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Query: Has Laser Nail Fungus Removal Been Proven Effective?


While the FDA approved the treatment of nail fungus with laser four years ago, in one of the best studies to date, published last year in The Journal of the American Academy of Dermatology, researchers found that laser treatments produced no improvements in patients with toenail fungus, even after five sessions.*


Using the Journal as a major source, the New York Times March 14, 2014 issue challenges the use of laser therapy for this common condition. Has anyone in podiatric medicine conducted controlled studies on laser therapy for onychomycosis?


*Carney C, Cantrell W, Warner J, Elewski B. Treatment of onychomycosis using a submillisecond 1064-nm neodymium:yttrium-aluminum-garnet laser. J Am Acad Dermatol. Oct;69(4):578-82; 2013


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

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Query: Epidermolysis Bullosa?


I recently saw a 15 year girl who had just returned from a long walk with a number of large bulla, filled with clear fluid on the plantar aspects of her digits, metatarsal heads, and heels (symmetrical). Her parents state that whenever she does any physical activity, this happens. Her PMH is unremarkable, and she does not blister anywhere else. No one else in her family has this problem. She has moist palms and soles, but no real signs of fungal or bacterial infections.


The only suggestions I had were for her to wear cool max socks, try to decrease the moderate hyperhidrosis, and to utilize a skin cream. I cast her for functional orthotics with Shear Ban under the balls of her feet and heels. I thought of using an entire top layer of Shear Ban, but it is expensive, and I am afraid she would slide off of it. I am open to suggestions, especially regarding the orthotic materials.



Query: Post-op Hematoma


I removed a bone fragment from the first intermetatarsal space at the base of the proximal phalange. Initially, all went well, but after sutures were removed, the patient developed a painful distension in the area. I have compressed it with an Unna boot, with no improvement. I think there is probably a hematoma. Does anyone have any hints for resolving this other than time?



Query: Charcot-Like Presentation


This patient is a 27 year old female who presented to the office after being told by the emergency room that she had fractured her left foot. She denies any sort of trauma to either foot. The condition was insidious in its onset. Clinical evaluation shows no deformity, but diffuse forefoot edema. Radiographic analysis is presented below consisting of fractures of the second, third, and fourth metatarsals with hypertrophic bone formation. The patient was not complaining of any pain in her right foot, but we x-rayed it for comparison, and it revealed a second and third metatarsal fracture as shown below, again with hypertrophic bone formation.


Charcot-Like Condition


She has an old fractue of her right 5th metatarsal base. The patient shows no signs of infection, ulceration, or open wound. Her lab work shows chronic anemia and an ESR of 90. The radiologists have read this as a neuropathic process. Certainly this appears to be an atypical presentation of what could be considered a Charcot foot. Presently she is ambulating minimally and has been placed in bilateral pneumatic fracture walking boots. Any input is welcome, especially from anyone who has seen this process in the forefoot before.



Query: Pruritic Lesions S/P Caribbean Cruise


A 35 year old woman presented to my office with a complaint of itching and a skin rash that has become progressively worse over the last month.


Pruritic Lesion S/P Caribbean Cruise


She had applied OTC antifungals without any relief. Shortly before the rash began, she relates that she was on a cruise to Mexico and the Caribbean. Any thoughts?



Query: Allergic Reaction to Econozole Cream  


A patient used econozole cream on her feet for two days and developed a rash on her face, whole body itching, shortness of breath and dizzyness. Has anyone had a patient who actually reacted systemically to econozole cream?


Norman A. Wortzman, DPM, Boston, MA



Query: Pernio vs. Raynaud's Disease


With diabetes and neuropathy, it may be difficult to differentiate pernio vs. Raynaud's disease in patients. The neuropathic patient may not feel pain or itching, which is the complaint at times with pernio. Both are vasospastic and otherwise look similiar. In this frigid weather, we are seeing these cases more commonly.


Are there any real differences in treatment? For those who recommend oral nifedipine, what is the recommended dosing? Other than topical or oral L-arginine, warms socks, etc. does anyone have any pearls as it relates to these conditions? 


Jeffrey Kass, DPM, Forest Hills, NY



Query: Patient With Foot/Ankle Swelling

I have a 21 y.o. female patient with initial ankle injury in Aug. 07 after jumping off the back of a combine. She was treated by another physician for ankle sprain and within a week, she was better. In December, the patient states that she started having foot and ankle swelling. She recalls no injury. She states that since then it has been swollen and slightly uncomfortable around the ankle joint. Patient has non-pitting edema from her toes to just above the ankle. There is no erythema, ecchymosis, temperature changes, or mottling.

Ankle joint ROM is normal with no laxity noted. The ankle is minimally tender with palpation to the medial and lateral ankle areas. STJ ROM is normal and non-tender. She has had x-rays and MRI all showing diffuse soft tissue edema and no other findings. She's had compression, ice, rest, PT, NSAIDs, all without reducing the edema. She is otherwise healthy, no medications. I've ordered stress ankle views and an arthrogram of the ankle. Any suggestions would be appreciated?

Theresa Hughes, DPM, Galesburg, IL



Query: Pain in Dorsal Foot After IV insertion

I have a 19 year old patient who was in the ICU about 2 weeks ago due to some complication with kidney/bladder surgery. An IV was inserted into the dorsal aspect of his foot. It was used for 2 days, then it infiltrated, and was removed. He presented to my office 2 weeks later with severe pain over the area. There is a small amount of swelling,but no signs of infection. X-rays, MRI, and venous ultrasound were done in the hospital prior to discharge; none of which showed any pathology. He was also given several narcotics, topical Voltaren, and Lyrica in the hospital, which did not help.  Does anyone have any suggestions for possible causes of the pain? Can anyone suggest some treatments to relieve the pain. 


Steven Lemberger, DPM, Freehold, NJ



Query: Botox for Hyperhydrosis

I need information on Botox injectables. I had a patient come in with sweaty feet who has tried almost everything. I also told her this procedure could be very painful. I might consider doing this outpatient with some sedation. Where can I obtain the product? Any info would be helpful.

Stephen Kinard, Rocky Mount, NC

Editor's note: An excellent article on the topic, Application of Botox® for Pedal Hyperhydrosis by Mostafa Niknafs, DPM & Mohsen Khoshneviszadeh, DPM , which appeared in Podiatry Management can be read at: