The infected diabetic lower extremity has enjoyed a surge in popularity in the medical literature. There have been numerous papers outlining classification systems for ulcer depth, surgical approaches, and microbiology. Discussions on antibiotic use have usually been directed toward therapy of the "diabetic foot infections" as a group, without regard to differences in severity and location of these infections. These infections can vary from the most superficial of processes to a severe life- and limb-threatening sepsis. The author presents a review of the processes involved in the diabetic lower extremity infection and suggests a classification system for selection of empiric antibiotic therapy based on the severity of the infection.
The author discusses the new oral antifungal agents for the treatment of onychomycosis. The history, mechanisms of action, efficacies, dosing, safety profiles, and costs of itraconazole, terbinafine, and fluconazole are reviewed. The author emphasizes that use of these effective antifungals represents an important paradigm shift for podiatric physicians away from the palliative therapy of nail debridement to a potentially curative treatment.
By following a systematic approach to the patient history, physical examination, and laboratory analysis in cases of infections, rapid and accurate therapeutic intervention becomes possible. This action can prevent possibly devastating infectious complications, ranging from partial amputation to death. The current litigious climate dictates thorough evaluation and documentation of all infectious diseases of the lower extremity.
Ciclopirox 8% nail lacquer has recently become the first topical antifungal agent to be approved by the US Food and Drug Administration for the treatment of onychomycosis. This article reviews the results of the two pivotal clinical trials of this drug that have been performed in the United States as well as those that have been carried out in other countries. The two US studies were both double-blind, vehicle-controlled, parallel-group, multicenter studies designed to determine the efficacy and safety of ciclopirox nail lacquer in the treatment of mild-to-moderate onychomycosis of the toenails caused by dermatophytes. The combined results show a 34% mycologic cure rate, as compared with 10% for the placebo. Data from the ten studies conducted worldwide show a meta-analytic mean (+/- SE) mycologic cure rate of 52.6% +/- 4.2%. As expected for a topical agent, ciclopirox nail lacquer was found to be extremely safe, with mild, transient irritation at the site of application reported as the most common adverse event. Ciclopirox nail lacquer may also have potential for use in combination or adjunctive therapy. Further studies will help to better position this agent for the treatment of this widespread podiatric condition.