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05/13/2014
RESPONSES/COMMENTS (CLINICAL)
From: Bryan C. Markinson, DPM
There are several topical treatments for both basal and squamous cell carcinoma, PROVIDED that the lesions are singular and have not spread to lymph nodes. The poster does not say why the patient is homebound. In any case, before treatment is begun, the patient needs a total body survey and lymph node exam. In my opinion, topical treatment of these cancers is best left to those who do it regularly, or if in this situation, it is possible for the DPM to consult with a dermatologist for advice, I would do so. I would definitely not fly solo, especially since the full evaluation of this may raise scope issues for the DPM. Kudos for the clinician who did the biopsy to get the diagnosis.
Other messages in this thread:
03/04/2025
RESPONSES/COMMENTS (CLINICAL)
RE: Plaque-Like Calluses on Weight-Bearing Surfaces
From: PM News Subscriber
This is a picture after I scraped away most of the plaque-like calluses. From this, I used a skin curette and obtained keratin samples that were sent to the lab for PCR testing. Results in three days. The lab returned: MRSA. I would do this before any invasive biopsy.
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Plaque-Like Calluses on Weight-Bearing Surfaces |
It treated well with mupiricin 2% ointment for one month.
PM News Subscriber
03/03/2025
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Gary S Smit, DPM, Elliot Udell, DPM
I have seen this as a side-effect of medications. This is anecdotal, but I've seen it with anxiety medications like Zoloft and I saw it once as a side-effect from an artificial insulin product. This is very frustrating to treat. I think that oral antifungals is a good idea.
Gary S Smit, DPM, Kme, PA
I recommend doing the biopsy because if it turns out to be psoriasis or some other autoimmune disease, there are great new drugs available that can address these issues.
One patient of ours had psoriatic plaques all over his body. He went from dermatologist to dermatologist for years and still suffered. Finally, he was placed on Skyrizi and within a short period of time, he had resolution of all of his plaques and feels like a new person. Please let all of us know what the final diagnosis turns out to be.
Elliot Udell, DPM, Hicksville, NY
03/03/2025
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: PM News Subscriber, David P. Luongo, DPM
This is a picture of my patient with T-cell lymphoma. A biopsy of your patient may be a good idea.
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Plaque-Like Calluses on Weight-Bearing Surfaces |
PM News Subscriber
I've seen this before. For my patient, it was the onset of menopause where there was a sudden change in hormones. Have that checked out.
David P. Luongo, DPM, Paramus, NJ
02/04/2025
RESPONSES/COMMENTS (CLINICAL)
From: Chuck Langman, DPM
I am also in the Philadelphia area and refer to David Dwyer, MD at Jefferson University Hospital. I believe he does pinpoint radiation for it. I’m not sure if that is appropriate for an 11-year-old but it is certainly worth the call.
Chuck Langman, DPM, King of Prussia, PA
12/12/2024
RESPONSES/COMMENTS (CLINICAL)
RE: Can a Nail Like This Ever Regrow Normally?
From: Christopher Stewart, DPM
The short answer is “YES”, a gryphotic/mycotic nail CAN grow back normally if the root causes are properly addressed. Over the past 20 years, I’ve had more successes than failures in tackling these nails. In my experience, osteochondromas are only a small part of the overall solution. We find these growths need to be removed about 74% of the time.
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Before and after photos |
As an aside, I no longer perform radiographic screening for these deformities because intraoperatively I was often getting surprised by chondromas once the offending nails were avulsed. These firm, protruding radiolucent chondromas must also be removed because they are just as problematic to nail attachment as true “bone spurs”.
Christopher Stewart, DPM, Charlottesville, VA
12/11/2024
RESPONSES/COMMENTS (CLINICAL) - PART 2
From: Ron Har-Zvi, DPM
The onychomycotic hallux nail can grow back normally if it is caused by an underlying subungual exostosis, either osseous or cartilaginous. I am retired but when I was practicing, I was 3 for 3 on correcting this condition. All 3 patients were in their 40s or 50s, and all 3 nails were normal after 1-2 years. The mycotic nail was removed 2-3 weeks before the bone surgery.
Ron Har-Zvi, DPM, Wayne, NJ
12/11/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1
From: Ivar E. Roth DPM, MPH, Jeffrey Kass, DPM
It is possible but first you must get rid of the fungus. Sometimes you may have to use ½” paper tape at the distal end of the toe to hold down the soft tissue. I am trying something new and that is applying a KeryFlex nail to put pressure on the distal tip to flatten out as the nail grows over. I will report on if this works. Plan on treating for an extended period of time as these nails are difficult to convert to “new nails”, but I have done it on occasion.
Ivar E. Roth DPM, MPH, Newport Beach, CA
I thank Dr. Weiss for linking us to his informative and very well written article on onychocrptosis and subungual exostosis. I am not sure how often the abnormal nail is a result of abnormal distal phalanx, but the intimate relationship he brings up is certainly of clinical value. Good job.
Jeffrey Kass, DPM, Forest Hills, NY
12/10/2024
RESPONSES/COMMENTS (CLINICAL)
From: David T Weiss, DPM, R. Alex Dellinger, DPM
Regarding the above question, it is common for a nail to grow poorly due to the underlying bone. Remember, the nail grows right on top of the distal phalanx. If there is an underlying bony or cartilage defect, the growth of the nail will continue to be pathological. Once the defect is surgically removed, the nail matrix typically creates more cosmetically pleasing nail tissue.
It takes SEVERAL nail cycles for this to happen, and the patient needs to be educated that it will take a while before they notice improvement. In addition, I will have my patients take collagen powder and Biotin. I published a recent paper on this condition and the treatment options involved in managing the growth of the nail.
David T Weiss, DPM, Richmond, VA
No.
R. Alex Dellinger, DPM, Little Rock, AR
12/06/2024
RESPONSES/COMMENTS (CLINICAL)
RE: Treatment of Onychomycotic Onycholysis
From: Elliot Udell, DPM
The toenail depicted is something we see commonly. It may be caused by trauma to the matrix and/or the underlying bone. Severe onychomycosis which damaged the root of the nail may be a culprit, or it may be an arthritic spur on the bone which is pushing up and not allowing the nail to grow out. Because the patient was living with this for a long time, conditions beneath the underlying nail present a perfect medium for all sorts of fungi and bacterial growth.
Culturing that area is akin to culturing the bottom of a garbage can. You will see lots of things growing which may not be clinically relevant. Treatment options: Debride the non-attached nail back to where it is still attached or remove the entire nail and give the patient a slim hope that it will regrow normally. Removal of the matrix is also a possibility and then the "sick" nail will be history. X-rays of the toe should also be taken to rule out a dorsal exostosis, and if this exists, it may have to be addressed surgically. If you do, opt to remove the entire nail with or without a matrixectomy; the specimen should be sent to a dermatopathology lab where they will examine the attached skin and make sure that you are not dealing with a neoplastic disease.
Elliot Udell, DPM, Hicksville, NY
10/15/2024
RESPONSES/COMMENTS (CLINICAL)
From: Kenneth Meisler, DPM
If you write enough Jublia, you are going to see the1-2% adverse reactions including dermatitis, vesicles, and pain that were described in the clinical trials. They did not describe it as an allergic reaction. If you write enough Jublia, you will see these reactions and I have. Dr. Lanthier thought it looks like the sequela from an onychia. I do not agree. I have found that it always responds to treatment as if it were an allergic reaction. I instruct the patient to discontinue the medication and apply topical steroid cream. If it were an onychia, some of the patients would probably not respond to that treatment.
Dr. Blum said, "one of the warnings when using Jublia is to avoid using on the skin." The application instructions state to apply to the nail and the "folds of the skin next to the sides of the toenail and underneath the end of the toenail," which is what I tell all patients. Interestingly, I have had patients who were on Jublia for many months before they started to develop these allergic-like symptoms, and many of them were extremely disappointed they had to stop because they were already seeing improvement. The very small amount of easily treated adverse reactions make Jublia an extremely safe medication.
Kenneth Meisler, DPM, NY, NY
10/14/2024
RESPONSES/COMMENTS (CLINICAL)
From: Larry Price, DPM
I actually saw an identical case/reaction to Jublia this week on all 10 toes. Immediate cessation and application of topical steroid cleared it up in a week.
Larry Price, DPM, Westwood, NJ.
10/12/2024
RESPONSES/COMMENTS (CLINICAL)
From: John Lanthier, DPM, Donald Blum, DPM, JD
There is a 1% incidence of onychia and 1% incidence of onychocryptosis from the use of efinaconazole according to the safety information packet. This looks like the sequela from an onychia.
John Lanthier, DPM, Sudbury, Ontario
One of the warnings when using Jublia is to avoid using on the skin. Perhaps the patient had a reaction to the medication getting on the skin? See the medication insert and warnings.
Donald Blum, DPM, JD, Dallas, TX
10/09/2024
RESPONSES/COMMENTS (CLINICAL)
From: Elliot Udell, DPM
Dr. Rubin is starting an interesting discussion. What rudimentary tests, learned at our academic clinics, should stand the test of time and what tests ultimately fade the moment the student graduates? For example, we learned the Buerger test when I was a student back in the late '70s but the test did not have longevity as compared to other tests that we still do today to evaluate arterial circulation.
Several years ago at a board meeting of the American Society of Podiatric Medicine, we tried to come up with a consensus on how to screen diabetics for peripheral vascular disease. Each practitioner was in some respected area of academia. Each had his or her pet set of tests that differed from the others in the room, including one who touted the Buerger test. We set out to formulate a consensus but realized that among the academicians in that room, there was and would not be a consensus.
Elliot Udell, DPM, Hicksville, NY
10/08/2024
RESPONSES/COMMENTS (CLINICAL)
RE: Should we sometimes go back to the future in diagnostic testing?
From: Lawrence Rubin, DPM
Valuable amputation prevention information about accomplishing early detection of PAD was recently posted in LinkedIn by Dr. David Armstrong. While reading it, I was bitten by the nostalgia bug; I was reminded of the testing for peripheral artery disease we depended upon back in the 1960s. I was a faculty member and clinical instructor at the Illinois College of Podiatric Medicine (now Scholl College of Podiatric Medicine). A routine test for what was then called "arterial insufficiency" (not PAD) was the Buerger test. The test is performed with the patient laying supine on the examining table and raising each leg individually to 45 degrees, then observing any blanching. Next, the patient sits on the side of the examining table and lets the legs hang down for about a minute.
Red flushing of the foot and ankle area skin helps confirm the diagnosis of arterial insufficiency. We also used to gently pinprick an area of the foot, usually on the top of the great toe, and then place a drop of dilute histamine solution on the area if the patient had no allergies. A small reddish area should appear, and the longer it took to appear, the more likelihood it was that there was arterial insufficiency.
My guess is that few if any clinicians are presently performing either of these tests, and maybe kudos are due to those who are. Those not giving kudos would be the commercial entities whose existence depends upon the robust sale of expensive equipment needed to establish a presumptive diagnosis of PAD.
Lawrence Rubin, DPM, Las Vegas, NV
08/14/2024
RESPONSES/COMMENTS (CLINICAL)
From: Bret Ribotsky, DPM
Marty - I join you in taking this first step that I hopefully everyone did 20 years ago. Today (or at least for the last decade since I was a founder of DermFoot), I’ve been recommending a dermatoscope to replace the proverbial stethoscope. I think Bill Scherer said it best, if you haven’t seen a skin cancer this week in your practice, it has seen you.
Bret Ribotsky, DPM, Fort Lauderdale, FL
08/09/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Paul Kesselman, DPM
Kudos to Dr. Pressman for pointing something out which I have been preaching for my over 40+ years as a clinician. I first came aware of non-invasive vascular technology back in the late 1970s and early ‘80s during my undergraduate medical education at rotations at various VA hospitals in the Chicago area. In those days, the machines were big, bulky, and took up an entire room. Their costs and size relegated them mostly to large clinical or research facilities.
With computer technology, eventually the machinery got more sophisticated and totally paper free and can integrate directly into your computer and eventually into your patient's EMR. Most cost 1/3 of what digital x-rays cost, with many fitting into your briefcase. The current machinery can combine pulse volume recording and photoplethysmography, which are far more sophisticated than...
Editor's note: Dr. Kesselman's extended-length letter can be read here
08/09/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Jeffrey Kass, DPM
I’d like to thank Dr. Pressman for the free pearl. I sincerely appreciated the pearl and was ecstatic for the first time someone was not trying to extract money from me. I have also come across patients with palpable pulses who have had stenosis or occlusions and the pearl he has shared is of utmost value.
Jeffrey Kass, DPM, Forest Hills, NY
08/08/2024
RESPONSES/COMMENTS (CLINICAL)
RE: Replace Your Neck Stethoscope with a Hand-Held Doppler to Save Limbs
From: Martin M Pressman, DPM
Podiatry standard of care requires us all to palpate pedal pulses. This standard alone is simply not high enough to get the job of limb preservation done. The following list contains some hard won knowledge acquired over the last 47 years of practice; hard won pearls given freely with the hope that some of the 20,000 subscribers might take notice. This note was motivated by a leg-off case where the podiatrist found +2 pulses and 9 days later the patient had an AK amputation for thrombosis. The current standard of care is pulse palpation. If a Doppler were used, perhaps this could have been avoided.
1. Your cardiologist does not palpate your heart; she uses auscultation with a stethoscope to hear cardiovascular flow abnormalities.
2. We need to up our game and use...
Editor's note: Dr. Pressman's extended-length letter can be read here.
07/30/2024
RESPONSES/COMMENTS (CLINICAL)
From: Donald Blum, DPM
Send the patient to a dermatologist for biopsy, please.
Reviewing this dermatology website, there are about 14 different items that this could be. Without a detailed history, perhaps using dermoscopy, and yes a nail unit biopsy could give you a more definitive diagnosis.
Donald Blum, DPM, Dallas, TX
05/03/2024
RESPONSES/COMMENTS (CLINICAL)
From: Howard Bonenberger, DPM
I appreciated the comments by Jeffrey Trantalis, DPM, however to be clear, I was writing specifically about FHL. This is worth learning about. Addressing it effectively will not only help your patients, it can grow your practice because your orthotic solved a problem that someone else's did not.
Howard Bonenberger, DPM, Nashua, NH
05/01/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1B
RE: Functional Hallux Limitis
From: Howard Dananberg, DPM
Howard Bonenberger mentioned in a post last week that one of my lectures on functional hallux limitus (FHL) inspired him to treat patients with chronic postural complaints. I appreciate his comments and am glad he was able to find these concepts valuable. I have written extensively on FHL over my career, and have come to the realization that this concept remains misunderstood. The reason why it can impact postural form lies in the following principle. Once the hallux makes ground contact during any step, IT DOES NOT MOVE AGAIN UNTIL TOE-OFF. ln any form of hallux limitus (structural or functional), what is restricted is not the hallux, but the remainder of the foot and proximal structures all the way to the neck.
As the body adjusts for these motions, various sites are stressed repeatedly during each step cycle. And since these motions are repeated thousands of cycles per day, the stress becomes a chronic irritant. In particular, loss of MTP joint motion restricts heel lift, shortens stride length, and causes the ensuing swing phase to be altered in such a way as to make toe-off mechanically inefficient. Since the iliopsoas is the primary hip flexor at toe-off, and originates directly from the lumbar spine, it becomes the site of pain. The references for this are below.
Howard Dananberg, DPM
05/01/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1A
RE: Functional Hallux Limitis
From: Jeffrey Trantalis, DPM
Howard Bonenberger, DPM hinted about a very important and prevalent condition that is seen in many, if not all, podiatry offices. This is hallux limitus. In the early 1980s, I had a professional NFL receiver come to me with hallux limitus. It was obvious that conservative treatment was the only option. At that time, orthotics with a hallux extension was the recommended treatment. So I tried this very treatment, knowing it would probably fail. Well it did fail.
At that time, I dispensed an orthotic where I increased the ability to plantarflex the first metatarsal by supporting the 1st metatarsal-cuneiform joint. This allowed for a more normal function of the first MPJ. This was very successful treatment that allowed the receiver to make his route maneuvers.
Jeffrey Trantalis, DPM, Delray Beach, FL
03/25/2024
RESPONSES/COMMENTS (CLINICAL)
From: Michael A. Uro, DPM
While I am very happy that Dr. Marino responded well to his carpal tunnel surgery, I wanted to point out that MLS laser treatments can help to minimize and in some cases totally alleviate the symptoms of carpal tunnel syndrome.
I have an MLS laser in my office. I was experiencing bilateral carpal tunnel syndrome. I treated myself using the laser, and after 3 to 4 treatments my symptoms subsided. I realize that not everyone has an MLS laser; however, if you can perhaps find a chiropractor or other practitioner who has one, I would recommend this treatment. Obviously, as podiatrists, we cannot treat carpal tunnel syndrome. Again I treated myself. The laser works on numerous nerve conditions on feet, such as tarsal tunnel syndrome and neuromas.
Michael A. Uro, DPM, Sacramento, CA
03/22/2024
RESPONSES/COMMENTS (CLINICAL)
From: Vince Marino, DPM
I recently (2 weeks ago) had bilateral carpal tunnel surgery done at one time. It took about 45 minutes under MAC. No post-op splints. I had minimal discomfort and was back in the office seeing patients (no palliative care) at 10 days post-op (included the weekend). I will be back doing surgery tomorrow at 17 days post-op.
My nerve studies were very abnormal and my fingertips constantly numb. Now I have no issues. I highly suggest you see a trained hand surgeon and talk about fixing the problem before it gets worse.
Vince Marino, DPM, Novato, CA
03/13/2024
RESPONSES/COMMENTS (CLINICAL) - PART 2B
From: Robert Kornfeld, DPM
I have spent more than 30 years treating chronic foot and ankle pain and have had many cases of “recalcitrant” PT tendinitis. Once you come out of the “next best treatment” mentality and focus on the patient, you will find answers. Functional medicine teaches you to examine the patient's total health landscape to uncover immune burdens and any epigenetic and genetic issues (SNPs) which will create inefficiency in repair pathways. These underlying mechanisms are managed prior to any treatment. Once you have up-leveled immune function, you can heal these chronic cases via regenerative medicine injection therapies. This is how every doctor should be practicing. I have loved my practice all these years.
Robert Kornfeld, DPM, NY, NY
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