamisil), itraconazole (Sporanox), and fluconazole (Diflucan).
• Antifungal topical medicine (creams, lotions, gels, and lacquers) are applied to the infected nail and surrounding areas of the skin. But they may not be as effective as oral medicines. They may be used for mild-to-moderate infections and to help prevent an infection from returning or to prevent athlete's foot from spreading to the nails. Topical medicines include terbinafine (Lamisil) and ciclopirox (Penlac).

Factors to consider when choosing a fungal nail infection treatment include:

• The type and location of infection. Fingernail and toenail infections are usually treated with different medicines, and the treatment time for fingernails is usually shorter. If you have a mild fungal infection or are concerned about the risks of oral antifungal medicine, consider using a topical treatment, such as Lamisil or Penlac.
• Your susceptibility to fungal nail infection. If you develop fungal nail infections often, you may need longer-term treatment.
• The medicine. Griseofulvin (Grifulvin V) was one of the first oral antifungal medicines. But it did not provide a long-term cure, had serious side effects, and required a long treatment time (12 to 18 months). The newer oral antifungals are more effective, relatively safe for healthy individuals, and don't take as long to work.
• Your risk factors for dangerous side effects from oral antifungal medicines. If you have a history of blood or liver disease or plan to drink alcohol during antifungal treatment, oral medicine is not a safe treatment option for you.
• Drug interactions. Commonly prescribed medicines can affect the levels of antifungal medicine in your body. Similarly, other medicines can build up in the bloodstream when taken with antifungal pills. Before you take oral antifungal medicine, let your doctor know what other medicines you are taking.
• The dosing method, if you are taking oral medication. Depending on the medicine and the severity of the infection, you may be able to choose between pulse therapy (taking medicine daily for 1 week a month for 2, 3, or 4 months) or continuous therapy (taking medicine each day).
• The cost for the entire course of medication treatment. Some oral antifungals cost more than others. Pulse dosing is often less expensive than continuous therapy.

For more information on deciding whether to use oral antifungal medicines, see:

Should I take oral antifungal medicine to treat a fungal nail infection?

Surgery

Surgical nail removal may be used to treat severe or recurring fungal nail infections. After the diseased nail tissue is removed, an antifungal cream can be applied directly to the infected area. This is likely to be more effective than using one of these treatments alone. Nail removal is rarely necessary.

Surgical nail removal can be done to remove either the entire nail plate (avulsion) or part of the nail plate (debridement).

Other Treatment

Nonsurgical nail removal may be used to treat severe or recurring fungal nail infections. A urea ointment is applied to the nail, which softens and dissolves it so that it can be easily removed. After the diseased nail tissue is removed, an antifungal cream can be applied directly to the infected area. This is likely to be more effective than using one of these treatments alone. Nail removal is rarely necessary.

Nonsurgical nail removal can be done to remove either the entire nail plate (avulsion) or part of the nail plate (debridement). This procedure is almost always painless.

Complementary therapy

Some people consider tea tree oil or cream to be an effective alternative for treating and preventing athlete's foot and mild fungal nail infections. It is typically used to treat minor cuts, burns, acne, athlete's foot, mild fungal nail infections, vaginal yeast infections, and respiratory problems (added to a bath or vaporizer).⁸ There is little research on how effective tea tree oil is for fungal nail infections.

Some people have found Vicks VapoRub to be useful for treating fungal nail infections. But no studies have been done to look at how effective Vicks VapoRub is in treating this condition.

Other Places To Get Help

Organizations

Related Information

• Athlete's Foot
• Ingrown Toenail
• Nail Problems and Injuries
• Ringworm of the Scalp or Beard
• Ringworm of the Skin

References

Citations

1. Roberts DT, et al. (2003). Guidelines for treatment of onychomycosis. British Journal of Dermatology, 148(3): 402–410.

2. Roamno C, et al. (2005). Retrospective study of onychomycosis in Italy: 1985–2000. Mycoses, 48(1): 42–44.

3. Verma S, Heffernan MP (2008). Superficial fungal infection: Dermatophytosis, onychomycosis, tinea nigra, piedra. In K Wolff et al., eds., Fitzpatrick's Dermatology in General Medicine, 7th ed., vol 2, pp. 1807–1821. New York: McGraw Hill.

4. Habif TP, et al. (2005). Tinea of the nails (onychomycosis) section of Fungal infections. In Skin Disease: Diagnosis and Treatment, 2nd ed., pp. 234—237. Philadelphia: Elsevier Mosby.

5. Rodgers P, Bassler M (2001). Treating onychomycosis. American Family Physician, 63(4): 663–672.

6. Sher RK, Baran R (2003). Onychomycosis in clinical practice: Factors contributing to recurrence. British Journal of Dermatology, 149(Suppl 65): S5–S9.

7. Habif TP (2004). Dermatophyte fungal infections section of Superficial fungal infections. In Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 4th ed., pp. 409–439. Philadelphia: Mosby.

8. Murray MT, Pizzorno JE Jr (2006). Melaleuca alternifolia (tea tree). In JE Pizzorno Jr, MT Murray, eds., Textbook of Natural Medicine, 3rd ed., vol. 1, pp. 1053–1056. St. Louis: Churchill Livingstone Elsevier.

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