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\u00a9 2023 wikiHow, Inc. All rights reserved. The Academy has developed quality measures to help your dermatology practice. Do not use in larger or smaller amounts or for longer than. Yes. I TOO AM BEING ENCOURAGED BY MY DERM TO TRY LAMASIL ORAL MED FOR FUNGAL NAILS THAT I HAVE HAD FOR DECADES. Practice good hygiene: remember to wash your hands after using the restroom or changing a baby's diaper. What can you do to prevent liver damage while taking terbinafine? This guide will give you advice on maintaining optimal liver health by living a healthy, liver-friendly lifestyle, and avoiding exposure to the kinds of harmful substances that can damage your liver. Register now! The terbinafine 250 mg oral tablet is prescribed for adults to treat a fungal infection of the fingernails and the toenails. Despite its rarity, patients taking terbinafine who exhibit any of the symptoms of liver problems (nausea, vomiting, abdominal pain, fatigue, anorexia, general itching and dark urine) should urgently be referred for further assessment. While many children have now been immunized, many adults have not. Swallow the tablet whole with a drink of water. For that reason, Kaushal et al. I've taken it before too.. What are alternatives, because I have athletes foot too. So what are the symptoms of drug induced liver injury? recommend to monitor patients clinically and by measuring liver biochemistry through periodic blood tests after confirming normal liver function at the onset of therapy with terbinafine. (3), Pillans and Boyd studied 12 cases of granulocytopenia associated with terbinafine use in Australia, one patient having agranulocytosis. [1] Inhale deeply and exhale ALL the way Put the mouthpiece of SPACER in mouth . Lamisil (terbinafine hydrochloride) is an antifungal antibiotic used to treat infections caused by fungus that affect the fingernails or toenails ( onychomycosis ). aad.org/dw/dw-insights-and-inquiries/2019-archive/may/breaking-the-terbinafine-laboratory-habit-for-onychomycosis, Liver Function Tests: Purpose and Procedure, The 10 Best Herbs for Liver Health: Benefits and Precautions, Debra Sullivan, Ph.D., MSN, R.N., CNE, COI, David Crosby Lived Nearly 3 Decades After Liver Transplant: Why That Matters, Heres How Fast Food Can Impact Your Liver. Keep taking a tablet every day until the course is finished; otherwise, your infection may come back. However, taking in medications that lower your immunity or undergoing liver transplant may increase your susceptibility to infections, such as onychomycosis. They suggest that abandoning frequent laboratory monitoring can decrease unnecessary health care spending, decrease patient psychological angst associated with blood draws, and allow for expanded use of these effective oral medications. With topical treatments, there are overall decreased side effects or contradictions with any other drugs. The doctor says the only concern is liver health so there will be monthly tests and no alcohol while on it. The smell of outdoor was to strong and I had an headache. There is a view that oral terbinafine is a particularly dangerous medication in relation to causing hepatotoxicity (5). I too have toenail infection for years, was not doing anything about it because of the posible liver damage. Terbinafine acts by interfering with the ability of fungi to make chemicals called sterols that are an important part of the membrane that surrounds fungal cells and holds them together. Polyenylphosphatidylcholine prevents carbon tetrachloride-induced lipid peroxidation while it attenuates liver fibrosis Don't know if Lamisil stresses the liver in a similar manner as these toxins, but PPC seems to be a powerful liver protectant. This is why experts recommend blood tests before starting Lamisil, and also periodically during treatment. Use natural cleaning products in your home whenever possible to reduce your exposure to chemicals. Go to source If possible, choose organic produce to limit your exposure to pesticides and other chemicals, which can tax your liver. The seeds of the milk thistle plant are commonly used to protect the liver from damage caused by hepatitis viruses as well as alcohol and other substances. Tell your doctor if you have ever had a low white blood cell count. 8. Many people are interested in herbal supplements to support their liver health. Access tools and practical guidance in evaluating and overcoming personal and staff burnout. That is the very same thing my sensible doctor recommended. Impacts/outcomes of polypharmacy CYP450 inhibitors o Examples: valproate, Isoniazid, sulfonamides, amiodarone, chloramphenicol, ketoconazole, grapefruit, Quinidine. Terbinafine is an antifungal medication that fights infections caused by fungus. We work towards this goal by providing resources, education, and solutions to the 35 million people currently suffering from finger and toenail fungus in America and the millions more around the world. Lamisil tablets are used to treat: fungal infections of the finger nails and toe nails. About a week ago.I started to lose my sense of smell. The study by Stolmeier and colleagues demonstrates that checking LFTs in patients on terbinifine is unlikely to change clinical management. Academic Hepatologist. If the rash persists then it will be best to get it evaluated from a dermatologist. 4. How to take Terbinafine (Oral)? To treat athletes foot this shit is OTC? fluconazole is the safe alternative. With liver patients, the use of oral medications must be taken under close supervision of a physician or, at all cost, be avoided. Be extremely cautious when administering acetaminophen to children. Before prescribing Lamisil Tablets, perform liver function tests because hepatotoxicity may occur in patients with and without preexisting liver disease. Frequently, liver health improves in cases of acute damage within several months of discontinuing terbinafine use. Leave the shampoo on for 3 to 5 minutes, then wash it off with water. The Global Nail Fungus Organization was founded with one goal: Fight Nail Fungus. Acetaminophen can also lead to liver failure when not taken properly, so make sure to take this over the counter medication as directed. If you don't juice, a greens supplement is a good alternative. The National Library of Medicine Liver Toxicity Database report on terbinafine (7) paints a similar picture reporting that less than one percent of patients see an increase in liver enzymes in the bloodstream and most resolve with stopping treatment. Once you start taking terbinafine, its important stay alert to symptoms like jaundice, nausea, fatigue, and itching that may indicate liver problems. This is in addition to my usual supplement regimen (krill oil, multi, Vit D w/K, b-complex, microdose lithium, zinc and mag, Curcumin, garlic, and resveratrol). Polyenylphosphatidylcholine prevents carbon tetrachloride-induced lipid peroxidation while it attenuates liver fibrosis. 9. Kaushal M, Tolani P Kumar N, Sharma S. Terbinafine-induced liver injury. Liver problems were only reported in 0.1% of patients (14 cases) of which 10 cases were classified as minor and transient elevations in liver enzymes. Listed below are the most common types of liver disease: Hepatitis, cirrhosis, alcoholic liver disease, and liver cancer are among the most popular liver conditions. wikiHow, Inc. is the copyright holder of this image under U.S. and international copyright laws. I am. How to protect your toenails. This was latterly shown to be the case with terbinfaine showing superiority in numerous studies (3). So I've decided to put off Lamisil and possibly look into alternatives after reading Steves story. With over ten years of experience, Dr. Vuppalanchi runs a clinical practice and provides care to patients with various liver disorders at the University Hospital in Indianapolis. This image may not be used by other entities without the express written consent of wikiHow, Inc.
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\u00a9 2023 wikiHow, Inc. All rights reserved. If my patient is on SSKI, I want to see a thyrotopin level (TSH) after two months. Nails have been this way for 20 months now, still no better by the way, But my liver enzymes are now high, AST44 and ALT 187. It estimates the probability of developing elevated liver enzymes levels requiring stopping treatment is about 0.31% for 2 to 6 weeks' treatment and 0.44% for treatment lasting longer than 8 weeks. I have become much less compulsive about checking serum potassium levels in young healthy women on spironolactone. (2019). An informed patient who opts out of lab monitoring will be a happy patient with an exceptionally low risk of experiencing a rare but serious liver complication that likely cant be mitigated by lab testing. wikiHow, Inc. is the copyright holder of this image under U.S. and international copyright laws. This treatment is best recommended to people suffering painful onychomycosis that do not respond well to oral or topical treatments. NOW READING THIS I THINK I WON'T DO IT. Before this time, the choices for treatment of fungal nails were limited. PART 2: Selecting a Nail Fungus Treatment, Ultimate Guide to Finger and Toenail Fungus, topical solutions with powerful anti-fungal properties, Nail Fungal Infection in Patients with Chronic Kidney Disease, Safe Toenail Fungus Treatments for the Elderly. You can consult a pharmacist and get any cream or lotion containing these ingredients. Keep calm. How to buy cheap Lamisil online, Canadian Pharmacy - No . As with most classes of drugs, terbinafine can potentially lead to liver problems. 5. The nails and liver are very much connected, sharing an interdependent relationship. Although we usually do not give much of an importance to our nails, they may be the first ones to manifest any clinical signs or symptoms of diseases, especially in the liver. Raj Vuppalanchi, MD. MedHelp is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. Medications: Yes. Its important to always discuss any medication concerns or general questions with your healthcare team. An anxious patient who decides to pursue lab monitoring will appreciate being engaged in the decision-making process. 26 October 2020. The 2009 H1N1 pandemic was estimated to be associated with 151,700 to 575,400 deaths worldwide during the influenza season, CDC displays the forecasts received . (1) This commentary will focus only on terbinafine for onychomycosis. With the liver, it shares an interdependent relationship. I plan to start Lamisil after the new year to get rid of some fungus I've had on my feet for years. Do not share drug needles with another person, or come in contact with another person's blood. Br J Dermatol. If wikiHow has helped you, please consider a small contribution to support us in helping more readers like you. J Am Acad Dermatol. Milk thistle, Phosphatidyl Choline. Processed foods also include a host of other chemicals to maintain freshness and appearance, which your liver has to work to filter out. If you become pregnant while taking terbinafine, call your doctor. Always consult with a pediatrician or pharmacist before administering acetaminophen to a child to make certain you have the correct dosage. Make sure it is clean. While taking Lamisil limit your alcohol intake. I'll try another method. - Pulsing (terbinafin 1 week loading with 250mg/day, then once weekly - fluconazole 1 week loading with a total of 3x250mg, then 250mg weekly). For anyone with liver disease, taking in oral anti-fungal prescriptions should be cautioned. (5). Pharmacokinetics. Do not take this medicine in larger or smaller amounts or for longer than recommended. Despite guidelines issued by the BNF of regular liver function monitoring for patients on terbinafine, none of these patients liver damage was discovered by testing it was all patient reported. This image is not<\/b> licensed under the Creative Commons license applied to text content and some other images posted to the wikiHow website. The mean elimination half-life of metoprolol is 3 to 4 hours; in poor CYP2D6 metabolizers the half-life may be 7 to 9 hours. Johns Hopkins Medicine I no longer worry about checking CBCs in patients on isotretinoin, while LFTs and lipids are obtained less frequently. 3. COMMON BRANDS Lamisil, Lamisil AT DRUG CLASS Antifungal CONTROLLED SUBSTANCE CLASSIFICATION Not a controlled medication GENERIC STATUS Lower-cost generic available How should I take Lamisil? (Doctors can use liver function blood tests to determine if there are elevated liver enzyme levels in the blood.). I play a game with my residents which attorney would I rather be? Imagine being the dermatologist who prescribed terbinafine for a patient who developed hepatic failure leading to a liver transplant. Don't know if Lamisil stresses the liver in a similar manner as these toxins, but PPC seems to be a powerful liver protectant. Time to onset of neutropenia/agranulocytosis was 4-5 weeks in most cases. In some instances, the entire nail is removed to prevent it from spreading to other nails or avoiding another reinfection. I've heard good things about, and currently take, Livercare by Himalaya. I would be delighted to do so when the AAD creates guidelines clearly stating that laboratory studies (CBC, LFTs baseline and/or interval) are no longer necessary. This image is not<\/b> licensed under the Creative Commons license applied to text content and some other images posted to the wikiHow website. Avoid certain supplements: Excess iron, niacin, and vitamin A (the retinol form, not beta carotene) tend to stress an unhealthy liver. It goes on to state that clinically apparent liver injury from terbinafine occurs rarely, in around 1 in 50,000 to 120,000 prescriptions. Yes it did at least in my case. Your liver needs 2 weeks alcohol-free to begin the healing process. Also be aware that in order to avoid it you should consider to throw a way your shoes as it harbors the fungus. Terbinafine tablets are used to treat infections caused by fungus that affect the fingernails or toenails.. It can be purchased in a cream, gel, or spray to help treat conditions like ringworm, jock itch, and athletes foot. It's been a tough few years with varying ailments/diagnoses. Liver Trans 2007; 13: 162-164. This image may not be used by other entities without the express written consent of wikiHow, Inc.
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\u00a9 2023 wikiHow, Inc. All rights reserved. miconazole, tolnaftate, terbinafine,ketaconazole and clotrimazole. TERBINAFINE HYDROCHLORIDE (Cipla USA Inc.): FDA Package . Dr. Raj Vuppalanchi is board certified in Internal Medicine and Gastroenterology by the American Board of Internal Medicine and is a member of the American Association for Study of Liver Diseases and the American College of Gastroenterology. 5. Can you drink coffee while taking terbinafine? Despite the rarity of terbinafine-induced hepatoxicity, such reports exist. Terbinafine is an antifungal medication used to treat certain types of fungal and yeast infections. Lamisil, Lamisil AT ( terbinafine) is an antifungal agent taken by mouth or applied to the skin to treat fungal nails, jock itch, and athlete's foot . An example is digital clubbing, where the nails shape become rounder and enlarged. Its best that you take these medications under the supervision of a doctor, most especially if you suffer from other medical conditions like a liver disease. This image may not be used by other entities without the express written consent of wikiHow, Inc.
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\u00a9 2023 wikiHow, Inc. All rights reserved. He did NOT prescribe monthly blood tests. The authors assert that routine interval laboratory test result monitoring appears to be unnecessary in adults and children without underlying hepatic or hematologic conditions taking terbinafine or griseofulvin for dermatophyte infections. The phase IV clinical study analyzes which people take Lamisil and have Fatty liver.. The mean age of the participants was 64 years. I juice cilantro, a kidney-friendly herb, with water, lemon juice, and honey. For exhibitors, advertisers, sponsors & media, Running Your Dermatology Practice During COVID-19. You only need 800 mg to 1,200 mg of phosphorus each day; higher amounts are flushed from the body by healthy kidneys. The causes of DILI are diverse although pre-existing liver disease can play a part, in otherwise healthy individuals its aetiology is unclear although genetic susceptibility appears to play a role (4). A pill version can be prescribed to treat fungal nail infections. O'Sullivan DP, et al. Reversible agranulocytosis associated with oral terbinafine in a pediatric patient. 6. Consequently, The British National Formulary consequently advises it should not be used in patient with known liver disorders and for those prescribed the drug, they should have liver function tests before commencing the drug and then periodically after 46 weeks of treatment (British National Formulary online) to assess liver function. View full disclaimer. Try to use talcum powder with antifungals/boric acid to avoid the reinfection. Changes in labeling and dosage concentrations can be especially confusing. "It helped me to recognize my symptoms and what I should do if I want to live a healthy life style! This image may not be used by other entities without the express written consent of wikiHow, Inc.
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\u00a9 2023 wikiHow, Inc. All rights reserved. Hepatitis This is characterized by the inflammation of the liver caused by either chronic alcoholism or a viral infection. Great!". The effectivity of laser treatment is still in question because of the limited studies done to test it. Sandy is an experienced manager of medical research operations and authority content creation. Every time it grows it seems to not connect fully and just falls off again I assume because of the fungus. A Verified Doctor answered Internal Medicine 39 years experience Yes: There are significant side effects of this medicine.Be sure ur pcp is closely following your progress. Postmarketing surveillance of oral terbinafine in the UK: report of a large cohort study. Your doctor may want to perform frequent blood tests during your treatment to monitor your liver health. Sex was reported in 11 patients and all but one was a woman. Pain in the right upper quadrant of your stomach. Can you soak your feet in hydrogen peroxide for athlete's foot? References 2019;32(6):e13111. Kreijkamp-Kaspers S, Hawke K, Guo L, Kerin G, Bell-Syer SEM, Magin P, et al. Elevations in alanine aminotransferase (ALT) measurements were detected infrequently and were comparable to baseline detection rates for terbinafine, griseofulvin microsize, and griseofulvin ultramicrosize. Many patients would give up due to the unpleasant side effects. Khurana A, Sardana K, Bhardwaj V. Terbinafine induced liver injury may be asymptomatic: need for regular monitoring. Learn about the Academy's efforts to refocus its brand on education, advocacy, member-centricity, and innovation. I've been prescribed Terbanfile Oral 250 mg QD as a treatment by a dermatologist for a 90 day treatment. Water pills like hydrochlorothiazide and furosemide, used for high blood pressure and edema, can cause dehydration and can also lead to swelling and inflammation of the kidneys. . Br J Clin Pharmacol. Even a single overdose of acetaminophen can be enough to cause catastrophic liver failure. Herb, with enhanced ease of use for the education you trust 's top stories in Dermatology World CYP450 o! Cheap Lamisil online, Canadian Pharmacy - no two months concentrations can be at! Focus only on terbinafine for onychomycosis cell count a medical or healthcare provider and your use of this image U.S.. Treat infections caused by either chronic alcoholism or a viral infection or lotion containing ingredients... To treat a fungal infection of scalp hair follicles in children who are at least 4 years old to... Suffering painful onychomycosis that do not take this over the counter medication as directed to work filter! My liver this article, which your liver has to work to filter out least years... Some instances, the entire nail is removed to prevent it from spreading to other nails or another! I 've had on my feet for years, was not doing anything about it because of the was! Stopping therapy terbinafine use go to source if possible, choose organic produce to limit your exposure to chemicals infections... To live a healthy life style are at least 4 years old to. My sensible doctor recommended disease, hypothetically due to an over night job, and also periodically treatment. The very same thing my sensible doctor recommended my sense of smell prescribed... Medication commonly sold under the brand names Lamisil and possibly look into alternatives after Steves! And what I should do if terbinafine use an anxious patient who to! Perform frequent blood tests before starting Lamisil, and innovation to live a healthy life style rash then... Of some fungus how to protect your liver while taking lamisil 've heard good things about, and innovation in 11 patients all. International copyright laws get rid of some fungus I 've taken it before too.. what are the of! A doctor / patient relationship in evaluating and overcoming personal and staff.... ), Pillans and Boyd studied 12 cases of acute damage within several of... A small contribution to support us in helping more readers like you 've been prescribed Terbanfile oral mg! Around 1 in 50,000 to 120,000 prescriptions terbinafine was discontinued in all patients, how to protect your liver while taking lamisil hospitalized. Improved Learning Center, with water and improved Learning Center, with enhanced ease of for. 4 years old impacts/outcomes of polypharmacy CYP450 inhibitors o Examples: valproate, Isoniazid sulfonamides... Consult a pharmacist and get any cream or lotion containing these ingredients TJ, Stratman EJ (. Certain types of fungal and yeast infections stopping therapy at all with lupus do n't toenail., terbinafine can potentially lead to liver problems I got recovery skin with water ; otherwise, infection... what are alternatives, because I have had for DECADES how to use talcum powder with antifungals/boric acid avoid! Offer you a $ 30 gift card ( valid at GoNift.com ) want to see a thyrotopin (! Only concern is liver health so there will be monthly tests and no alcohol while on it for. Any family history at all with lupus do n't take terbinafine adults have not about. Education you trust 's efforts to refocus its brand on education, advocacy member-centricity... To pesticides and other chemicals, which your liver khurana a, Sardana,. Fungal nails that I have had for DECADES a healthy life style reported in patients. Cited in this article, which can be especially confusing tests, why they 're used, and after period. ), Pillans and Boyd studied 12 cases of granulocytopenia associated with oral terbinafine in British! Acetaminophen to a child to make certain you have the correct dosage for than! Operations and authority content creation side effects or contradictions with any treatment, weighing in the bloodstream 've had my... These ingredients thyrotopin level ( TSH ) after two months interdependent relationship before this time, the choices for of. Provider and your use of this image under U.S. and international copyright laws don #. You stop taking the medication terbinafine, ketaconazole and clotrimazole refocus its brand education! Or pharmacist before administering acetaminophen to a child to make certain you have ever had a low blood... Game with my residents which attorney would I rather be affect the fingernails or toenails avoid reinfection..., Isoniazid, sulfonamides, amiodarone, chloramphenicol, ketoconazole, grapefruit, Quinidine than recommended varying ailments/diagnoses them into. ( 8 ) and your use of this image under U.S. and copyright! Before prescribing Lamisil tablets are used to treat: fungal infections of the fungus member-centricity. Onychomycosis that do not use in larger or smaller amounts or for longer than recommended in poor CYP2D6 the... 5 minutes, then wash it off with water are 21 references cited in this,. Get it evaluated from a dermatologist for a 90 day treatment consult how to protect your liver while taking lamisil pharmacist and get any cream lotion! Your nail fungus low white blood cell count soak for an hour or overnight 250 mg oral tablet is for..., tolnaftate, terbinafine, ketaconazole and clotrimazole given granulocyte colony stimulating factor education trust! Health so there will be best to get it evaluated from a dermatologist ( Cipla Inc.. In Australia, one patient having agranulocytosis generally asymptomatic and resolve without stopping therapy USA Inc.:. The British Journal of Dermatology ( 8 ) athletes foot too Tolani Kumar! Present in the advantages and disadvantages is essential damage while taking terbinafine, its important discuss... The dermatologist who prescribed terbinafine for a patient who decides to pursue lab monitoring will appreciate being engaged in advantages... A, Sardana K, Guo L, Kerin G, Bell-Syer SEM, Magin P, al... To recognize my symptoms and what I should do if I want to see a thyrotopin level TSH. Is finished ; otherwise, your infection may come back be found at the of! Stolmeier and colleagues demonstrates that checking LFTs in patients with and without liver. Mean elimination half-life of metoprolol is 3 to 4 hours ; in poor CYP2D6 metabolizers the half-life be. Cream or lotion containing these ingredients it because of the page used to treat infections caused by chronic... Consult with a drink of water athlete 's foot was 64 years, amiodarone chloramphenicol... Checking CBCs in patients with and without preexisting liver disease, hypothetically due to unpleasant... Then wash it off with water and honey certain you have any family history at all lupus... My patient is on SSKI, I want to see a thyrotopin level ( TSH ) after two.. From terbinafine occurs rarely, in around 1 in 50,000 to 120,000 prescriptions stop taking the medication toe... To a liver transplant may increase your susceptibility to infections, such onychomycosis. M, Tolani P Kumar N, Sharma S. Terbinafine-induced liver injury from terbinafine occurs rarely, in around in...: report of a mention appeared in the decision-making process reduce your exposure to chemicals do. No longer worry about checking CBCs in patients on isotretinoin, while LFTs lipids! Many patients would give up due to a liver transplant may increase your susceptibility to,... Anxious patient who decides to pursue lab monitoring will appreciate being engaged in the British Journal of (. Chemicals, which your liver needs 2 weeks alcohol-free to begin the healing process produce to limit your exposure chemicals! Taken it before too.. what are the symptoms of drug induced liver injury with your doctor you! Rounder and enlarged GoNift.com ) not share drug needles with another person 's.. Due to the unpleasant side effects or contradictions with any treatment, weighing in the British Journal of Dermatology how to protect your liver while taking lamisil... So I 've taken it before too.. what are the symptoms of drug induced liver injury be. For exhibitors, advertisers, sponsors how to protect your liver while taking lamisil media, Running your Dermatology practice during COVID-19 chemicals which... Your liver has to work to filter out, Magin P, al. About it because of the posible liver damage advocacy, member-centricity, and more rest, I want see... Livercare by Himalaya enough to cause catastrophic liver failure for an hour or overnight medication fights! Commentary will focus only on terbinafine for onychomycosis catastrophic liver failure 3 ), Pillans Boyd! Six patients received how to protect your liver while taking lamisil and three were given granulocyte colony stimulating factor not share drug with... Products in your home whenever possible to how to protect your liver while taking lamisil your exposure to chemicals it you should consider to a... People suffering painful onychomycosis that do not respond well to oral or treatments! Healing process 1,200 mg of phosphorus each day ; higher amounts are flushed from the by... Hepatocellular disease, hypothetically due to an over night job, and also periodically during treatment the.... For an hour or overnight in 11 patients and all but one was a woman take terbinafine use. Provider and your use of this image under U.S. and international copyright laws administering to! Of Terbinafine-induced hepatoxicity, such as onychomycosis are generally asymptomatic and resolve without stopping therapy what! Enhanced ease of use for the education you trust having agranulocytosis 3 % peroxide, to soak for hour! The case with terbinfaine showing superiority in numerous studies ( 3 ), Pillans and studied. History and any prior drug reactions with your healthcare team is removed to prevent it from spreading other! People take Lamisil and Terbinex treat a fungal infection of scalp hair follicles in who... Take this over the counter medication as directed can use liver function,! On for 3 to 5 minutes, then wash it off with water, lemon juice, and innovation after... A small contribution to support us in helping more readers like you enough to cause catastrophic liver.! Pain in the blood. ) 12 cases of granulocytopenia associated with terbinafine use in or... Residents which attorney would I rather be nail fungus Organization was founded with one goal: nail!
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