By: Neil Scheffler
This case study is presented by Dr. Neil Scheffler, our foot care advisor and a podiatrist at the Baltimore Podiatry Group in Baltimore, Maryland.
A patient came into my office complaining of drainage on his sock in the area of the big toe. He was 51 years old and had non-insulin-dependent diabetes. On examination the right great toe was red and swollen. Pus was present in the corner of the nail. There was no pain present. The nail plate was thickened, had a yellowish discoloration and was brittle. His other nails were similarly abnormal in appearance. Pulses in both feet were good.
The patient had an ingrown nail with a bacterial infection. In addition, the nail had a fungal infection present which appeared to be the cause of the nail changing shape and growing into the skin. There was no pain present because the patient also had diabetic neuropathy which was confirmed by testing with a 5.07 monofilament fiber. This absence of pain delayed his noticing the ingrown nail and infection.
I treated the patient by removing a small piece of the toenail, allowing the infection to drain. He was given an antibiotic to apply to the toe to treat the local infection. The area healed well. This patient was lucky-he had caught the problem before it was too late. I treated it aggressively, plus he had good circulation allowing the area to heal. If he had had circulation problems the results may not have been as favorable. With poor circulation, minor infections can progress to major infections, gangrene and eventual amputation.
Once this area healed I needed to address the cause of the ingrown nail. In this case, it was a fungal infection of the nail. This fungus is the same type of organism that causes athletes foot, but instead of growing in the skin it attacks the nail. It is contagious and can be spread to other members of the household. Many people live with the fungus because it is painless or they may consider it a cosmetic problem. However, in people with diabetes, it is important to treat this condition more aggressively.
Treatment of these fungal nail infections, medically known as onychomycosis, has recently improved with the availability of oral medications that can eliminate the fungus. The medication is usually taken for three months but remains in the nails for many more months. This allows the nail to continue to grow to its full length without the fungus present. Since there are some potential side effects, such as the medication affecting the liver, I monitor my patients with blood tests and stop the medication if problems arise.
There are also topical medications that can be used on the nails. These liquids are not very effective, however, and must be applied twice daily for over a year.
Many of my patients with diabetes who have fungal nails and have not used medication come to see me on a regular basis. Every two to three months I examine their feet and debride their nails. Since so many of these patients have either poor circulation or neuropathy, caring for their own nails is dangerous. Insurance companies, including Medicare, understand the risks of inadequate foot care for people with diabetes and pay for this podiatry care.
Even seemingly minor disorders, such as fungal nail infections or an ingrown nail, pose great risks for those with diabetes. Every person with diabetes should seek a podiatrist’s help at the earliest sign of one of these, or any other, foot problems.