Background: We sought to determine the frequency of toenail onychomycosis in diabetic patients, to identify the causative agents, and to evaluate the epidemiologic risk factors.
Methods: Data regarding patients’ diabetic characteristics were recorded by the attending internal medicine clinician. Clinical examinations of patients’ toenails were performed by a dermatologist, and specimens were collected from the nails to establish the onycomycotic abnormality. All of the specimens were analyzed by direct microscopy and culture.
Results: Of 321 patients with type 2 diabetes mellitus, clinical onychomycosis was diagnosed in 162; 41 of those diagnoses were confirmed mycologically. Of the isolated fungi, 23 were yeasts and 18 were dermatophytes. Significant correlations were found between the frequency of onychomycosis and retinopathy, neuropathy, obesity, family history, and duration of diabetes. However, no correlation was found with sex, age, educational level, occupation, area of residence, levels of hemoglobin A1c and fasting blood glucose, and nephropathy. The most frequently isolated agents from clinical specimens were yeasts.
Conclusions: Long-term control of glycemia to prevent chronic complications and obesity and to promote education about the importance of foot and nail care should be essential components in preventing onychomycosis and its potential complications, such as secondary foot lesions, in patients with diabetes mellitus. (J Am Podiatr Med Assoc 101(1): 49–54, 2011)
Efinaconazole 10% solution is a new triazole antifungal agent developed for the topical treatment of onychomycosis. This article reviews the pooled results of the two pivotal clinical trials of this drug that have been performed in the United States, Canada, and Japan.
The two studies of 1,655 patients were both double-blind, vehicle-controlled, parallel-group, randomized, multicenter studies designed to determine the efficacy and safety of efinaconazole 10% solution in the treatment of mild-to-moderate onychomycosis of the toenails caused by dermatophytes. Treatment was provided once daily for 48 weeks, and the primary end point was at week 52.
The combined results show a 56% mycologic cure rate compared with 17% for vehicle at week 52. Clinical treatment success was achieved in 43% of patients treated with efinaconazole 10% solution at follow-up (week 52). Clinical treatment success was achieved in 47% of patients. As expected for a topical agent, the use of efinaconazole 10% solution was found to be safe, with mild, transient irritation at the site of application reported as the most common adverse event.
The efficacy and safety profile of efinaconazole 10% solution suggests that it may represent an important advance in the topical treatment of onychomycosis. Further studies will help us better understand the role of this agent for the treatment of this widespread podiatric medical condition.
Background: Several studies have shown a significant relationship between depressive symptoms and wound healing, but these studies have not assessed the effects of depressive symptoms on diabetic foot prognosis. We specifically designed our study to assess the role of depressive symptoms in healing and recurrence of diabetic foot ulcers.
Methods: A consecutive series of 80 type 2 diabetic patients aged 60 years and older with foot ulcers was enrolled in a cohort observational study with a 6-month follow-up. Patients who healed within 6 months of enrollment were included in a 12-month follow-up study for assessment of ulcer recurrence. Depressive symptoms were assessed with the geriatric depression scale.
Results: Healing was associated with a smaller ulcer area, shorter delay between ulcer onset and treatment, lower glycosylated hemoglobin, and higher ankle-brachial index. Both smoking status and Texas and Wagner scores also had a significant impact on healing. Patients who healed had significantly lower scores on the geriatric depression scale, and those with scores = 10 had a significantly higher risk of not healing at 6 months (relative risk, 3.57; 95% confidence interval, 1.05–12.2). Patients with a recurrent ulcer (59.3%) showed significantly higher total cholesterol levels, higher scores on the Greenfield index of disease severity and geriatric depression scale, and a higher prevalence of cerebrovascular disease. Depressive symptoms maintained a significant association with persistence and recurrence of ulcer even after adjustment for confounders.
Conclusions: Depressive symptoms are associated with impaired healing and recurrence of ulcers in elderly type 2 diabetic patients. (J Am Podiatr Med Assoc 98(2): 130–136, 2008)
Onychocryptosis is a pathologic condition of the nail apparatus in which the toenail damages the nail fold. It is a common condition provoking pain, inflammation, and functional limitation. It principally occurs in the hallux. Onychocryptosis is one of the most frequent complaints regarding the foot and accounts for many clinical consultations. The disorder has been classified in terms of the stages of the pathologic condition. In our practice, we discovered a clinical entity that was not previously classified in the literature. We classify onychocryptosis into stages I, IIa, IIb, III, and the new stage IV. A treatment plan is offered for each stage of this classification, with both general and specific indications given. In onychocryptosis treatment, it is important to select the surgical technique best suited to the patient’s particular clinical situation. (J Am Podiatr Med Assoc 97(5): 389–393, 2007)
We sought to evaluate the relationship between baseline hemoglobin A1c (HbA1c) level and clinical outcomes, including foot ulcer outcome (resolved versus unresolved) and wound-healing time, in individuals with type 2 diabetes.
A prospective observational study was conducted on 99 patients presenting with a diabetic foot ulceration. Patient and ulcer characteristics were recorded. Patients were followed up for a maximum of 1 year.
After 1 year of follow-up, 77% of ulcers healed and 23% did not heal. Although this study demonstrated that the baseline HbA1c reading was not a significant predictor of foot ulcer outcome (P = .603, resolved versus amputated), on further statistical analyses, when HbA1c was compared with the time taken for complete ulcer healing in the resolved group (n = 77), it proved to be significant (P = .009).
These findings have important implications for clinical practice, especially in an outpatient setting. Improving glycemic control may improve ulcer outcomes. Prediction of outcome may be helpful for health-care professionals in individualizing and optimizing clinical assessment and management of patients. Identification of determinants of outcome could result in improved health outcomes, improved quality of life, and fewer diabetes-related foot complications.
Topical onychomycosis therapies are usually inadequate, and patient compliance to systemic therapies is poor. Recently, interest in laser therapy for the treatment of onychomycosis has increased. We sought to investigate the efficacy of long-pulsed Nd:YAG laser therapy for onychomycosis.
Thirty patients with mycologically confirmed onychomycosis received long-pulsed 1064-nm Nd:YAG laser therapy, moving the beam in a spiral pattern over the whole nail plate two times, with a 1-minute pause between passes. Laser therapy was performed with a spot diameter of 4 mm at a speed of 25 mm/sec once weekly for 4 weeks using fluencies ranging from 40 to 60 J/cm2, depending on the thickness of the nail plate. Patients were evaluated in terms of clinical improvement and mycologic cure.
Thirty patients started and 15 completed the study. Mycologic cure was achieved in nine patients (60%), of whom eight (89%) were infected with Trichophyton sp. Complete clinical improvement was achieved in seven patients (47%), all of whom were infected with Trichophyton sp. Mycologic cure was not achieved in one of two patients infected with Epidermophyton or in either patient in whom the agent was Candida or Aspergillus; complete clinical improvement did not occur in any of these patients. No serious adverse events were observed.
Based on these results, long-pulsed Nd:YAG laser can be used as an effective treatment for onychomycosis, but further studies are needed to draw firmer conclusions.
Porcine-derived xenograft biological dressings (PXBDs) are occasionally used to prepare chronic wound beds for definitive closure before split-thickness skin grafts (STSGs). We sought to determine whether PXBD influences rate of STSG take in lower-extremity wounds.
Lower-extremity wounds treated with STSGs were retrospectively reviewed. Patients were included in one of two groups: wound bed preparation with PXBD before STSG or no preparation. Patients were excluded if they received wound bed preparation via another method. Patient demographics, comorbidities, wound history, wound bed preparation, and 30- and 60-day outcomes were collected.
There was no difference in healing outcomes between the PXBD (n = 27) and no preparation (n = 39) groups. At 30- and 60-day follow-up, percentage of STSG take was not significantly different between groups (77.9% versus 79.0%, P 30 = .818; 82.2% versus 80.9%, P 60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P 30 = .902; 1.2 cm2 versus 1.1 cm2, P 60 = .689). The PXBD group had a higher mean ± SD hemoglobin A1c level (8.3 ± 3.5 versus 6.9 ± 1.6; P = .074) and age (64.9 ± 12.8 years versus 56.3 ± 11.9 years; P = .007) versus the no preparation group.
Application of PXBDs for wound bed preparation had no effect on wound healing compared with no wound bed preparation. The two groups varied only by mean age and hemoglobin A1c level. The PXBD may be beneficial, but these results call for randomized controlled trials to determine the true impact of PXBDs on wound healing. In addition, PXBDs may have utility outside of clinically oriented outcomes, and future work should address patient-reported outcomes and pain scores with this adjunct.
Background: Complementary and alternative medicine (CAM) is one of the fastest growing areas of health care. This has necessitated an increased awareness and understanding of CAM by conventional health professionals.
Methods: A questionnaire seeking information about use of and attitudes toward CAM was mailed to 1,365 Australian podiatric physicians.
Results: Ninety-one percent of Australian podiatric physicians surveyed have used at least one CAM therapy in the past 12 months, and 93% have treated patients with CAM or have recommended its use to patients. Overall, the respondents rated their knowledge of various CAM therapies as “average,” and responses on the CAM Health Belief Questionnaire indicated that respondents tended not to endorse CAM health beliefs, with statements about CAM therapies being seen as “a threat to public safety” and effects being “usually due to the placebo effect” producing the strongest responses.
Conclusions: Complementary and alternative medicine therapies are already being used in podiatric medical practice, and there are significant opportunities for further research into CAM education and clinical research relevant to podiatric medicine. (J Am Podiatr Med Assoc 99(2): 121–128, 2009)
Sixty-two patients were treated for single or multiple warts by intralesional injection of bleomycin sulfate (1.5 U/mL) and then were observed for 6 months. The dose varied according to the size of the lesion and ranged from 0.25 to 1.0 mL per injection per lesion, up to a maximum dose of 3 mL. The total cure rate was 87% after one or two injections. Twelve of the 62 patients required a second injection. (J Am Podiatr Med Assoc 96(3): 220–225, 2006)
Background: A variety of treatment modalities have been described for cutaneous warts. We sought to determine the safety and efficacy of a topical formulation of cantharidin, podophyllotoxin, and salicylic acid in the treatment of plantar warts. This combination treatment is widely used in Europe and elsewhere but has not been described in the podiatric medical literature.
Methods: A retrospective study was conducted of 144 patients with simple or mosaic plantar warts who were treated with a topical, pharmacy-compounded solution of cantharidin, 1%; podophyllotoxin, 5%; and salicylic acid, 30%. All of the patients, aged 8 to 52 years (mean ± SD, 20.9 ± 11.0 years), were treated according to the authors3 standard protocol. Of the 144 patients, 92 were being treated for the first time. None of the 52 previously treated patients had received more than one other type of treatment in the past.
Results: After 6 months of follow-up, complete eradication of the plantar warts was noted in 138 of the 144 patients (95.8%). Of these patients, 125 (86.8%) required a single application of the solution, and 13 (9.0%) needed two or more applications. No significant adverse effects or complications were observed.
Conclusion: A topical solution of cantharidin, podophyllotoxin, and salicylic acid was found to be safe and effective in the treatment of simple and mosaic plantar warts. This formulation is a promising alternative treatment modality for plantar warts. (J Am Podiatr Med Assoc 98(6): 445–450, 2008)