In our era of evidence-based clinical practice, it’s surprising to hear about doctors who still practice in ways unsupported by the medical literature. It’s surprising but not out of the ordinary. Here are two podiatric myths that have been well debunked but somehow continue to exist.

Myth #1: Antibiotics for Ingrown Toenails

Like just about all podiatrists in the United States, ingrown toenails are a highly common pathology that I treat in the office. And like most podiatrists, these patients often come to me already on oral antibiotics prescribed by their primary care physician for an “infection.” Sometimes I even hear about podiatrists who do this. What does the science say?

Reyzelman and colleagues performed what I consider to be the best study to answer this question. They prospectively studied 154 patients with onychocryptosis and paronychia. Patients were randomized to one of three groups: (1) antibiotics plus phenol matricectomy at the initial visit, (2) antibiotics for a week and then phenol matricectomy one week later, or (3) a phenol matricectomy and no antibiotics. They found no difference between patients receiving antibiotics and matricectomy and those receiving matricectomy alone. Those receiving the antibiotics and matricectomy healed significantly faster than those receiving the delayed matricectomy.¹

In my book, this study is the definitive statement that proves we don’t need to prescribe antibiotics for ingrown nails. The appropriate treatment is immediate matricectomy for treatment of the foreign body reaction that is occurring. Antibiotics are necessary only in those cases with frank cellulitis of the digit, which for me is erythema and edema extending proximal to the interphalangeal joint when affecting the hallux. Some podiatrists perform only the nail avulsion with a matricectomy either at a later date or if the patient has a recurrence, but I would argue that in almost all cases, the matricectomy does not make the problem worse and eliminates the morbidity of a second procedure. Unfortunately, there is no definitive evidence-based study to answer this aspect of the question, but – completely non-scientifically – I’ve been using this method for 12 years without any known complications.

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“Performing the matricectomy at the initial visit does not make the problem worse and eliminates the morbidity of a second procedure”

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Myth #2: All Pedal Rashes are Tinea Pedis

This is probably the most common podiatric myth I’ve heard of during my time in this profession. This myth has been beautifully debunked by Dr Dockery in a recent lecture at the Western Foot and Ankle Conference.

Dr Dockery noted two studies to demonstrate this point. The first was a 1990 study by Broberg and Faergemann that found 100% of pediatric foot rashes in children between 1 and 14 years of age suspected of being tinea pedis were actually dermatidities.²

In the second study, Fuchs, et al performed cultures and PAS staining on 874 patients with a clinical diagnosis of tinea pedis. Of these patients, 68% were dermatoses, and only 32% were confirmed to be tinea.³

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“In the Fuchs study of 874 patients with a clinical diagnosis of tinea pedis, 68% were dermatoses, and only 32% were confirmed to be tinea.”

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When we see a rash on the plantar foot, it may be better to assume it is a dermatitis than tinea rather than the opposite, more commonly diagnosed today. Treating with a topical steroid right from the start appears to be a better option than starting with a topical antifungal. Of course, if we’re not sure, we should biopsy the lesion. It’s well known that podiatrists don’t take as much advantage of this procedure as we should, especially when compared with dermatologists, who seem to biopsy everything. For a heavily surgical specialty, it’s odd that podiatrists don’t push for more biopsies.

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“When we see a rash on the plantar foot, it is statistically more likely to be a dermatitis rather than tinea. Think twice before reflexively prescribing that topical antifungal…”

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Why do these mythconceptions still exist? I’m not certain why, but I’d hazard a guess that it’s simply more expedient to prescribe a medication than it is to face the reality, which may be a little more challenging. Primary care doctors are much less qualified to do nail surgery than podiatrists are, which is likely why the antibiotic-for-ingrowns myth persists so strongly in their circles and less so in ours. Similarly, it’s easier to chalk up every rash on a foot to dermatophytes rather than the more complex dermatitis.

Regardless of the reason, the evidence clearly points to a proper method of treatment for each of these dermal problems. Clearly podiatrists have “skin” in this game and should follow the evidence for best patient care.