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From: Steven J Berlin, DPM


I have been reading about podiatric training with the use of Mohs surgical therapy. It is fine for basal and squamous carcinoma and often very successful even though I would prefer the complete surgical excision of the lesions. However, when it comes to subungual melanoma, it is not the treatment of choice. Too often even in situ melanomas can be misdiagnosed and be in a class of acral lentiginous melanomas that often act very irrational. The treatment of these melanomas are a simple amputation of the distal portion of the digit. After all, subungual melanomas have one of the highest incidents for metastasis of the foot.  


Steven J Berlin, DPM, Baltimore, MD

Other messages in this thread:



From: Jeffrey Kass, DPM


The discussion of Mohs surgery has been going on for a few days. Some podiatrists have chimed in that this is something beyond the scope of podiatrists where other colleagues have disagreed stating you should be able to if you have the training. 


The NYSPMA apparently appears to side with the camp that podiatrists should NOT be able to perform Mohs surgery. This is evidenced by the podiatry scope bill that is currently trying to be passed. This bill which makes “technical corrections” to the bill specifies podiatrists are NOT allowed to perform Mohs surgery. 


Jeffrey Kass, DPM, Forest Hills, NY 



RE: Treatment for Ungual Melanoma in Situ (Leonard A. Levy, DPM, MPH)

From: Bryan C. Markinson, DPM


Dr. Levy’s persistence on the issue of podiatrists performing Mohs surgery on the foot is perplexing. He is supporting his opinion based on advances podiatry as a profession has made over decades regarding residency training and practice act changes. Dr. Levy asks, "Are we or are we not physicians?" Personal feelings aside, including mine, the fact is that this question is still a raging debate closer to question than consensus, and has nothing to do with performing Mohs surgery.


He states, "We should not be denied training to perform any kind of surgery on the foot and ankle." Really? Sorry Dr. Levy, when it comes to many kinds of surgery involving the foot, others may be more endowed with the requisite knowledge, training, and experience. Would Dr. Levy support removal of a malignant nerve sheath tumor by a ...


Editor's note: Dr. Markinson's extended-length letter can be read here.



From: Joe Agostinelli, DPM


Having read the back/forth on the “melanoma/Mohs surgery emails, Dr. Markinson has “hit the nail on the head.” Too many times, as DPMs, we think of obtaining clinical or surgical skills “to do a new surgery” as purely a “technical skill” without the requisite base knowledge accumulated by standard training. I looked up the requirements for Mohs post-graduate training which is one of two years post dermatology/plastic surgery residency. As DPMs, we can’t matriculate to these fellowships because of our degree! Dr. Markinson is absolutely correct in that there is a pathway - MD/DO, dermatology/plastic surgery residency/Mohs fellowship. 


Just obtaining the training is not a viable way to perform this technique. This is an issue of referring cases benefiting from Mohs surgery to the trained physician able to perform it, not DPMs!


Joe Agostinelli, DPM, Niceville, FL



From: Leonard A. Levy, DPM, MPH


A question arose by a reader of PM News regarding a submission that I wrote for the April 23, 2020 edition on Mohs surgery. Currently, such procedures are performed by dermatologists and, in some cases, by plastic surgeons. However, podiatric physicians in all states are licensed to perform foot surgery with virtually no restrictions. I suggest that the manufacturer that makes the materials to perform Mohs surgery be contacted (e.g., Henry Schein Medical). Perhaps they may also have the resources to train or arrange for the training of DPMs interested in becoming proficient in this now commonly performed procedure.


The profession should make whatever arrangements are needed for DPMs to acquire the required skill set for this potentially invaluable procedure. 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL 



From: Elliot Udell, DPM 


Reading Dr. Landsman's comment on Dr. Jacobs' comment reminds me of the story of a Rabbi who was called to counsel a married couple. He listened to the husband’s story and said he was right and then listened to the wife's story and said she was right. A bystander overhearing the conversation said, "Rabbi how can both of them be right?" The rabbi turned to him and said, "You are also right."


Dr. Landsman is correct in that the study quoted by Dr. Levy was based on a fairly small number of patients. With a sample being so small, incorrect conclusions can occur. On the other hand, Dr. Jacobs is also right. In our practice, many patients have come in over the years having paid thousands of dollars for laser treatments of their nails and pointed their finger at us saying, "you podiatrists are all a bunch of crooks." 


Could those patients have been inappropriately worked up and treated for some other ailment that causes nail thickening? It’s possible. Was the administrator of the treatment less than competent? That is also possible. Could it be that the therapy itself is not always effective? That too is possible. I hope that there could be more studies involving thousands of patients and only then will we be certain whether laser therapy for onychomycosis is clinically effective or a sham.


Elliot Udell, DPM, Hicksville, NY



From: Keith Gurnick, DPM


I have rarely seen any patients who have come to me after having a laser toenail treatment or multiple repeat laser toenail treatments for "fungal appearing" toenails, tell me they are satisfied with the results. These patients had laser treatments done by either a podiatrist or a dermatologist, or at a cosmetic or aesthetic clinic setting. They tell the same story, they either refused or were not offered oral or topical conventional medications, and the laser treatment(s) were presented as a "cure" or solution to the problem that if it works, their toenails will come back to looking normal.


One day, maybe someone will present to my office with the same "after" results that are often pictured on podiatry websites, but I just have not...


Editor's note: Dr. Gurnick's extended-length letter can be read here.  



From: Ira Baum, DPM


It's hard for me to believe that this issue is still being addressed for more than 20+ years. I'm not sure that I understand the purpose of regurgitating studies that compare these devices for treatment of foot pain. Most studies on this topic have obvious flaws, such as a person's weight, foot type, and structure, activities, footgear, and primary weight-bearing surface. Besides all those variables, it's a waste of time to compare the two. Either you believe in abnormal foot function as a cause of deformity and pain or you don't. 


As a profession, I hope we believe the former. However, we will never educate the public or the insurance companies on the superior benefit of custom foot orthotics to OTC arch supports, so why bother. Insurance companies will never capitulate to reimbursing for custom foot orthotics and there will always be people looking for simple solutions; that's their choice. That's not to say that every person with foot pain won't benefit from OTC arch supports; they may. For those that do, great; for those that don't, well thought-out and well made custom orthotics should benefit them if their problem is due to abnormal foot function - period.


Ira Baum, DPM, Naples, FL



From: Tom Silver, DPM


Yes, there are those who will respond well to OTC arch supports, heel cushions, arch pads, change of shoes, etc. and don't need Rx. foot orthotics.  But, for those who have biomechanical faults and especially those with chronic (several months or more) "plantar heel pain", then the "proper" functional foot orthotics are essential for long-term PHP/PF relief.


For those who would benefit from Rx orthotics, the keys to getting the best fitting orthotics with the best chance of eliminating PHP/PF are: 1) a complete biomechanical exam to evaluate for leg-length discrepancy, scoliosis, pelvic tilt, muscle imbalance, along with analysis of stance & gait; 2) Careful evaluation of the orthotic impressions to make sure the feet were held in the proper neutral position as the lab will make the orthotics from whatever impression they are given; 3) The proper prescription (shell material, depth of heel cup, postings, etc.) for that individual patient's pathology, weight, shoes, etc.


The owner of the major orthotic lab that I use told me recently that most of the very large clinics that he makes orthotics for will check off exactly the same things on the prescription form for every pair of orthotics ordered and that it's surprising how many podiatrists take orthotic impressions with the patients standing and think the lab will know what adjustments to make for the orthotics to realign their patients' feet. I would be interested to see the results of this study if the above factors are taken into consideration.


Tom Silver, DPM, Minneapolis, MN



From: Bryan C. Markinson, DPM


Some caution regarding Dr. Steinberg's statement, "Now routine post-op antibiotics are the standard of care." This may be in his hospital, but I even doubt that. In my hospital, the standard for foot and ankle surgery involving bone is intra-operative antibiotics. As a quality measure, we strive for 100% adherence. Occasionally, a patient who may already be on antibiotics (in-patients with infection for example) would not be given additional antibiotics in the operating room. However, routine post-operative antibiotics are not a standard of care AND more than ever universally still not recommended.


Bryan C. Markinson, DPM, NY, NY

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