Programme for prevention of foot dermatoses in patients with work-related skin diseases: Baseline data and first results of a prospective cohort study (OCCUPES).

BACKGROUND: Programmes for prevention of hand dermatoses in patients with work-related skin diseases (WRSD) are well established. Similar interventions for foot dermatoses (FD) are widely missing. OBJECTIVE: To evaluate the effectiveness of a programme for prevention of FD based on health education in patients with WRSD while investigating the impact and possible causative factors of FD. METHODS: In a prospective cohort study (OCCUPES), 231 patients with WRSD and FD participating in the programme were recruited. The skin was examined and questionnaires were completed, including assessment of footwear, FD severity, symptoms and health-related quality of life. RESULTS: The baseline and some early results are presented. A work-related causation of FD was likely in 60 patients (26.0%) with irritant contact dermatitis being the most frequent diagnosis. Work-related FD were associated with male sex (p = 0.012), sweating in footwear (p = 0.004) and wearing of safety footwear (p = 0.013). FD were often long-lasting with a high degree of work-absenteeism, quality of life impairment, itch and pain, particularly in work-related FD. CONCLUSIONS: Interventions are needed to reduce the burden of FD in patients with WRSD. The programme addresses current shortcomings in prevention of FD. A long-term evaluation of its effectiveness follows.

Onychomycosis in Athletes.

Onychomycosis is a common disorder that is difficult to cure. Prevalence is lower in children (0.7%), but athletes are 2.5-fold more likely to develop the disease, with infections of the toenails seven times more prevalent than those of the fingernails. This is a concern for athletes as it can interfere with their performance. The risk of developing onychomycosis is increased by the warm environment of many sports activities; the use of occlusive footwear; the warm, moist environment associated with socks and sweating; shared, close quarters among athletes; and trauma to the foot and toenail. Once infected, onychomycosis treatment requires a long duration of treatment with strict compliance, a potential problem for younger patients. Treatment carries the risk of significant side effects, and recurrence rates remain high. Avoiding infection can be a potent first line of defense and may circumvent the need for treatment. Preventive recommendations such as keeping toenails short and proper washing of laundry, to name a few, can be effective and are discussed here. Technological improvements such as synthetic, moisture-wicking socks and well-ventilated, mesh shoes have also been shown to reduce moisture and injury. Education about preventing fungal spread and improving hygiene in the locker room, gym, and pool are of critical importance. This overview of onychomycosis focuses primarily on the preventive measures and innovative changes in athletic gear. It also provides a compact step-by-step guide to prevention intended to be useful for both the general public and the professional. It can be reproduced to use as a handout for athletes, trainers, and coaches.

A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level.

Onychomycosis is a fungal nail infection caused by dermatophytes, non-dermatophyte molds, and yeasts. Treatment of this infection can be difficult, with relapse likely to occur within 2.5 years of cure. The objective of this article is to review factors that can impact cure and to suggest practical techniques that physicians can use to maximize cure rates. Co-morbidities, as well as disease severity and duration, are among the many patient factors that could influence the efficacy of antifungal therapies. Furthermore, organism, treatment, and environmental factors that may hinder cure include point mutations, biofilms, affinity for non-target enzymes, and exposure to fungal reservoirs. To address patient-related factors, physicians are encouraged to conduct confirmatory testing and treat co-morbidities such as tinea pedis early and completely. To combat organism-focused factors, it is recommended that disruption of biofilms is considered, and drugs with multiple routes of delivery and unique mechanisms of action are prescribed when traditional agents are not effective. Extending follow-up periods, using combination treatments, and considering pulse regimens may also be of benefit. Through these practical techniques, physicians can maximize cure and limit the risk of relapse and re-infection.

Concepts in Onychomycosis Treatment and Recurrence Prevention: An Update.

In considering therapy for onychomycosis, the most important factor to take into account is patient selection rather than treatment selection. Patients should be screened and evaluated for the extent of nail involvement, the amount of subungual debris, the degree of dystrophy, their ability and willingness to follow the regimen, and whether comorbidities are present that may affect the efficacy and/or safety of one or more therapies. Onychomycosis is a chronic disease with a high recurrence rate. Commonsense measures to reduce the risk for reinfection include patient education and a clinician-patient team approach to long-term management.

Is it possible to sanitize athletes' shoes?

CONTEXT: Footwear should be designed to avoid trauma and injury to the skin of the feet that can favor bacterial and fungal infections. Procedures and substances for sanitizing the interior of shoes are uncommon but are important aspects of primary prevention against foot infections and unpleasant odor. OBJECTIVE: To evaluate the efficacy of a sanitizing technique for reducing bacterial and fungal contamination of footwear. DESIGN: Crossover study. SETTING: Mens Sana basketball team. PATIENTS OR OTHER PARTICIPANTS: Twenty-seven male athletes and 4 coaches (62 shoes). INTERVENTION(S): The experimental protocol required a first sample (swab), 1/shoe, at time 0 from inside the shoes of all athletes before the sanitizing technique began and a second sample at time 1, after about 4 weeks, April 2012 to May 2012, of daily use of the sanitizing technique. MAIN OUTCOME MEASURE(S): The differences before and after use of the sanitizing technique for total bacterial count at 36 °C and 22 °C for Staphylococcus spp, yeasts, molds, Enterococcus spp, Pseudomonas spp, Escherichia coli , and total coliform bacteria were evaluated. RESULTS: Before use of the sanitizing technique, the total bacterial counts at 36 °C and 22 °C and for Staphylococcus spp were greater by a factor of 5.8 (95% confidence interval [CI] = 3.42, 9.84), 5.84 (95% CI = 3.45, 9.78), and 4.78 (95% CI = 2.84, 8.03), respectively. All the other comparisons showed a reduction in microbial loads, whereas E coli and coliforms were no longer detected. No statistically significant decrease in yeasts (P = .0841) or molds (P = .6913) was recorded probably because of low contamination. CONCLUSIONS: The sanitizing technique significantly reduced the bacterial presence in athletes' shoes.

Ability of hydroxypropyl chitosan nail lacquer to protect against dermatophyte nail infection.

The development of a topical agent that would strengthen the nail, improve the natural barrier, and provide better drug penetration to the nail bed is needed. In this study, we examined the effects of a hydroxypropyl chitosan (HPCH)-based nail solution using a bovine hoof model. Following application of the nail solution, changes in the hardness of the hoof samples were measured using the Vickers method. Tensile and flexural strengths were tested by stretching or punching the samples, respectively. The ultrastructure was examined using scanning electron microscopy (SEM), and samples stained with periodic acid-Schiff (PAS) stain were used to determine the fungal penetration depth. The comparators included 40% urea and 70% isopropyl alcohol solutions. The HPCH nail solution increased hoof sample hardness in comparison to the untreated control sample (mean, 22.3 versus 19.4 Vickers pyramid number [HV]). Similarly, the HPCH solution increased the tensile strength (mean, 33.07 versus 28.42 MPa) and flexural strength (mean, 183.79 versus 181.20 MPa) compared to the untreated control. In contrast, the comparators had adverse effects on hardness and strength. SEM showed that the HPCH solution reduced the area of sample crumbling following abrasion compared to the untreated control (7,418 versus 17,843 pixels), and the PAS-stained images showed that the HPCH solution reduced penetration of the dermatophyte hyphae (e.g., penetration by Trichophyton mentagrophytes was <25 µm at day 9 versus 275 µm in the untreated control). Unlike chemicals normally used in cosmetic treatments, repeated application of the HPCH nail solution may help prevent the establishment of new or recurring fungal nail infection.

The enemy of the feet: blisters in ultraendurance runners.

BACKGROUND: Blisters are the most common dermatologic problem in ultraendurance runners. Their incidence, localization, pain scores, and risk factors in field conditions are poorly understood. METHODS: We conducted an observational field-based cohort study during the 5-day multistage 2010 and 2011 Al Andalus Ultimate Trail (219 km). Daily postrace data on blister frequency, localization, severity, and preventive measures from 50 ultramarathon runners were collected through the direct interview technique. RESULTS: After 4 days of running (182 km), blisters occurred in 76% of the participants (P < .001 versus stage 1) compared with 34% after day 1, 54% after day 2, and 72% after day 3 (P < .001 versus stage 1). Most of the blisters formed on the toes (65%) (P < .001), followed by blisters on other locations of the foot: the ball of the foot (16%), heel (14%), and sole (5%). Blisters were more painful toward the end of the race, and those on the sole and heel tended to be the most painful, although this did not reach statistical significance. Prophylactic measures studied (type and fabric of socks; application of antiperspirants, talcum powder, or lubricant to feet; and prophylactic taping) did not show any reduction in blister rates. The only predictive marker for reduced blister incidence was previous ultramarathon experience in men (r = -0.44, P < .05). CONCLUSIONS: Blisters are extremely common in multistage ultramarathon races. Race experience in male ultramarathon runners is associated with reduced blister rates.

The effect of hydration on the risk of friction blister formation on the heel of the foot.

BACKGROUND: Friction blister research has focused on prevention and treatment approaches rather than exploring the pathophysiology of the friction blister. Increased skin hydration has been purported to be a key risk factor in friction blister development. This study aimed to test the effect of increased skin surface hydration on the risk of friction blister creation. METHODS: The skin on one foot was hydrated by soaking the foot in water. Intermittent loading was carried out until an observable change of 3°C was evident using infrared thermography. The contra lateral foot acted as a control. Skin hydration and elasticity was measured using electrical capacitance and negative pressure respectively. RESULTS: The rate of temperature change of the hydrated group was significantly greater than that of the non-hydrated foot group (P = 0.001) and showed a strong positive correlation (r = 0.520) with skin surface hydration. Weak negative correlations were seen between skin elasticity and rate of temperature change in response to load application (r = -0.166) and skin surface hydration and elasticity at baseline (r = -0.195). CONCLUSION: In controlled experimental conditions increased skin surface hydration increases the rate of temperature change of the skin in response to load application and consequently increases the risk of blister creation.

Factors influencing the awareness of diabetic foot risks.

INTRODUCTION: The aim of the present study was to identify factors influencing diabetic patients' awareness of the risk of foot problems. METHODS: We performed a prospective study of diabetic patients hospitalized or seen in consultation. Various factors were analyzed in order to identify those related to the patients' level of awareness of risk factors in diabetic foot. RESULTS: Ninety-one patients were included (mean age: 48; male/female gender ratio: 0.63). Over 50% of the study population was not aware of the risks of diabetic foot. Educational level and socioeconomic status had an impact on awareness of good foot health and care. Poor knowledge of the degenerative complications of diabetes was associated with age, a low educational level and low socioeconomic status. DISCUSSION: Our results revealed low levels of patient awareness concerning the potential severity of diabetic foot and the means of preventing foot problems. The patients gave a range of explanations for this marked lack of awareness; including a lack of information and financial constraints. Hence, patient education is still a major aspect of prevention in diabetes. CONCLUSION: In diabetes, there is still a need for easily assimilated, locally provided patient education.

[Main treatment and preventive measures for hand-foot syndrome, a dermatologic side effect of cancer therapy]. / A daganatterápia egyik dermatológiai mellékhatása, a kéz-láb szindróma fõbb kezelési és megelõzési elvei.

Hand-foot syndrome is a highly unpleasant adverse reaction caused by treatment protocols containing capecitabine (an orally administered drug), docetaxel, liposomal doxorubicin infusions or continuously infused 5-fluorouracil. It affects the skin of the palms and soles manifesting characteristic symptoms like erythema, inflammation, dysesthesia, pain, thickening, desquamation and cracking of the skin that may progress to cause wounds and ulceration, negatively influencing quality of life, psychological state and belief in recovery, which often result in the need of permanent or temporary interruption of the oncologic treatment and are potential sources of danger to the completion of the therapy. Adequate provision of the syndrome is of particular importance since a decline in adherence due to adverse events endangers precise maintenance of the self-sufficient oral treatment at home. Early recognition of symptoms, regular oncologic checkups and patient education on how to prevent or soothe the unpleasant skin toxicities could ensure a more successful treatment.

Smelly foot rash.

A previously healthy Caucasian girl, 6 years of age, presented with pruritic rash on both heels of 6 months duration. The lesions appeared as multiple depressions 1-2 mm in diameter that progressively increased in size. There was no history of trauma or insect bite. She reported local pain when walking, worse with moisture and wearing sneakers. On examination, multiple small craterlike depressions were present, some coalescing into a larger lesion on both heels (Figure 1). There was an unpleasant 'cheesy' odour and a moist appearance. Wood lamp examination and potassium hydroxide testing for fungal hyphae were negative.

Management of tyrosine kinase inhibitor-induced hand-foot skin reaction: viewpoints from the medical oncologist, dermatologist, and oncology nurse.

One significant toxicity associated with the anticancer tyrosine kinase inhibitors (TKIs) is hand-foot skin reaction (HFSR). We provide an overview of HFSR, emphasizing experience-based prevention techniques and nursing management strategies from the viewpoints of a medical oncologist, a dermatologist, and an oncology nurse. Supporting data include (1) published preclinical and phase I-III clinical studies and (2) published abstracts of phase II-III clinical trials of sorafenib and sunitinib. HFSR has been reported in up to 60% of patients treated with sorafenib or sunitinib. TKI-induced HFSR may lead to dose reductions or treatment interruptions and reduced quality of life. Symptoms of TKI-associated HFSR can be managed by implementing supportive measures and aggressive dose modification. Patients educated about HFSR can work with their health-care teams to proactively detect and help manage this cutaneous toxicity, thus preventing or reducing the severity of TKI-associated HFSR. Successful prevention and management of TKI-associated HFSR can help to ensure that patients achieve optimal therapeutic outcomes. Implementation of such measures may increase the likelihood that therapy is continued for the appropriate interval at an appropriate dose for each patient. Optimal management of TKI-associated HFSR is predicated on establishing appropriate partnerships amongmedical oncologists, dermatologists, oncology nurses, and patients.

Placebo-controlled trial to determine the effectiveness of a urea/lactic acid-based topical keratolytic agent for prevention of capecitabine-induced hand-foot syndrome: North Central Cancer Treatment Group Study N05C5.

PURPOSE: Hand-foot syndrome (HFS) is a dose-limiting toxicity of capecitabine for which no effective preventative treatment has been definitively demonstrated. This trial was conducted on the basis of preliminary data that a urea/lactic acid-based topical keratolytic agent (ULABTKA) may prevent HFS. PATIENTS AND METHODS: A randomized, double-blind phase III trial evaluated 137 patients receiving their first ever cycle of capecitabine at a dose of either 2,000 or 2,500 mg/m(2) per day for 14 days. Patients were randomly assigned to a ULABTKA versus a placebo cream, which was applied to the hands and feet twice per day for 21 days after the start of capecitabine. Patients completed an HFS diary (HFSD) daily. HFS toxicity grade (Common Terminology Criteria for Adverse Events [CTCAE] v3.0) was also collected at baseline and at the end of each cycle. The primary end point was the incidence of moderate/severe HFS symptoms in the first treatment cycle, based on the patient-reported HFSD. RESULTS: The percentage of patients with moderate/severe HFS symptoms was not different between groups, being 13.6% in the ULABTKA arm and 10.2% in the placebo arm (P = .768 by Fisher's exact test). The odds ratio was 1.37 (95% CI, 0.37 to 5.76). Cycle 1 CTCAE skin toxicity was higher in the ULABTKA arm but not significantly so (33% v 27%; P = .82). No significant differences were observed in other toxicities between groups. CONCLUSION: These data do not support the efficacy of a ULABTKA cream for preventing HFS symptoms in patients receiving capecitabine.

Randomized trial of two different doses of pyridoxine in the prevention of capecitabine-associated palmar-plantar erythrodysesthesia.

AIM: The aim of the present study was to compare the efficacy of 200 mg versus 400 mg daily of pyridoxine in preventing or delaying the onset of palmar-plantar erythrodysesthesia (PPE) in capecitabine-treated patients. METHODS: Patients with histologically confirmed breast cancer or colorectal cancer receiving single agent capecitabine started at 2000 to 2500 mg/m(2) daily from day 1 to 14 every 3 weeks were randomly assigned to receive 200 mg or 400 mg daily of pyridoxine for PPE prophylaxis. The primary endpoint was the reduction of incidence of grade 2 or greater PPE. Secondary endpoints were reduction of severe PPE and prolongation of time to development of grade 2 or greater PPE. RESULTS: There were 56 patients in this study. The baseline characteristics were generally similar in both groups. The high dose arm had less PPE than the low dose arm (11 of 28 or 39% vs 20 of 28 or 71%, relative risk = 0.26 [0.08, 0.79], P = 0.031). Grade III PPE developed in 3 of 28 (10.7%) versus none in patients receiving 200 mg versus 400 mg pyridoxine, respectively (relative risk 2.12 [1.594, 2.819], P = 0.24). High dose pyridoxine had a longer time to development of grade 2 or greater PPE compared to the low dose arm, 87 days versus 62 days. The 400 mg pyridoxine group had, however, a worsened tumor response and tended to have greater tumor treatment failure and shorter time to treatment failure. CONCLUSION: With the limitation of sample size in this study, there was a trend to improve PPE incidence and time to event with a higher dose of pyridoxine. Further validation of these results in a larger population is warranted.

Pyridoxine is not effective to prevent hand-foot syndrome associated with capecitabine therapy: results of a randomized, double-blind, placebo-controlled study.

PURPOSE: To determine whether concurrent pyridoxine therapy can prevent the development of hand-foot syndrome (HFS) in patients being treated with capecitabine. METHODS: Chemotherapy-naive patients with GI tract cancers scheduled for capecitabine-containing chemotherapy were randomly assigned to concurrent oral pyridoxine (200 mg/d) or placebo. Patients were stratified by chemotherapy regimen and monitored until development of National Cancer Institute Common Toxicity Criteria grade 2 or worse HFS or capecitabine-containing chemotherapy ended. Patients in the placebo group who developed grade 2 or worse HFS were randomly assigned again to receive pyridoxine or placebo in the next chemotherapy cycle to determine whether pyridoxine could improve HFS. RESULTS: The median number of chemotherapy cycles to grade 2 or worse HFS was three in both groups. Grade 2 or worse HFS developed in 55 (30.6%) of 180 placebo-treated patients and in 57 (31.7%) of 180 pyridoxine patients. The cumulative dose of capecitabine to grade 2 or worse HFS was not different between the two groups (median not reached in either group; hazard ratio [HR] = 0.95; P = .788). Randomization of the 44 patients in the placebo group with grade 2 or worse HFS to placebo or pyridoxine for the next cycle resulted in no significant difference in the proportion showing improvement of HFS (42.9% v 47.8%; HR = 1.12; P = .94). By multivariate analysis, age > or = 56 years (HR = 1.768; 95% CI, 1.190 to 2.628; P = .005) was an independent risk factor for grade 2 or worse HFS, and combined use of docetaxel (HR = 2.046; 95% CI, 0.880 to 4.755; P = .096) was of borderline significance. CONCLUSION: Pyridoxine is not effective in prevention of capecitabine-associated HFS.