Treatment for Simple Plantar Verrucae
Monochloroacetic Acid and 10% Formaldehyde versus 10% Formaldehyde Alone
Verrucae are small, benign, highly vascular epithelial neoplasms that occur singly or in a multiple presentation. Plantar verrucae are usually caused by infection with human papillomavirus types 1, 2, and 4. A clinical trial was conducted to assess the safety and efficacy of monochloroacetic acid and 10% formaldehyde versus 10% formaldehyde alone in the treatment of simple plantar verrucae. Of 57 patients enrolled in the study, 26 were in the monochloroacetic acid and 10% formaldehyde group and 31 were in the 10% formaldehyde alone group. The overall cure rate for this population was 61.4%. There was no statistically significant difference in the cure rate between treatment groups. (J Am Podiatr Med Assoc 96(1): 53–58, 2006)
Onychomycosis is an extremely common condition that is increasing in prevalence. Although often innocuous, it may be complicated by discomfort and secondary bacterial infections. Recently introduced oral medications may be highly effective in the eradication of this condition; however, they may carry with them significant expense and potentially serious side effects. Prior to the initiation of antifungal oral therapy, definitive diagnosis is mandatory. This study compares the sensitivity of potassium hydroxide (KOH) preparations, surgical pathology diagnostic testing (SPDT), and culture techniques for the detection of onychomycosis in 50 cases of clinically suspected onychomycosis. Analysis showed that SPDT was significantly more sensitive when compared to KOH and culture. The results suggest that SPDT may be the true gold standard for the diagnosis of onychomycosis. (J Am Podiatr Med Assoc 91(7): 351-355, 2001)
Onychomycosis is a fungal infection of the nail that can be caused by dermatophytes, yeasts, or nondermatophyte molds. To diagnose onychomycosis, a clinician must use the patient's history, physical findings, and diagnostic testing, which can include calcofluor white/potassium hydroxide (KOH) mount, fungal culture (FC), and periodic acid–Schiff (PAS) stain. Some insurance companies require authorization for antifungal medication and request laboratory results to confirm infection. We sought to compare the reliability of KOH, PAS, and FC diagnostic results for confirmation of fungal disease, to determine the sensitivity and specificity of each test, and to investigate the cost of each test. In addition, we statistically observed the relationship between the test results and demographic variables.
Toenail clippings were obtained from 108 patients clinically diagnosed as having onychomycosis. Diagnostic tests were then performed on each sample; the results were obtained from medical records.
For PAS, KOH, and FC, 60.2%, 43.5%, and 39.8% of results, respectively, were positive. Agreement for each pair of tests was slightly higher for FC and KOH. Sensitivities for KOH and PAS were 0.64 and 0.79, respectively. Specificity was 0.79 for KOH and 0.54 for PAS. Both PAS and KOH had a higher percentage of positive test results for men than for women.
Of the three tests evaluated, PAS gives the most consistent positive results and has the highest sensitivity. Therefore, PAS should be considered as the best test to verify clinically significant onychomycosis.
Onychomycosis, by definition, is a mycotic infection of the keratinized tissue of the nail plate. Although it is commonly considered to be caused by one of the dermatotropic fungi, a variety of other organisms have been implicated as etiologic agents in the disease, including some bacteria and yeasts. When it is caused by a fungus, any or all of three types of organisms can be involved: dermatophytes, yeasts, and nondermatophyte organisms. The purpose of this study was to identify the microorganisms found in fungal cultures of clinically suspected onychomycosis in the patient population of the Foot Clinics of New York in New York City, the largest foot clinic in the world. Of the 1,800 medical charts reviewed, 214 had culture results, of which 120 were positive. Trichophyton rubrum was the most prevalent pathogen, found in 67% of positive cultures. The most remarkable risk factor was age, with 80% of affected individuals older than 35 years. False-negatives may account for the high percentage (44%) of negative cultures in this study. (J Am Podiatr Med Assoc 92(6): 327-330, 2002)
Surgical Treatment of Pressure Ulcers of the Heel in Skilled Nursing Facilities
A 12-Year Retrospective Study of 57 Patients
Background: Chronic nonhealing pressure ulcers of the heel in nursing homes are frequent occurrences among bedridden patients with lower-extremity contractures of varying degrees of severity. Conservative local wound care for these patients can be time consuming, ineffective, costly, and may only delay an eventual major leg amputation. This study evaluates the efficacy of limb salvage surgical procedures, partial calcanectomy, total calcanectomy, and excision of the entire calcaneus and talus, for heel ulcers.
Methods: We performed a retrospective review of 57 nursing home residents who had chronic infected nonhealing pressure ulcers of the heel that we had treated over 12 years. Forty-three patients underwent partial calcanectomy, nine underwent total calcanectomy, and five underwent excision of the entire calcaneus and talus. Average postoperative follow-up was 15 months. Also included in this study are representative surgical cases.
Results: Forty-three patients completed follow-up. Complete healing occurred in 25 patients (58%). Failure to resolve the heel ulcer owing to persistent infection, or recurrence was seen in 18 patients (42%) who eventually had a below-the-knee or above-the-knee amputation. All of the patients with heel pressure ulcers were found to have lower-extremity contractures.
Conclusions: In the nonambulatory contracted patient with a heel ulcer, partial or total calcanectomy or excision of the entire calcaneus and talus offer a viable alternative not only for resolution of infection but also for prevention of limb loss. An aggressive plan must also be instituted to address the lower-extremity contractures in order to prevent recurrence. (J Am Podiatr Med Assoc 101(2): 167–175, 2011)
The increasing resistance of bacteria to antibiotics and the frequency of comorbid conditions of patients make the treatment of diabetic foot infections problematic. In this context, photodynamic therapy could be a useful tool to treat infected wounds. The aim of this study was to evaluate the effect of repeated applications of a phthalocyanine derivative (RLP068) on the bacterial load and on the healing process.
The present analysis was performed on patients with clinically infected ulcers who had been treated with RLP068. A sample for microbiological culture was collected at the first visit before and immediately after the application of RLP068 on the ulcer surface, and the area was illuminated for 8 minutes with a red light. The whole procedure was repeated three times per week at two centers (Florence and Arezzo, Italy) (sample A), and two times per week at the third center (Stuttgart, Germany) (sample B) for 2 weeks.
Sample A and sample B were composed of 55 and nine patients, respectively. In sample A, bacterial load decreased significantly after a single treatment, and the benefit persisted for 2 weeks. Similar effects of the first treatment were observed in sample B. In both samples, the ulcer area showed a significant reduction during follow-up, even in patients with ulcers infected with gram-negative germs or with exposed bone.
RLP068 seems to be a promising topical wound management procedure for the treatment of infected diabetic foot ulcers.
Onychomycosis is a chronic nail infection caused by dermatophytes, Candida, nondermatophyte molds, and Trichosporon. The purpose of this study was to identify the underlying pathogen in patients with onychomycosis in our region.
A retrospective analysis of 225 cases with onychomycosis, diagnosed over a 27-month period at the Department of Dermatoveneorology, Bezmialem Vakif University, Istanbul, Turkey, and confirmed with culture, was performed.
Patient age ranged from 2 to 87 years (mean ± SD, 41.59 ± 17.61), and female patients were more commonly affected (120 cases, 53.3%) than male patients. Lateral and distal subungual onychomycosis was detected in 180 cases (80%). Etiologic agents were as follows: Trichophyton rubrum, 77 cases (34.2%); Trichophyton mentagrophytes, 30 cases (13.3%), Candida albicans, 28 cases (12.4%); Candida parapsilosis, 25 cases (11.1%); Acremonium species, one case (0.4%); Aspergillus species, two cases (0.9%); Fusarium species, four cases (1.3%); and Trichosporon species, three cases (1.3%).
The most frequent isolated etiologic agents were T rubrum for toenails and C albicans for fingernails.
Magnetic resonance imaging (MRI) is both sensitive and specific in the diagnosis of osteomyelitis, and it is an important imaging modality in preoperative planning of resection of infected bone. In many cases, however, the extent of osseous infection is evident on plain radiographs, and little additional information is gained from the MRI. The goal of this study was to assess the accuracy of radiographs against MRIs in assessing the spread of suspected osteomyelitis from one phalanx to another or to a metatarsal.
A medical record review was performed, and 14 patients with 16 toes confirmed to have osteomyelitis involving one or more phalanges were included in the study. An investigator blinded to the MRI findings interpreted the extent of osseous involvement based solely on the radiographic and clinical presentation. The accuracy of the radiographic interpretation was then calculated against the MRI findings.
In 14 of the 16 toes (87.5%), whether osteomyelitis had spread from one bone to another was determined based on the radiographic and clinical presentation. In one toe, the radiograph did not adequately depict osteomyelitis in adjacent infected bone. In one more toe, the radiograph depicted features of osteomyelitis in uninfected bone.
In a large percentage of patients, the phalanges affected by osteomyelitis had visible findings on the radiograph, and operative planning could have been based on the radiograph alone.
Maggot Therapy in “Lower-Extremity Hospice” Wound Care
Fewer Amputations and More Antibiotic-Free Days
We sought to assess, in a case-control model, the potential efficacy of maggot debridement therapy in 60 nonambulatory patients (mean ± SD age, 72.2 ± 6.8 years) with neuroischemic diabetic foot wounds (University of Texas grade C or D wounds below the malleoli) and peripheral vascular disease. Twenty-seven of these patients (45%) healed during 6 months of review. There was no significant difference in the proportion of patients healing in the maggot debridement therapy versus control group (57% versus 33%). Of patients who healed, time to healing was significantly shorter in the maggot therapy than in the control group (18.5 ± 4.8 versus 22.4 ± 4.4 weeks). Approximately one in five patients (22%) underwent a high-level (above-the-foot) amputation. Patients in the control group were three times as likely to undergo amputation (33% versus 10%). Although there was no significant difference in infection prevalence in patients undergoing maggot therapy versus controls (80% versus 60%), there were significantly more antibiotic-free days during follow-up in patients who received maggot therapy (126.8 ± 30.3 versus 81.9 ± 42.1 days). Maggot debridement therapy reduces short-term morbidity in nonambulatory patients with diabetic foot wounds. (J Am Podiatr Med Assoc 95(3): 254–257, 2005)
An Assessment of Intralesional Epidermal Growth Factor for Treating Diabetic Foot Wounds
The First Experiences in Turkey
Intralesional epidermal growth factor (EGF) has been available as a medication in Turkey since 2012. We present the results of our experience using intralesional EGF in Turkey for patients with diabetic foot wounds.
A total of 174 patients from 25 Turkish medical centers were evaluated for this retrospective study. We recorded the data on enrolled individuals on custom-designed patient follow-up forms. Patients received intralesional injections of 75 μg of EGF three times per week and were monitored daily for adverse reactions to treatment. Patients were followed up for varying periods after termination of EGF treatments.
Median treatment duration was 4 weeks, and median frequency of EGF administration was 12 doses. Complete response (granulation tissue >75% or wound closure) was observed in 116 patients (66.7%). Wounds closed with only EGF administration in 81 patients (46.6%) and in conjunction with various surgical interventions after EGF administration in 65 patients (37.3%). Overall, 146 of the wounds (83.9%) were closed at the end of therapy. Five patients (2.9%) required major amputation. Adverse effects were reported in 97 patients (55.7%).
In patients with diabetic foot ulcer who received standard care, additional intralesional EGF application after infection control provided high healing rates with low amputation rates.