Query: Prescribing Protocol for Oral Antifungals
Has anyone changed their prescribing protocol for oral antifungals? I read a recent study where the authors did not see appreciable increases in liver enzymes throughout a 3-month course of Lamisil therapy. These patients did have higher than normal liver enzymes prior to starting the medication. If that is true and oral antifungals do not cause an increase in liver enzymes, then is there really a need to order a LFT prior to prescribing these medications?
Is anyone prescribing Lamisil (or any other oral antifungal) without first requiring a liver function test? Or, for that matter, prescribing oral antifungals to patients with already high liver enzymes (out of normal range)? This potentially creates a huge shift in how most of us practice. Are you aware of other studies with similar findings?
Dave Williams, DPM, El Paso, TX
Query: Treatment for Nail Problem in an 8 Year Old
I have an 8 year old patient with hallux nails that grow into the distal tuft. I successfully phenolized the borders so that he no longer gets infections.
Nail Problem in an 8 Year Old
I am asking for suggestions for care. How can I get these nails to grow over and beyond the tuft?
Query: Petechial Flexural Eruption and Digitate Papulosquamous Rashes?
1. petechial flexural eruption.
2. digitate papulosquamous rashes.
The post goes on to state "these skin conditions could occur at any time during and after infection and may contribute to the feeling of burning skin". The 98 symptoms were reported by what are now called "Covid Long Haulers", who may have had a severe or mild initial case of the contagion, but gets relapses of these symptoms for some time. About 10% of all clinical cases (not positive blood tests that have been conflated as cases) may be in that category. Can a dermatology maven out there translate these two descriptions into usable clinical images?
Robert Teitelbaum, DPM, Naples, FL
Query: Amniotic Fluid Injections for Moderate to Severe Osteoarthrosis
I have a 57 year old healthy, female patient with right ankle trauma in 1987. Recent x-rays, MRI and CT resulted in the following conclusions: Mild posterior subtalar joint osteoarthrosis, severe talonavicular joint osteoarthrosis, mild calcaneocuboid joint osteoarthrosis, moderate navicular-intermediate cuneiform joint osteoarthrosis, moderate navicular-lateral cuneiform joint osteoarthrosis, and mild navicular-medial cuneiform joint osteoarthrosis. She is looking to avoid surgery, as her only real option is multiple mid-foot fusions. She has worn a Ritchie brace, undergone cortisone injections, and exhausted all traditional, conservative medical care.
My question to my colleagues who have incorporated amniotic fluid injections and utilized them for a severe case is what were the results? I understand that everybody will respond differently. The patient is very open to the idea and I further believe that amniotic fluid will be more beneficial for her than PRP. With the multiple involved joints involved, the plan is for at least 4cc of fluid into multiple joints. The cost is not an issue, but I am curious what your experiences have been with its use for what I would consider to be a more extreme scenario than just PF, mild OA, neuroma, etc.
Query: Consecutive Hiccough Bouts Following Heel Injection
Just a clinical question as to whether any colleagues have ever encountered this - severe and persistent hiccough following heel injections on two separate occasions (the same patient after opposite heel injections one month apart). The patient reported unremitting hiccoughing hindering sleep that resolved the first time at 48 hours. The patient sought treatment the second time in a local urgent room where his symptoms were attributed to the injection. He was treated to resolution with baclofen. Apparently, this reaction has been reported with systemic administration but rarely (few case reports on cursory search) with regional injections.
Query: Raynaud’s Phenomenon in a Teenager
A 13 year old girl presented with her mom with the complaint of purple discoloration of her toes with itching for the past month. She is otherwise very healthy and was active in school sports, but has been very inactive for the past month or more due to distance learning at home. Her feet were icy cold and purplish in color. With pressure, the toes turned white with very slow capillary filling time. She said her hands have started to get really cold at times too. My first thought is Raynaud's phenomenon. When I mentioned this, she said that's what her grandmother has. There was no evidence of Covid toes which I had seen a few times this past spring, and no rash, blisters, or signs of chilblains.
Normally, I prescribe nifedipine 10mg capsules once daily and, if needed, increase it to one b.i.d., but I am a bit hesitant as she weighs only 70 pounds. The youngest person I have treated with Raynaud’s was an 18 year old girl at adult weight. Has anyone had any experience in treating Raynaud's in someone at this age and weight?
Query: Gout or Not gout?
I had a new patient come in who had gastric sleeve surgery 2 months ago. Since then, her right first MTPJ has been red hot and swollen. She has a history of a diagnosis of gout ten years ago. Both her parents have gout and are managed with colchicine and allopurinol. She was placed on Colcrys and allopurinol with no relief for the last two months.
She stated that she sees a rheumatologist for RA who feels this is not gout. She is getting no relief from the colchicine once daily and allopurinol. She brought in x-rays which were normal at the first MTPJ and for the entire foot. I had her increase the colchicine to TID for the next three days and will see her after that. If not improved, I will give her a posteior tibial nerve block to create a vascular flush of the area and a local steroid injection. My differential Dx at this time is 1) gout 2) pseudogout or 3) RA. Comments?
Query: Treating Verrucae in an Immunocompromised Patient
Recently, I treated a teenage heart transplant patient with a plantar 1st metatarsal crest area verruca. As far as I know, almost all transplant patients (kidney, heart, liver, etc.) take one or more immunosuppressive drugs to lessen the possibility of organ rejection. My patient was on oral Tacrolimus. Are there dermatologists who have experience with this type of case that I could or should have referred her to?
Is this a case that I had no good reason to take on in the first place? On further analysis, there are 5 or more immunosuppressive medicines advertised on TV used in rheumatology that suppress immune function and allow pathogens to spread. Is the same advice relevant for doctors treating these patients? Please advise.
Query: Relentless Heel Pain
We had a healthy 23 year old male present for fat grafting to his heel. He was a competitive ski jumper. Two years prior to his visit to us, he jumped and landed wrong on his left heel. He developed severe left heel pain but reported that his x-rays and MRI studies did not reveal a fracture. Initially, he limited weight-bearing and pressure on his left heel without relief. He reported he tried orthotics, had PT, EPAT, and “stem cell treatment with placenta”, but continued to have pain after two years of these various treatments. He presented to us asking for autologous fat grafting.
On examination, he had minimal pain on direct palpation of his heel but no pain on compression of his heel. He had a palpable “click” at the plantar central aspect of his heel. X-ray, ultrasound, and MRI were all negative for pathology. He reported that pain is always present when standing and walking on his heel, but it was difficult to elicit pain on palpation. We did attempt autologous fat grafting in the hopes the adipose tissue could ease any scar tissue he had. He is 9 months post-procedure with only minimal relief. Does anyone have any thoughts or ideas about his heel pain?
Query: Treatment of Interdigital Maceration
I have a few patients with excessively macerated skin between their toes - usually seen in the 3rd and 4th interspaces. There is typically no evidence of tinea infection. This appears to be caused by medial contraction of toes, which in turn causes very tight interspaces to become chronically moist.
I have tried toe spacers, lamb's wool, etc. with some limited success. I have also tried gentian violet in years past, but it's very messy & stains. I am curious what my colleagues are doing to treat chronically macerated interspaces?
Tom Silver, DPM, Minneapolis, MN
Query: Off-loading the Second Toe
What suggestions are there to off-load the second digit after a hallux amputation? I have tried orthotics, moldable custom silicone toe wrap, and different shoes. Any help would be appreciated.
Jeffrey Klirsfeld, DPM, Levittown, NY
Query: Unusual Pathogen in Paronychia
I received a culture report from a paronychia swab that grew a pathogen I have never encountered before. It is Leclercia adecarboxylata. It is sensitive to the usual antibiotics. Staph aureus (MSSA) was also in the culture. The patient is a healthy young man. I am wondering if anyone else has encountered this bacteria in a paronychia or other wound culture.
Howard E Friedman, DPM, Suffern, NY
Query: Fixation of 5th Metatarsal Osteotomies
In our practice, we most commonly perform a "Reverse-Austin" for Tailor's bunion deformities. Over the years, we have used K-wire, Orthosorb, and screw fixation for the distal V-shaped osteotomy. Most were done with a single tapered Orthosorb pin. I am looking for a small screw alternative. Our hospital encourages us to use the Synthes screw sets. We use 2.7mm fully-threaded cortical screws for our distal 1st metatarsal Austin osteotomies.
I am interested in learning what type of fixation my colleagues are using for distal 5th metatarsal osteotomies.
Greg Caringi, DPM, Lansdale, PA
Query: Cutting Edge Laser Technologies
I am considering getting into "laser technology". Has anyone dealt with "Cutting Edge Laser Technologies", a company out of New York? The salesperson basically says that this technology is great for post-op healing and acute pain, wound healing, neuropathy, and inflammatory condition, etc. It is not covered by insurance and I have concerns about the risk/benefit of including it in my practice which is financially strapped due to COVID-19. Both good and bad experiences would be appreciated.
Tip Sullivan, DPM, Jackson, MS
Query: Lengthening the Extensor Tendons with a Hammertoe Repair
I have a question about lengthening the extensor tendons with a hammertoe repair. From my education and experience, the extensor tendons to the lesser digits are elongated/stretched with the deformity and the flexor tendons contract/become tight. Shouldn't the flexor tendons be lengthened? I know this would have to be done cautiously in that over-lengthening the flexor tendon(s) would lead to decreased toe purchase, but I would like some other perspectives on this topic.
Anthony R. Hoffman, DPM, Oakland, CA
Query: Overlapping 2nd Toes, Bilateral in a 2 Year Old
This 2 year old is asymptomatic, but his mother is concerned about the condition getting worse. I'm looking for treatment options.
Overlapping 2nd Toes, Bilateral in a 2 Year Old
I'm already familiar with stretches, taping, toe spacers, and orthotics. Does anyone have other ideas? Would one ever consider surgery?
Query: Possible Post-COVID-I9 Pedal Pain
We have been seeing a number of patients in our office who have been presenting with unilateral foot and ankle pain in the soft tissues and joints. All tests including radiographs and bloods were normal. The only thing that they all have in common is that in March they had COVID-19 with minimal symptoms which included loss of taste and low grade fevers that lasted for 48 hours. The pedal symptoms and their histories of having COVID-19 might be purely coincidental or they may not be. Has anyone else come across this in their practices?
Elliot Udell, DPM, Hicksville, NY
Query: Sea Urchin Injury
My daughter’s friend thinks she stepped on a sea urchin yesterday. I met her in the office today to exam her foot. She had several “spines” around her heel and 5th MPJ. Slight pain was noted around the MPJ area, but was improving. Some redness is noted but no temperature increase or red streaking is noted. She soaked her foot in vinegar for several hours. She did get a prescription from another friend’s father for Cipro. She is allergic to penicillin. The spines, as pictured below, are the diameter of a hair.
Sea urchin injury
I tried removing some of them but they are very fragile and break into smaller fragments. I didn’t want to anesthetize the multiple areas to remove them because I felt it would do more harm than good. I instructed her to get a tetanus shot if she is due and to take the Cipro as prescribed. I’m not sure if the small spines need to be removed. If anyone has experience with this, your input would be appreciated.
Query: Inferior Extensor Retinaculum
All DPMs are aware of and treat tarsal tunnel syndrome, either conservatively or surgically. I need some information on the inferior extensor retinaculum. I have a patient who gets a "severe stinger" in his right hallux when he wears socks that might constrict him at the ankles.
Upon examination, he has a distinct Tinel's sign during percussion of a certain spot at the anterior-medial ankle. Does anyone have experience with this type of condition, and is the algorithm of treatment similar to that of tarsal tunnel?
Query: Photodermatitis During Terbinafine Dosing
I am curious about whether the readership has any quantitative data or clinical experience regarding photodermatitis during terbinafine dosing. Is complete avoidance of sunlight necessary or is skin sensitivity related to time of exposure? Are there other factors that are contributory? Does sunscreen provide any or some protection from possible photodermatitis while taking terbinafine? Our southern California weather is sunny most of the time, so questions regarding sunlight effects and medication are especially pertinent.
Neil H Hecht, DPM, Tarzana, CA
Query: Phenol Injections for Neuromas
Due to the unavailability of sclerosing alcohol, I have been reading about phenol injections for neuromas. Has anyone tried this method?
Karen Wasserman, DPM, Dallas, TX
Query: Panacos Procedure for Warts
For those who perform the Panacos procedure for warts, what is the longest anyone has seen results? The success rate is really high. The disadvantage with this procedure is that it takes months to work. I recently had 2 patients whom I did the procedures on a year ago but the warts have not resolved yet. I am wondering if there is still a chance for them to resolve. If not, I wonder what I might be doing wrong. I've been cutting out smaller lesions now, about 2-3mm to re-implant into the abductor hallucis muscle. Should they be larger?
Query: Bilateral Ankle Instability
I have a 16 year old patient who presents to see me regarding bilateral ankle instability and pain around the fibular malleolus from chronic sprains. She has a high arched foot structure and ankle equinus. She also has significant tibia varus and what may be impingement of the calcaneus on the fibula. I sent her to PT for strengthening and stretching but she has not seen much improvement of the area.
I have cast her for custom made foot orthoses but am unsure of the rearfoot posting. I believe that the calcaneus is a component of this problem and think a mild varus post would help decompress laterally, but I do not want to contribute to instability. Any thoughts or suggestions?
Query: Fireworks Foot?
Has anyone encountered pedal or lower extremity injuries from fireworks? If not yet, it will probably happen soon because the out-of-control use of these devices is no longer restricted to "fun and games" on the Fourth of July.
Elliot Udell, DPM, Hicksville, NY
Query: Unknown Hallux Lesion
I have a 40 year old male patient, no medical history with a great toenail that looks like half a Ping-Pong ball. No trauma, no pain, no infection, no discoloration, but in 2015 he tells me that it was much smaller. The toe was x-rayed and the nail removed for inspection.
Unknown Hallux Lesion
The DP film shows a calcification channel from the grown into the 1st interspace. The lateral shows a very good outline of the growth as well. This patient does not have insurance, but will likely pay out-of-pocket for what I would expect to be a full excision as opposed to a punch biopsy. That discussion is pending a final diagnosis. Your thoughts are appreciated.