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BACKGROUND: Nail excisions are indicated for onychocryptosis and nail spicules. They are technically demanding and require a refined skill set. We aimed to characterize practice patterns of US providers performing nail excisions. METHODS: We conducted a retrospective analysis of Medicare provider use and payment data, part D, for all claims of partial or complete nail/nail matrix excision with/without nail plate removal/destruction (current procedural terminology code 11750). High performers were defined as providers performing annual nail excisions 2 standard deviations above the mean. We analyzed demographic risk factors for nail excision high performers, including practice location, years of experience, household median income, practice type, and provider gender. Statistical analysis was conducted in SAS v9.4, with values of P < .05 considered statistically significant. RESULTS: Providers (n = 32,279) and high performers (n = 942) performed mean 34.7 and 173 nail excisions annually. Unsurprisingly, podiatrists constituted 99.7% of all nail excision performers. Providers in the South versus Midwest and Northeast were more often nail excision high performers (odds ratio [OR], 1.95; P < .0001, and OR, 1.46; P < .0001). Solo versus group practitioners were more likely, respectively, to be nail excision high performers (OR, 2.15; P < .0001). With linear regression analysis, for every 10-year increase in years of provider experience, there was an increase of 1.2 nail excisions annually per provider (P < .0001). For every $100,000 increase in household median income of practice location, there was a decrease of 9.9 nail excisions annually per provider. CONCLUSIONS: Southern podiatrists, podiatrists with more years of experience, solo practitioners, and those practicing in regions with lower household median incomes were more likely to perform higher numbers of nail excisions. Identifying performance trends among podiatrists can help podiatrists understand how their performance of nail excisions compares to other podiatrists across the country.
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Podiatría , Práctica Privada , Humanos , Estudios Retrospectivos , Masculino , Femenino , Estados Unidos , Práctica Privada/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Uñas/cirugía , Medicare , Uñas Encarnadas/cirugía , Competencia ClínicaRESUMEN
BACKGROUND: Dermatophytoma, also described as a longitudinal streak/spike, is a form of onychomycosis that presents as yellow/white streaks or patches in the subungual space, with dense fungal masses encased in biofilm. This scoping review of the literature was conducted to address a general lack of information about the epidemiology, pathophysiology, and treatment of dermatophytomas in onychomycosis. METHODS: A search was performed in the PubMed and Embase databases for the terms "longitudinal spike" or "dermatophytoma." Outcomes of interest were definition, prevalence, methods used for diagnosis, treatments, and treatment efficacy. Inclusion and exclusion of search results required agreement between two independent reviewers. RESULTS: Of a total of 51 records, 37 were included. Two reports provided the first unique definitions/clinical features of dermatophytomas. Overall, many descriptions were found, but one conclusive definition was lacking. Prevalence data were limited and inconsistent. The most frequently mentioned diagnostic techniques were clinical assessment, potassium hydroxide/microscopy, and fungal culture/mycology. Oral terbinafine and topical efinaconazole 10% were the most frequently mentioned treatments, followed by topical luliconazole 5% and other oral treatments (itraconazole, fluconazole, fosravuconazole). In studies with five or more patients without nail excision, cure rates were highest with efinaconazole 10%, which ranged from 41% to 100% depending on the clinical and/or mycologic assessment evaluated. Other drugs with greater than or equal to 50% cure rates were topical luliconazole 5% (50%), oral fosravuconazole (57%), and oral terbinafine (67%). In studies that combined oral terbinafine treatment with nail excision using surgical or chemical (40% urea) methods, cure rates ranged from 50% to 100%. CONCLUSIONS: There is little published information regarding dermatophytomas in onychomycosis. More clinical research and physician education are needed. Although dermatophytomas have historically been considered difficult to treat, the efficacy data gathered in this scoping review have demonstrated that newer topical treatments are effective, as are oral antifungals in combination with chemical or surgical methods.
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Antifúngicos , Onicomicosis , Humanos , Onicomicosis/diagnóstico , Onicomicosis/epidemiología , Onicomicosis/terapia , Onicomicosis/tratamiento farmacológico , Antifúngicos/uso terapéutico , Prevalencia , Dermatosis del Pie/diagnóstico , Dermatosis del Pie/terapia , Dermatosis del Pie/epidemiología , Dermatosis del Pie/microbiología , Tiña/diagnóstico , Tiña/terapia , Tiña/epidemiología , Tiña/tratamiento farmacológico , Femenino , MasculinoRESUMEN
This Viewpoint discusses the need for a broader approach to nail pathology, in which infectious, inflammatory, systemic, and structural factors are considered.
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Enfermedades de la Uña , Uñas , Humanos , Enfermedades de la Uña/diagnóstico , Enfermedades de la Uña/patología , Uñas/patologíaAsunto(s)
Uñas Encarnadas , Calidad de Vida , Humanos , Masculino , Femenino , Persona de Mediana Edad , Uñas Encarnadas/terapia , Adulto , Prótesis e Implantes , Uñas/patología , Anciano , Resultado del TratamientoRESUMEN
The objective of this article is to provide a brief overview of the critical analysis and design of unique and perhaps less common methodologies in podiatric science. These include basic science translational designs, cadaveric investigations, gait analyses, dermatologic studies, and database analysis. The relative advantages, disadvantages, and inherent limitations are reviewed with an intention to improve the interpretation of results and advance future foot and ankle scientific endeavors.
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Dermatología , Análisis de la Marcha , Humanos , Investigación Biomédica Traslacional , Articulación del Tobillo , Cadáver , Marcha , Fenómenos BiomecánicosRESUMEN
Good adherence to treatment is necessary for the successful treatment of onychomycosis and requires that an appropriate amount of medication be prescribed. Most prescriptions for efinaconazole 10% solution, a topical azole antifungal, are for 4 mL per month but there are no data on patient factors or disease characteristics that impact how much medication is needed. Data from two phase 3 studies of efinaconazole 10% solution for the treatment of toenail onychomycosis were pooled and analyzed to determine monthly medication usage based on the number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex. Participants with two or more affected nails required, on average, >4 mL of efinaconazole per month, with increasing amounts needed based on the number of nails with onychomycosis (mean: 4.39 mL for 2 nails; 6.36 mL for 6 nails). In contrast, usage was not greatly impacted by target toenail involvement, BMI, or sex. Together, these data indicate that the number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe. J Drugs Dermatol. 2024;23(2):110-112. doi:10.36849/JDD.7676.
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Dermatosis del Pie , Onicomicosis , Humanos , Onicomicosis/diagnóstico , Onicomicosis/tratamiento farmacológico , Onicomicosis/microbiología , Uñas , Administración Tópica , Triazoles/uso terapéutico , Antifúngicos , Dermatosis del Pie/diagnóstico , Dermatosis del Pie/tratamiento farmacológico , Dermatosis del Pie/microbiologíaRESUMEN
BACKGROUND: Hyperkeratosis is a hypertrophic thickening of the skin. A callus (tyloma) is considered diffuse thickening, whereas a corn-also known as a clavus, heloma durum, or intractable plantar hyperkeratosis (IPK)-is a more focal, circumscribed hyperkeratotic lesion with a central conical core of keratin. Treatment (including surgical excision) of plantar keratoses is often sought because of pain and discomfort. The aim of this study was to collect and chart data regarding the surgical excision of plantar corns. The emerging themes were then mapped so that suggestions for areas of future research could be made. METHODS: A scoping review of the literature was performed using the six-stage methodologic framework (minus stage 6) proposed by Arksey and O'Malley incorporating the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews reporting guideline. A database search by means of the United Kingdom National Health Service Care Advanced Database Search yielded 1,056 articles, 12 of which appeared to be of potential relevance. After removing five duplicate articles, this total was reduced to seven, which were retrieved as full texts. Three were excluded. Thirteen further articles were found through Google Scholar and reference lists from the full texts retrieved to give 17 articles for review. One was discounted as not being in English/irrelevant; and one article did not relate to IPK excision, leaving 15 articles for data extraction. RESULTS: Iterative charting of the included articles yielded overlapping codes and two main themes. The first theme was closure: by primary intention (with or without a skin flap) or by secondary intention. The second theme was whether excision was performed in combination with IPK excision with other (bony) surgery. CONCLUSIONS: There is modest evidence that excision of the lesion with either primary closure or healing by means of secondary intention can be useful for the management of IPKs. A further consideration is an emerging hypothesis that many of these IPKs are viral in origin, rather than mechanical, which implies that prospective studies are required with cross-reference to lesion excision by anatomical site and histopathologic confirmation of the diagnosis.
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Callosidades , Queratosis , Humanos , Callosidades/cirugía , Pie , Queratosis/cirugíaRESUMEN
INTRODUCTION: Onychomycosis, a common nail disorder caused by fungal infection, can be managed pharmaceutically with oral or topical treatments. While oral treatments are often used first-line to treat nail infections, these systemic antifungals are not appropriate for all patients, and no oral treatments are approved for use in children in the USA. Given this need, topical antifungals were developed, which can be used as monotherapy or in combination with oral drugs. AREAS COVERED: Efinaconazole 10% solution is an azole antifungal indicated for topical treatment of toenail onychomycosis in pediatric and adult patients. This qualitative literature review summarizes available chemical, pharmacological, efficacy, safety, and post-marketing surveillance data of efinaconazole 10% topical solution. Efinaconazole 10% has been shown to be safe and efficacious regardless of disease severity/duration at baseline; patient gender, ethnicity, or age (including pediatrics); or comorbidities such as diabetes or tinea pedis. Overall, efinaconazole is a safe and effective clinical option for the treatment and management of onychomycosis. EXPERT OPINION: Efinaconazole is the first new antifungal approved for onychomycosis in 10 years in the USA. It has comparable efficacy to systemic antifungal agents such as itraconazole, and a favorable adverse events profile with minimal systemic exposure and no drug-drug interactions.
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Onicomicosis , Pediatría , Administración Tópica , Adulto , Antifúngicos/uso terapéutico , Niño , Humanos , Onicomicosis/tratamiento farmacológico , Triazoles/uso terapéuticoRESUMEN
BACKGROUND: Onychomycosis affects around 14% of individuals in North America and Europe and is undertreated. Treatment is challenging as toenail growth can take 12–18 months, the nail plate may prevent drug penetration, and disease recurrence is common. National guidelines/consensus documents on onychomycosis diagnosis and treatment were last published more than 5 years ago and updated medical guidance is needed. METHODS: This document aims to provide recommendations for the diagnosis and pharmaceutical treatment of toenail onychomycosis following a roundtable discussion with a panel of dermatologists, podiatrists, and a microbiologist specializing in nail disease. RESULTS: There was a general consensus on several topics regarding onychomycosis diagnosis, confirmatory laboratory testing, and medications. Onychomycosis should be assessed clinically and confirmed with microscopy, histology, and/or culture. Terbinafine is the primary choice for oral treatment and efinaconazole 10% for topical treatment. Efinaconazole can also be considered for off-label use for maintenance to prevent recurrences. For optimal outcomes, patients should be counseled regarding treatment expectations as well as follow-up care and maintenance post-treatment. CONCLUSIONS: This article provides important updates to previous guidelines/consensus documents to assist dermatologists and podiatrists in the diagnosis and treatment of toenail onychomycosis. J Drugs Dermatol. 2021;20(10):1076-1084. doi:10.36849/JDD.6291.
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Dermatosis del Pie , Enfermedades de la Uña , Onicomicosis , Administración Tópica , Antifúngicos/uso terapéutico , Dermatosis del Pie/diagnóstico , Dermatosis del Pie/tratamiento farmacológico , Humanos , Enfermedades de la Uña/tratamiento farmacológico , Uñas , Onicomicosis/diagnóstico , Onicomicosis/tratamiento farmacológico , Terbinafina/uso terapéutico , Resultado del TratamientoRESUMEN
Onychomycosis is one of the most frequent nail pathologies in podiatry practices. Differential diagnoses with the clinical presentation may delay an accurate diagnosis and timely treatment. This article discusses the technique and benefits of using a dermatoscope to improve patient care of this common disorder.
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Onicomicosis , Podiatría , Dermoscopía , Diagnóstico Diferencial , Humanos , Onicomicosis/diagnóstico por imagenRESUMEN
Traditionally, plantar warts or verrucae are often diagnosed by visual appearance and the lateral squeeze test. At times, these methods are not able to elucidate the difference between a plantar wart and a callus. The use of the dermatoscope can not only distinguish the difference between a wart and a callus, which ultimately helps to customize treatment plans to increase efficacy, but also be used to follow the therapeutic effects of treatment. The dermatoscope is a tool that can be used in the diagnosis of plantar verrucae and in assessment of the success of therapy.
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Enfermedades del Pie , Verrugas , Dermoscopía , Enfermedades del Pie/diagnóstico por imagen , Humanos , Papillomaviridae , Verrugas/diagnóstico por imagen , Verrugas/terapiaRESUMEN
Recent studies have shown that a superficial fungal infection such as onychomycosis may form complex biofilms. Although most individuals susceptible to documented fungal biofilm infections are immunocompromised, physical damage to the nail or concurrent infection with other organisms is also a common risk factor in developing nail biofilm. The complex nature of the biofilm, which includes efflux pumps and the formation of a virulent extracellular matrix, helps it evade the immune system. Although there is no standardized treatment for fungal biofilms in onychomycosis, various studies using antimicrobials and lasers have shown some efficacy in treating human fingernails.
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Uñas , Onicomicosis , Antifúngicos/uso terapéutico , Biopelículas , Humanos , Onicomicosis/tratamiento farmacológicoRESUMEN
Disappearing nail bed (DNB) is a condition characterized by irreversible epithelialization of the nail bed following long-standing onycholysis. This phenomenon can occur in fingernails and toenails. Factors implicated in the development of DNB include trauma, manicuring, and onychotillomania and dermatologic conditions like psoriasis and dermatitis. Specifically for the toenail, contributing factors also include increasing age, history of trauma, surgery, onychomycosis, and onychogryphosis. A grading system that stages the progression of onycholysis to DNB has been proposed to aid clinicians in the diagnosis and treatment of these conditions. Several methods have been designated for the treatment of DNB.
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Enfermedades de la Uña , Onicólisis , Onicomicosis , Psoriasis , Humanos , Enfermedades de la Uña/diagnóstico , Enfermedades de la Uña/etiología , Enfermedades de la Uña/terapia , Uñas/cirugía , Onicólisis/diagnóstico , Onicólisis/etiología , Onicólisis/terapiaRESUMEN
The chemical composition and thickness of nails are obstacles for treatments of various nail diseases, such as onychomycosis. Topical medications are currently the preferred method of treatment because of reduced adverse systemic effects. However, penetration of the product from the nail plate into the nail bed continues to be an issue because of factors such as distance required to reach the target area, chemical barriers, and drug inactivation upon keratin binding. Beyond developing novel drugs, some studies have investigated mechanical and chemical methods to optimize drug delivery. The issue of nail diseases is still a challenge and requires multifactorial treatments.
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Uñas , Onicomicosis , Administración Tópica , Antifúngicos , Humanos , Onicomicosis/tratamiento farmacológico , PenetranciaRESUMEN
Plantar psoriasis negatively affects the quality of life for patients due to its weight-bearing location. Most therapeutic studies for psoriasis focus on total body surface changes and rarely report specific effects of the plantar and palmar areas. This review focuses on therapeutic options for plantar psoriasis ranging from topical therapy to phototherapy to biological therapy. Treatment should be approached as a stepwise gradient beginning with topicals and progressing to systemics. As always, review of the patient's severity of condition, health status, and impact on quality of life is needed to individualize therapy for the best patient care.
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Psoriasis , Calidad de Vida , Humanos , Fototerapia , Psoriasis/diagnóstico , Psoriasis/terapiaRESUMEN
Psoriasis is a common inflammatory disorder with potentially severe systemic and dermatologic consequences. As traditional treatments for this condition fail, biologics are emerging as the next promising therapy for moderate-to-severe cases, especially for the lower extremity. This review examines current research on monoclonal antibodies that target specific cytokines including interleukin-23 (IL-23), IL-12, tumor necrosis factor alpha, and IL-17 involved in pathologic inflammatory processes.
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Productos Biológicos , Psoriasis , Anticuerpos Monoclonales/uso terapéutico , Productos Biológicos/uso terapéutico , Humanos , Interleucina-23 , Psoriasis/tratamiento farmacológico , Factor de Necrosis Tumoral alfaRESUMEN
Shoe dermatitis is a type of contact dermatitis precipitated by allergens or irritants found in shoes. Potassium dichromate, commonly used in leather processing, is one of the most prevalent agents responsible for shoe dermatitis; however, it is not the only one. Shoe dermatitis caused by an allergen or an irritant may affect a person of any age, sex, or ethnicity. Numerous treatments exist for shoe dermatitis, the most simple yet important being avoidance of causative agents. Pharmaceutical agents commonly used are emollients, humectants, and topical corticosteroids. In more severe cases, topical calcineurin inhibitors and phototherapy may be used.
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Dermatitis Alérgica por Contacto , Dermatosis del Pie , Alérgenos , Dermatosis del Pie/diagnóstico , Dermatosis del Pie/etiología , Dermatosis del Pie/terapia , Humanos , Pruebas del Parche , ZapatosRESUMEN
Diabetes mellitus is one of the most common conditions that affects the US population and burdens the health care system. Knowledge of the skin conditions that may occur before diagnosis of diabetes mellitus is made or after the diagnosis is made is pertinent for the practitioner. This article reviews skin disorders found on the lower extremity that are associated with diabetes mellitus.