!

A posting on Barry Block’s Podiatry Management On-line today speaks of a subject that has been dear to my heart for many years.

                                                           Onychodystrophy vs. Onychomycosis.

 

The posting read:

 Discolored Nails Can Be Due to Micro-Trauma: Canadian Podiatrist

Podiatrists, such as Dr. Marshall Baer of Victoria, are more concerned with improper summer footwear than the toenails. And as for toenails, Baer said a big cause of discoloration or curling can be traced to allowing them to grow too long. When toenails become too long, or are not properly maintained, they can be subjected to repeated pressure applications, or “microtraumas” inside a shoe such as when the toes are jammed into the toe. 

“Repetitive micro-trauma injuries are the No. 1 cause of toenails to become discolored,” said Baer. “I see that all the time in my practice. A patient comes in and says ‘My GP says this is a fungus.’ I look at it and say ‘This is not a fungus, this is wear and tear on the toenail.’ ” The repetitive stress can also cause the toenail to lift off the nail bed and cause a painful blister underneath.

 

Now that summer is here and sandals and flip flops are exposing more and more ugly toenails, I think this is a great opportunity for podiatry to educate the public about them once and for all with white papers and appropriate input to the social and print media that is evidence based and accurate.

The dermatology community has been rather silent on this subject, Rxing Lamacil for the most part. IN opposition, the majority of the podiatry press and our website dialogue unfortunately has condensed the subject down to “fungal toenails” as we march our patients into a room with a laser and/or Rx/dispense an oral or topical antifungal medication without culture or biopsy evidence of infecting organisms in order to “cure” the etiology that “only we can unprofessionally see with our naked eyes”.

The media, the Internet and many practitioners armed with folklore, poor results, expert opinions and little evidence continue to foster that Ugly Toenails are inevitable if you go to a gym, swim in a pool or have your toenails treated with a pedicure when the immunological status, the shoe wardrobe, the inherited mechanics and the incubators of closed in shoes for harvesting bacteria, mold, yeast and fungus are primarily involved as Dr Baer advises.

Is it time for us to stand up as a profession and claim title to this subject IMHO with accurate information, patient education and a broad acumen of care, n=1, for those suffering from Ugly Toenails?

Dennis  

  • Comments (36)
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  • Dermoscopy can be a valuable tool regarding tinea 

    1. Regarding Tinea Nigra, wispy pigmentation can be a dermatoscopic finding.

    2. The spiked pattern is sometimes present in some cases of onychomycosis.

     

  • Three years have past since I suggested a multimodal treatment plan that includes toenail health, repetitive micro-trauma and underpinning biomechanical pathology as important pieces of "The Ugly Toenail Puzzle" on this thread and elsewhere.

    Curing (and I mean a clinical cure) remains an impossible, never considered goal in the care of ugly toenails by Podiatry.

    Our topicals remain 18% effective at best and we need DNA Testing in order to decide which one we need to use.

    Orthotics for ugly toenails "How Absurd" when  actually our current diagnostic protocols, treatments plans and curative goals demand me to statre "How Absurd.

    EBM:

    Ghannoum M, Isham N: Fungal Nail Infections (Onychomycosis): A Never-Ending Story?: PLOS pathogens; 2014 Jun; 10(6)  
     
    Is Onychomycosis Still a Problem?

    The great majority of superficial fungal infections are caused by dermatophytes, which belong to one of three genera (Trichophyton, Epidermophyton, and Microsporum), with T. rubrum being the most prominent cause of nail infection. Among superficial fungal infections, by far the most difficult to cure is toenail onychomycosis. In North America, the incidence of onychomycosis is up to 14% with fungal infection responsible for 50% of all nail disease. With millions of dollars being spent annually on oral and topical prescriptions, laser treatments, over-the-counter products, and home remedies, it is obvious that people are still bothered by their fungal toenail infections and are determined to get rid of them. Unfortunately, this is easier said than done. To successfully cure toenail onychomycosis requires long treatment duration that may extend to a full year. Even then, complete cure, defined as clinical cure (implying nail clearing) plus mycological cure (both negative microscopy and dermatophyte culture), is often unattainable.

    Dennis

  • Dr. Baer here, again.

    I have been non-practicing for a few years now due to spinal degeneration and neurogenic claudication. However, something has come to my attention that I thought was common knowledge--

    Chemical matrixectomies performed with phenol and alcohol" P&A's"
    need to be permanently shelved.

    One can greatly improve post-op healing results by using 10% sodium hydroxide in an aqueous base followed by white table vinegar lavage ( acetic acid). I will call this an
    "N&V"

    The mechanism is simple high school chemistry. NaOH a base + acetic acid = salt( sodium acetate) + H2O . This completely neutralizes the liquification necrosis of the remaining matrix cells.

    I thought this was common knowledge in the podiatric community but it has come to my attention that phenol
    and alcohol are still commonly used.

    Thank you
  •  

     

     

    RMT causing ingrowing, incurvating and onychodystrophy

     

     

     

      Fungus infection is late after the nail is compromized by RMT, Onycholysis and ingrowing corners.

     

    Dennis

     

     

  • Tinea Pedis 2 months Post Clinical Cure Onychodystrophy

    The n=1 Maintenance Program

     

     

    Sweaty Feet and Socks

    Damp Toe Box Environment

    Obvious tinea pedis

    Diagnostic Testing:    2 2mm biopsy punches

    Treatment: Pulse Dose Lamacil, foot powder, ETOH to shoes, topical antifungal, size shoes larger

     

    Treatment Pearl:

    Invest time in educating the patient and get them to commit to The Maintenance Program and schedule regular follow-ups to maintain clear toenails.

    Athletes Foot Poor Maintenance

     

     

     

     

     

     

     

     

     

     

    Dennis

  • 52 Y/O female

    Onychodystrophy, right hallux toenail, tibial border only (one toe, one side)

    Many years

    Previous Fungus treated with laser therapy and three months (120 days)

    Onychodystrophy remains

    Patient wears low toe boxed fashion shoes with and without heels

    Fibular borders of hallux, B/L were painfully ingrown with P&A procedures performed 20+ years ago

    Rigid, Flexible FFT with a high SERM-PERM Interval, Short Limb, left

    Impression:  Repetitive Microtrauma, hallux toenail, Right

    Treatment:

    Foot Centering Pads with lift left side

    Order shoe wardrobe modification to introduce higher toe boxed shoes with removable insoles

    Rx NuVail....OD or BID to hallux toenails

    RMT one corner one toe

    RMT one corner one toe Closeup

     

     

     

     

     

     

     

     

    Dennis

  • Primary Fungus Infection

    All ten nails

    PAS Positive Biopsy Moderate to Heavy Growth

    Heavy Sweating

    Chronic

    Concomittent Tines Pedis

    Subungual Debris and Hyperkeratinization

     

    Left Foot Debrided                               Right Foot Original Presentation

    Primary Fungus Jinfection Debrided

    Primary Fungus Infection

     

     

     

     

     

     

    Treatment:

    Lamacil Pulse Dosed

    Laser Therapy

    Reducing Moisture in Shoes

    Foot Powder

    Manual Debridement

    Chemical Debridement

    Treat Tinea Pedis

     

    Diagnostic Pearl:  It is difficult to clinically distinguish beyween Primary Fungal Infection and a Late Stage Secondary Fungal Infection

    Dennis

     

     

     

  • Chronic Toenail Dystrophy 2-3 RT Repetitive Microtrauma - Low Toe Boxed Shoes

     

    Patient presented with 6+ year history of ugly toenails 2 and 3 of the right foot only

    No other nails involved

    She presents with low toe boxed shoes bulging at the contact spots of the 2nd and 3rd toes distally

    Impression: RMT onychodystrophy

    Low Toe Box Shoe with 2-3 Bulge Plan: Higher toe boxed shoes

    Rx'd Nuvail

    RTO 2 months

     

     

    Dennis

  • Hallux Limitus/Rigidus Onychodystrophy

    Fungal biopsy/PAS Negative

    Hallux is the only/major digit of involvment

    Precursor Hallux Limitus/Rigidus

    Shoe Toe Boxes often involved

     

    Hallux Rigidus Onychodystrophy

     

     

     

    Treatment:

    Treat the Precursor Hallux Limitus.Rigidus

    LifeStyle Adjustments to Avoid Overuse

    Shoe Modification, prn

    Observe Toenail Clearing Over Time

    Measures to Reduce/Prevent Onycholysis as Toenails Clear

    Dennis

  • Ballistic/Acute Trauma Onychodystrophy

    Fungal biopsy/PAS Negative

    Sudden Onset

    History of Acute Injury or Overuse

    History of Overusing a Pair of Tight Shoes

    subungual hematoma great toes

     

     

     

     

    Treatment:

    Observe Toenail Clearing Over Time

    Measures to Reduce/Prevent Onycholysis as Toenails Clear

    Nuvail

    Generous Shoes

    LifeStyle Adjustments to Avoid Overuse

    Dennis

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