Discolored toenails is a common complaint presented to podiatric physicians, dermatologists, and primary-care physicians. Although various local and systemic conditions influence changes in nails, nearly 50% is due to fungal infections. We surveyed the health professions student population to gain insight into how future medical professionals may approach this condition and to explore perceptions of onychomycosis, treatments, and effects on quality of life.
The primary outcome measure was a self-reported online Google Forms survey developed by the authors and sent to podiatric, allopathic, and osteopathic medical students and nursing students in Philadelphia, Pennsylvania.
Of the 245 respondents, 92% agreed that toenail fungus is both a health and a cosmetic concern. Seventy-seven percent of respondents said “yes” when asked if they would seek treatment, and 67% would wait 1 month to 1 year to see a medical professional. When seeking treatment, 57% reported that they would see a primary-care physician initially, and 27% and 5% would seek care from a podiatric physician or dermatologist, respectively. A total of 91% would spend up to $300 annually for treatment, with only 4% willing to spend more than $500 per year. Respondents' greatest concern would be physical appearance.
Although agreement exists among the health professions students surveyed that toenail fungus presents both a cosmetic and a health concern, inconsistencies regarding time to treatment, treating professional, and effects on quality of life persist. It is not reasonable for all medical professionals to effectively recognize and treat nail disease, but it is paramount that patients are directed to medical professionals who can accurately exclude other conditions to alleviate social and financial burdens patients may face due to onychomycosis.
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.
Medical students (MSs) in allopathic and osteopathic medical programs may not be adequately exposed to the role of podiatric physicians and surgeons in health care. We explored perceptions of the specialty field of podiatric medicine from the perspective of MSs in the Philadelphia, Pennsylvania, area.
In this cross-sectional survey study, responses regarding podiatric education and scope of practice were collected via a 16-question, self-reported, anonymous online survey distributed to MSs at one osteopathic and three allopathic medical schools in the Philadelphia area. Inferences and conclusions were drawn from the percentages of respondents. Statistical analyses for school of attendance, year of study, and physician relative subgroups were performed.
The 129 survey responses obtained revealed misunderstandings regarding podiatric education and training. Only 45.7% correctly answered that podiatric medical students do not take the United States Medical Licensing Examination. The results also showed the perception of podiatry in a positive light, with approximately 80% of respondents agreeing that the term doctor is applicable when referring to a podiatrist. Respondents with a physician relative were more likely to rate podiatry's role in health care higher on a scale from 0 (inessential) to 5 (equivalent to MDs/DOs) than those without a physician relative.
The results of this preliminary survey were generally positive and optimistic while also identifying some misconceptions regarding MS perceptions of podiatric medical training and scope of practice. Further studies are needed to evaluate perceptions of podiatry from the perspective of other members of the health-care team to improve interprofessional relations and understanding.
Hyperhidrosis is defined as excessive and uncontrollable sweating due to overactivity of the eccrine sweat glands. The first line of treatment for plantar hyperhidrosis consists of conservative therapies such as topical solutions (ie, antiperspirant applications and aluminum chloride preparations) and iontophoresis. When the patient has failed these standard treatments, the other available medical options are rather limited and not well tolerated. Botulinum toxin type A (Botox, Allergan Inc, Irvine, California) is a purified neurotoxin complex approved by the US Food and Drug Administration in 2004 for multiple medical conditions, including severe primary axillary hyperhidrosis that failed conservative topical therapies. Few recent clinical studies have suggested that botulinum toxin is effective in the treatment of plantar hyperhidrosis. In this case study, two patients received intradermal injections of botulinum toxin type A into the plantar aspect of both feet. A 3-month follow-up evaluated the efficacy of botulinum toxin type A by subjectively assessing the amount of residual sweating. In these two patients, botulinum toxin type A was an effective and safe treatment for plantar hyperhidrosis. (J Am Podiatr Med Assoc 98(2): 156–159, 2008)
The proximal interphalangeal joint arthrodesis is frequently performed to correct hammer toe deformities. This study was conducted to compare the inherent stability of the three proximal interphalangeal joint arthrodeses—peg-in-hole, end-to-end, and V constructs—in the sagittal plane by means of load-to-failure testing of 30 fresh-frozen cadaveric specimens fixated with a 0.045 Kirschner wire. The peg-in-hole construct was associated with significantly higher peak loads at failure compared with the other two procedures. Furthermore, the peg-in-hole construct had significantly higher stiffness values as compared with the V procedure. This study thus provides evidence that the peg-in-hole procedure is the most biomechanically stable surgical construct for proximal interphalangeal joint fusions under sagittal plane loading. (J Am Podiatr Med Assoc 91(2): 63-67, 2001)
INTRODUCTION AND OBJECTIVES: Psoriasis is a systemic condition with several dermatological manifestations that affect many individuals on a daily basis. According to Langley et al in a study titled “Psoriasis: epidemiology, clinical features, and quality of life,” psoriasis affects 2% of the American population, which is approximately 6 million people. Out of these 6 million people, approximately 2–3% are affected by palmoplantar psoriasis (Farber et al). Plantar psoriasis in particular can cause significant functional and social disabilities. To date there is paucity of information regarding the standard of treatment for plantar psoriasis. We will attempt to compile and summarize the research that will help doctors treat patients with plantar psoriasis using evidence-based medicine.
METHODS: A thorough review of the literature that has been published regarding the care of plantar psoriasis will be investigated and summarized. In this effort, we aim to create a resource to aid the physician in designing a treatment plan for the patient that will be most effective with the highest rate of successful skin clearance.
RESULTS: Although many studies have been done about psoriasis and its many forms, not much has been published focusing on plantar psoriasis. There lacks one concise source in regards to which treatment is most efficacious. We predict that through a thorough literature review an effective treatment protocol can be developed for plantar psoriasis.
CONCLUSIONS: The intent of this study is to perform a literature review on various treatment modalities to develop a protocol to medically manage plantar psoriasis.
INTRODUCTION AND OBJECTIVES: The benefits of using amniotic tissue in skin regeneration are well documented. Today, cryopreservation technology allows for better availability and maintenance of mesenchymal stem cells. This is of particular interest in treating the diabetic foot ulcer as this population has fewer mesenchymal stem cells. The objective of this case series investigation was to compare the efficacy of cryopreserved human amniotic stem cells in treating foot wounds of different etiologies. We will present data and case photos for a diabetic foot ulcer, venous leg ulcer, arterial ankle ulcer, and a pyoderma gangrenosum ulcer
METHODS: Cryopreserved human amniotic stem cell grafts were applied to patients with chronic ulcers of different etiologies that had been subjected to at least 4 weeks of standard wound care and did not show adequate clinical progress. Wound area was recorded and photographed on weekly basis. Area reduction was charted over time and the results of each individual case were compared to one another.
RESULTS: All ulcers displayed results that well exceeded the established parameters of weekly healing rates for effective wound treatment modalities.
â€¢ Pyoderma gangrenosum displayed the poorest response to treatment. However, it is worth noting that the patient was not compliant in the prescribed adjunctive treatment regimen but managed to achieve 64% wound reduction.
â€¢ All ulcers showed the largest appreciable amount of healing in both total area reduction and week-to- week closure percentage after the first application.
CONCLUSIONS: Cryopreserved human amniotic stem cell grafts can aid in the decreasing the time to closure of various types of lower extremity ulcerations. The therapy is a clinically viable option for physicians to consider when formulating a treatment plan for a patient with an ulcer.
A retrospective study was performed to compare the prevalence of complications in peg-in-hole and end-to-end arthrodesis procedures. The authors reviewed 177 second, third, and fourth proximal interphalangeal joint fusions for the correction of hammer toe deformities in 85 patients from 1988 to 1998 at the Temple University School of Podiatric Medicine. The average age of the patients was 49 years. Sixteen percent (14) of the subjects were male and 84% were (71) female. Upon follow-up, the fourth digit was generally associated with a greater number of complications for the end-to-end and peg-in-hole procedures, with the second digit being the most common site of fusion. The prevalence of complications was evaluated using contingency table analysis and expressed as a percent of total complications (27%, the end-to-end group; 17%, the peg-in-hole group). A subset of complications deemed clinically relevant was also computed. Similarly, the prevalence of clinically relevant complications for the end-to-end (10%) and the peg-in-hole (9%) procedures was not statistically significant. Therefore, this study showed no statistically significant differences in the total or clinically relevant complications between end-to-end and the peg-in-hole arthrodesis procedures. (J Am Podiatr Med Assoc 91(7): 331-336, 2001)
Onychomycosis is a fungal infection, and, as such, one of the goals of treatment should be eradication of the infective agent. Despite this, in contrast to dermatologists, many podiatric physicians do not include antifungals in their onychomycosis treatment plans. Before initiating treatment, confirmation of mycologic status via laboratory testing (eg, microscopy with potassium hydroxide preparation, histopathology with periodic acid–Schiff staining, fungal culture, and polymerase chain reaction) is important; however, more podiatric physicians rely solely on clinical signs than do dermatologists. These dissimilarities may be due, in part, to differences between specialties in training, reimbursement patterns, or practice orientation, and to explore these differences further, a joint podiatric medicine–dermatology roundtable was convened. In addition, treatment options have been limited owing to safety concerns with available oral antifungals and relatively low efficacy with previously available topical treatments. Recently approved topical treatments—efinaconzole and tavaborole—offer additional options for patients with mild-to-moderate disease. Debridement alone has no effect on mycologic status, and it is recommended that it be used in combination with an oral or topical antifungal. There is little to no clinical evidence to support the use of lasers or over-the-counter treatments for onychomycosis. After a patient has achieved cure (absence of clinical signs or absence of fungus with minimal clinical signs), lifestyle and hygiene measures, prophylactic/maintenance treatment, and proactive treatment for tinea pedis, including in family members, may help maintain this status.