Archive for May, 2010

Fungus Among Us

May 24, 2010

Fungal infection of the nails, also known as onychomycosis, is a very common foot condition treated by podiatrists.  This condition is usually found in older patients. It is reported that 60% of people over 40 years old have evidence of fungus in their toe nails.  Fungal nails are white to yellow in color and cause the nail to become thickened and lose their normal shape. Nails that have become abnormal in shape are called dystrophic.  If the infection is severe, the thickened nail can begin to crumble. These infected thickened nails can also result in pain and discomfort when wearing shoes.

Lab tests for fungal nails:
The presents of thickened dystrophic nails maybe an indication of a fungus infection. However, they can also occur in patients with a skin condition called psoriasis. Sometime, thickened nails can occur in patients with damaged nail roots due to major trauma such as a having an heavy object fall on the toe. More commonly, the trauma can be delivered to the toe in small doses, this is called micro trauma. This is caused by jamming the toenail into the top of the shoe. This kind of micro trauma is often associated with runners and people who wear narrow pointed shoes. Thus, before prescribing any creams, solutions, or oral medication to treat fungal nails, the podiatrist must send a sample of the nail to the lab to confirm the presence of fungus.

Prescription treatment of Fungal Nails:
Using prescription medications to treat fungal nails usually takes many months before any improvement is seen in the nail. This is due to the long life cycle of the fungal organism and the slow growth of the toe nail. Most anti-fungal drugs attack the replication or reproducing cycle of fungus. Therefore, the improvement will only be seen in new growth of the slow growing nail  Thus, a great deal of patience is required in treating fungal nails. It is also important to realize that after the completion of anti-fungal drugs, there can be a recurrence in fungal infection.

Common Types of Anti-fungal drugs:
Terbinafine also known as Lamisil is the most potent anti-fungal drug used for fungal nails. It is easily distributed by the body into the nail via the nail root. Since terbinafine is broken down in the body by the liver, it is essential that a liver function blood test is performed before starting this drug. Patients with liver problems should not use terbinafine since this can result in severe damage to the liver. Thus, the podiatrist must request a blood test before prescribing this medication and during the course of the medication. The drug is taken once a day for 3 months. If side effects such as stomach or abdomen pain, diarrhea, rashes or headaches occur, the podiatrist should be notified. Lamisil will work to cure the fungus about 77% of the time.

Itraconazole (Brand name is Sporanox) is another oral anti-fungal drug that prevents the fungus from building its skeletal structure. The course of this treatment is 3 months as well. Additionally, this drug interacts with other medications, so a complete list of current medications should be given to the podiatrist. Cure rate is about 66%.

Ciclopirox 8% lacquer is an anti-fungal solution that is applied to the entire nail and 5 mm of surrounding skin for 12 months. This prevents the fungus from receiving its nutrients needed to grow. Common side effect is redness around the nail.  There is a cure rate of 29%-36% with this medication.

During the course of the treatment for the fungal nails patients should follow the a hygiene protocol.
Wash the feet two times a week with Betadine and soap. (As long as there is no history of Iodine allergy)
Use anti-fungal foot powder in the socks.
Change socks every day.
Use a fungal spore killing agent in the shoes such as Micomist by Gordon Labs, as directed.

Management of Fungal Nails:
For patients with poor kidney/liver disease, prescription medication may worsen these medical problems. Oral anti-fungal medication can decrease kidney and liver function. Thus, the best option in these cases may be routine nail debridement by a podiatrist. The podiatrist will cut the thickened fungal nails with special nail clippers, which then may be followed by grinding and filing of the nail by using a sanding disc or burr. The routine nail debridement usually requires the patients to return to the podiatrist about every 3-4 months.

Prevention of Fungal Nails:
1. Wear sandals when using public showers
2. Alternate shoes every day
3. Change socks daily
4. Avoid sharing shoes or socks

Final Thoughts:
Lasers for the treatment of fungal nails. This therapy has become very popular in the last two years. There are currently two types of lasers being used to treat fungal nails. The first uses patented technology to attack the fungal spoors. The other laser uses infrared light waves to cause light or photo damage to the fungal cells.
At this time the have been no large studies to prove the effectiveness of these treatment modalities.  At this time, there are multi-center studies in progress to accurately determine the cure rates for the use of lasers on fungal nails. However, until these studies are published there is no evidence based proof that lasers can successfully treat this condition.


GOUT: Causes and Treatment

May 2, 2010

Gout is a very painful and sometime debilitating joint disease caused by uric acid crystal formation in the joints. However, early diagnosis, management and treatment, can result in decreasing the severity and the frequency of gout attacks. Most patients who are experiencing a gout attack usually complain of severe pain in the affected joint. This pain tends to be worse at night. One of the most common areas affected is the big toe joint at the ball of the foot.  Typical symptoms that occur in a gout attack are hot and extremely swelling and redness. The pain can be very excruciating to the point that even light touch from bed sheets can cause pain.

Interestingly, the painful symptoms of gout usually occur during the night when the body temperature drops. Once the body temperature is lower, there is a higher occurrence of uric acid crystals that slowly begin to form in the joints. This process is very similar to dissolving sugar in hot water. When the hot water cools, the dissolved sugar slowly begins to reform similar to uric acid crystals formation in the foot when the body temperature decreases.

Origin of gout:
Gout is a disease commonly found in older men and postmenopausal women. The causes of gout is divided into two categories, either the body overproduces uric acid, which is the main component of uric acid crystals, or the body under excretes uric acid. Under excreting uric acid is the most common cause of the two categories. However, in both cases, there is a high uric acid concentration in the body and thus increased formation of the uric acid crystals into the joints.

Diagnosis of gout:
If gout is suspected, an X-ray may be taken of the foot to evaluate the joint. In a patient with chronic gout, the uric acid crystals can cause bone erosions that can be visualized on X-ray. Also, x-rays are taken to rule out the possible other causes for this type of pain, such as a fracture or arthritis. Blood tests may be performed to determine the amount of uric acid in the body. It should be noted, however, that there could be normal uric acid levels in the blood even though the patient has gout or symptoms of gout. Also, gout can be diagnosed by aspirating the joint. This procedure requires local anesthetic to numb the joint, then using a needle and syringe; a sample of joint fluid is removed for analysis. The joint fluid in gout has a white cottage cheese appearance as opposed to a normal joint that has clear joint fluid. This joint fluid is then sent to the lab for analysis.  Uric acid crystals can be visualized in the lab using a microscope.

Conservative treatment:
One way to decrease the incidence of gout attacks is by changing to a diet that is low in foods such as red meats and wine because these types of food are high in purine.  Purine, is a chemical that is broken down into uric acid in the body when the amount of uric acid becomes to high the crystal of acid collect in the joint and cause the painful attack.  Decreasing purine consumption results in less uric acid build-up.

Oral medication can also decrease the incidence and severity of gout attacks. Indomethacin, a non-steroidal anti-inflammatory, is used to decrease the swelling and inflammatory symptoms of gout. Another medication called Colchicine may be recommended to prevent the inflammatory reaction caused by the acid crystals.

In order to decrease the amount of uric acid in the body, allupurinol may be used. This medication inhibits the conversion of purine to uric acid crystals and thus prevents crystal formation in the joint.