|Thank you for your consult. Based on the reviewed photos and history, it appears your patient has onychomycosis, which is a fungal nail infection. A chronic paronychia (which is an inflammation of the nail folds) is possible as well, as sometimes a chronic paronychia can lead to a fungal nail infection. The best treatment is a 6 week course of oral terbinafine (250mg/day). This would have an interaction with his metoprolol so it may require dose adjustment for that medication. Alternatively you can use 8% ciclopirox nail lacquer. If symptoms persist despite treatment then I would treat for a chronic paronychia with fluocinonide ointment twice a day for 2-4 weeks. It is also important to avoid prolonged exposure to water which can worsen this. It takes 6 months for a fingernail to fully replace itself, but the new growth should look normal. Hope that helps!