Laser Therapy for Treatment of Onychomycosis: Fact or Fiction?

Back in April, in our Blog entitled: “Achoo! The Common Cold of the Feet” we discussed in detail, fungal nail infections. Much discussion, in both the Podiatric and Dermatologic communities surrounding Laser Therapy Treatment for onychomycosis (fungal nail infections), has surfaced in recent months and years. The topic of laser therapy was briefly mentioned in April’s blog, but this week, I’d like to provide you with a little more insight as to what Laser Therapy aims to do in order to treat fungal nail infections, and if it will be effective or not.

Lets quickly review the basics: what is onychomycosis? Onychomycosis (on-EE-ko-my-KO-sis) is a fungal infection of the nail that can be caused by 3 types of fungus: non-dermatophytic molds, yeasts, and dermatophytes. The most common infective "bug," accounting for 70% of all toenail infections, is a dermatophyte by the name of T. rubrum. The names, none of which are important, mean very little in relation to treatment modalities that can be used. It is, however, important to know that the types of fungus causing toenail infection thrive in moist environments, therefore keeping feet clean and dry helps prevent infection by one of these "bugs." It is also important to clean community showers frequently with chemicals like bleach, killing any organisms living on the tile. Wearing shower shoes, in situations where you are not responsible for cleaning, is also a wise decision!

When the organism gets into the bed of the nail and/or the nail matrix (the tissue from which the nail grows), your nails will become thickened, discolored, and often brittle. Patients experience associated pain with fungal nails due to increased thickness which causes the nails to become pressed up against the inside of shoes. Nails become difficult to trim at home and embarrassment in open-toed shoes or sandals is imminent!

Treatments, as they are currently available, do very little for long-term cures. Several pills and nail lacquers do help the appearance of nails and decrease thickness. However, they are not without their side-effects, and when use of these medications are discontinued reoccurrence of fungal infection is likely is 70% of patients. Over the counter methods such as mouthwash, Vicks Vapor Rub and Vitamin E lotion seem to benefit in decreasing thickness, but long-term research studies have yet to be conducted to determine the effectiveness of such remedies for providing a cure. My guess would be that their cure rates would be similar to oral and topical prescription medications, as fungal nail infections are typically VERY difficult to treat. The problem with treating and curing fungal infections long-term is seeded in the way the fungus manifest within the nail, making it very difficult to get to the source of the infection and kill it from the inside out.

The science behind laser therapy for treatment of onychomycosis is still relatively new, unknown and lacking research! The Patholase "Pinpoint Foot Laser" featured in the news recently, although approved by the FDA for use in Dentistry and Soft-Tissue cutting, is not currently FDA approved for the treatment of Onychomycosis. The initial study Patholase conducted to support its "off-label" use for the treatment of toe-nail fungus centered around 16 patients, which is never large enough of a research pool to deem something effective and safe for continued use. The price is astronomical, mentioned to be close to $1200 per session to have all 10 nails treated, with no safe bets for complete resolution of fungal infection.

The Noveon Laser, by Nomir Medical, is a laser therapy device currently undergoing FDA Clinical Trials for approval of its use in treating Onychomycosis. It holds more promising evidence than Patholase in its effectiveness in treating and possibly curing fungal nail infections. At this time, Nomir Medical makes no claims that treatment with its laser is more or less effective than the currently available oral and topical medications and admits that further clinical trials need to be conducted.

In short, fungal nail infections are extremely difficult to treat and only time and continued research will tell if a long-term cure is a possibility, especially in the realm of Laser Therapy. The best option available today is to try one of the currently approved methods, and once treatment has concluded, prevention of reoccurrence becomes key!

For more on prevention of recurrence, check back to Aprils blog!

No More Vaseline!

The most common response from my patients, when asked about what agents they use to moisturize their legs and feet is: Vaseline. It is a complete myth that Vaseline moisturizes skin, but it does a very good job at creating that façade!

The skin is composed of three main layers: the epidermis, dermis and subcuticular layers.

Epidermis: the upper/outermost layer of skin, which is obviously the most visible layer and itself has 5 distinct layers. It acts as the initial barrier to protect the body from invasion by bacteria and other foreign materials and substances. Its main cellular component is called a “keratinocyte,” which makes its way from the lowest layer of the epidermis to the top layer of the epidermis. By the time keratinocytes reach the top layer of the epidermis, a.k.a. the surface of the skin, these cells are dead and thus, dry skin!!

Dermis: the second layer of skin, that is not visible to the eye, and is made of up two distinct layers. The dermis plays a very important role in the formation of hair follicles and sweat glands, helping to regulate the temperature of the skin and body. It also contains blood vessels that supply the skin.

Subcuticular: the deepest of the three layers that make up the skin. It consists mainly of fat cells that store energy, varying in thickness depending on what area of the body the skin is covering.

The skin has a very distinct cycle of growth, development and death (dry skin). The keratinocytes (principle cells in the epidermis) take 8-10 weeks to rise from the bottom of the epidermal layer to the top of the epidermal layer. As I mentioned before, once they reach the top layer, they are no longer “living cells” and appear as dry skin. To keep the skin healthy, this top layer of non-living Keratinocytes needs to be removed, and moisture put in its place. Vaseline neither removes non-living keratinocytes nor imparts moisture into the skin. Therefore, it is not a good option for “moisturizing,” but because it seals in any moisture that might already be present in the skin, it does a very good job at ‘pretending’ to moisturize!

So what is a good option for moisturizing the skin? The answer: it depends on the condition of the skin. For mild conditions, imparting moisture into the skin may provide adequate results, but in more severe conditions of dry skin, keratinocytes need to be removed so that the moisturizing agents can reach healthier layers of the skin. Therefore combinations of desquamation agents (used to remove keratinocytes) and moisturizing agents are best!

In a patient with mildly dry skin, moisturizers alone (substances that impart moisture into the skin), can work fairly well and can be found over the counter at your local drug store. Some good options include: CeraVe, Eucerin and Vaseline Intensive Care.

In a patient with mild to moderately dry skin, there are prescription lotions that will help remove some of the keratinocytes on the surface of the skin as well as impart moisture. These agents usually contain an ingredient called Lactic Acid. A commonly prescribed lotion for mild to moderately dry skin is called AmLactin.

For patients who have severely dry skin, prescription strength lotions can be given to remove most of the keratinocytes on the surface of the skin in addition to imparting moisture. These agents contain an ingredient called Urea. Examples of such lotions include Umecta and Keralac.

It is important to have nice healthy skin to prevent breakdown or ulceration, in addition to helping the skin maintain its functions in protecting from foreign substances and body temperature regulation. The best time to apply moisturizing agents is within the first two minutes after you’ve showered, as the pores are the most open during that time interval and the moisturizer can penetrate into deeper layers of the skin.

If you’ve attempted over the counter lotions, such as the ones mentioned above without success, speak with your Podiatrist about trying a prescription moisturizer that will help remove keratinocytes. You may see healthier looking skin in no time.

No more Vaseline!

“The Leg Bones Connected to the, Knee Bone…” by Tendons!

Tendons are tough, yet flexible bands of fibrous tissue that connect a muscle to a bone. Such tendons are responsible for transmitting a muscle contraction to the bone in which it connects, invoking movement. The most well know tendon in the body is the achilles tendon. This tendon arises from two muscles in the posterior compartment (calf) of the leg and attaches to the heel bone (calcaneus). When either of the two muscles from which it arises contract, the achilles tendon pulls on the heel bone and causes plantarflexion of the foot at the ankle joint (movement of the toes in a downward direction). The tendon itself provides no contraction and ultimately no strength to the movement, but its integrity is important for normal joint functions. Without the achilles tendon specifically, plantarflexion of the foot would be very challenging, if not impossible! This would be the case for any joint motion, as without tendons, muscles cannot exert their pull on a bone.

Tendons can rupture (completely tear) at their “watershed” areas, typically as the tendon is bending around another anatomical structure along its path. These areas are best described as the weakest points of the tendon due to their poor vascularity (blood supply). Although we are not discussing tendon ruptures today, keeping these areas in mind is helpful when discussing tendonitis, as these same areas are also at a higher risk for development of tendonitis.

Tendonitis is irritation and inflammation of a tendon that is most felt by the injured individual when its corresponding muscle is being contracted. The presence of inflammation prevents the tendon from “gliding” as it should, when attempting to transfer the muscle contraction to the bone, resulting in pain. Inflammation within the tendon is usually secondary to over-use, and is most commonly seen in the novice individual, but can also be seen in professional athletes. It’s the kind of injury, that although attributed to over use, the occurrence in a well-trained athlete is peculiar and has no definitive explanation other than over use!

Whatever the etiology of tendonitis in an athlete, pain and discomfort is a very real thing. The athlete will most likely suffer from tendonitis in a tendon they use frequently (eg. tendons of the elbow’s in a quarterback; the achilles tendon or lower leg tendons in centers etc), and thus with repeated movement and contraction of the muscles to which that tendon is responsible, pain with motion in eminent. Pain directly over the tendon and along its course into the bone, in addition to crepitus (a “crunchy” feeling) within the tendon is diagnostic for this condition. X-rays typically will not show tendonitis, as tendons are not dense enough to show up on x-ray, however and MRI is much more sensitive for detecting the inflammation in and around the tendon. Is an MRI necessary? Not always, but will typically be ordered for athletes who fails to improve after several weeks of treatment.

Treatment is much the same as treatment of muscle sprains and turf toe, which we’ve reviewed the past two weeks. RIICE: Rest, Ice, Immobilization, Compression and Elevation. Although in this situation, rest is the most important thing. It will give the tendon a chance to heel and for the inflammation to decrease. Again, over the counter anti-inflammatory medications and/or tapered systemic steroids will decrease local tendon inflammation, while injections are not typically utilized for tendonitis. Depending on the location of the tendonitis, steroid injections may be associated with an increased risk of tendon rupture.

Risk of increased pain and even rupture is associated with this type of injury if not treated properly, or if the inflammation isn’t given sufficient time to subside before a return to activity. Therefore, a slow but important recover, with physical therapy, and most importantly rest cannot be expedited! It may take several weeks for a return to normal activity.

As old Greek Mythology proclaims, the heel was the most vulnerable part of Achilles’ body, and thus, it was his weakness and ultimately an injury in that area that killed him. Although this injury will not kill a professional athlete or any athlete for that matter, tendonitis in the achilles and other tendons of the body, can be painful and temporarily debilitating!

Strains, Sprains and…Automobiles?!

This month we’re taking on the topic of commonly suffered injuries by our most beloved National Football League players. As mentioned last week, it’s hard for us to be sympathetic towards players who suffer injuries we think they are capable of playing through. The hope is that with a little more understanding of their injuries, our sympathy might go a stitch further…although probably not too far!

Last week we discussed turf toe including the limitations and long-term implications this injury can have on a professional athlete if not treated properly. As promised, this week we will be discussing muscle injuries! In order to do so, there are a few distinctions that must first be made.

1. A strain describes an injury to a muscle. Essentially a strain describes a series of “micro-tears” in a muscle belly, which may also be referred to as a “muscle pull.”
2. A sprain describes an injury to a ligament. Ligaments are bands of tough (fibrous) tissue that connect bone to bone and provide support to joints (ankle, knee etc) preventing motion of the joint in an abnormal direction. Sprains will not be the focus of this week’s blog.
3. A torn muscle describes a partial or complete tear that is typically much more debilitating to the athlete than a strain would be.
4. A ruptured muscle is also a torn muscle, but only refers to a complete tear in the muscle and typically indicates shortening of the muscle fibers, making repair and recovery much more difficult.

Now that we’ve clarified those few terms, lets discuss how an athlete, who may be among the most “in-shape” individuals, suffers an injury to their muscle. A muscle becomes strained, torn or ruptured when a sudden, extreme force is applied to the muscle and stretches the muscle fibers beyond their capacity. This may occur by a direct force to a joint for which the muscle or the muscle tendon may cross, or may also occur with an abnormal motion of the muscle in a direction in which it is not designed to act. No matter which mechanism occurs, if you’ve ever watched an athlete suffer a muscle injury, you will notice that they immediately grab the area of injury, indicating the instant pain and inflammation that occurs!

To differentiate between a strain, torn, or ruptured muscle, the best and most definitive study would be an MRI (Magnetic Resonance Imaging). It is able to capture defects in the muscle belly in addition to inflammation in and around the area of complaint. However, testing the strength of the injured muscle compared to the healthy side can also provide an indication as to the extent of injury and help classify it as a strain, partially torn or ruptured muscle.

Initial treatment for a muscle injury includes ice and rest, in addition to anti-inflammatory medications. After several days of this, gentle and passive stretching (meaning by a physical therapist and not by the athlete) can be initiated. This stretching will prevent the muscle fibers from healing in a shortened position, which would predispose the muscle to becoming re-injured. The best indicator of healing is the amount of pain, or the decrease in pain the athlete is suffering from. However, an increase in muscle strength from initial examination after the injury is also indicative of healing. In the most benign of muscle injuries (strains) the athlete can be back in action within two weeks. However, with a torn muscle (one that is not completely ruptured) this process can take much longer, sometimes more than a month! In the worst-case scenario where the muscle has been ruptured, surgical repair is often recommended, for which recovery can be months long!

As with most things that we’ve discussed over the last year, prevention of muscle injuries provides the best scenario for the athlete and for his/her supporters. Of course, athletes must focus on flexibility and strength through training, but proper stretching and ensuring adequate warm-up before and cool-down after activity will also help prevent muscle injuries. It is important that at the first sign of possible injury, the athlete be evaluated by their “on-staff” Podiatrist, Orthopedist or Athletic Trainer to prevent further or more detrimental injury! Early evaluation can make the difference between a simple strain, or a strain that turns into rupture.

Turf Toe

With the advent of football season starting this past weekend, I thought it appropriate that we try to “tackle” common injuries suffered during the season. As some of you may know, when players in the NFL are injured it completely messes up our Fantasy Football seasons and we quickly scramble to pick up “free agents.” Aside from our frustrations, however, it’s the players who are suffering from ankle injuries, muscle sprains, tendonitis and so forth. Understanding some of their conditions might provide us with a small amount of sympathy for the ridiculous amount of money they’re making to sit on the sidelines!

Professional athletes are considered to be in tip-top shape compared to the average citizen, and many people wonder how, being in such great shape, they still manage to injure themselves. I can assure you, although some injuries occur secondary to poor preparation most occur secondary to over-use, direct impact, or abnormal force vectors through the body.

This week I would like to discuss Turf Toe. It seems like an ambiguous diagnosis, but it is a real diagnosis with those most frequently afflicted being athletes that play on turf surfaces. The actual injury is a disruption of the plantar ligaments (those underneath) the big toe secondary to hyperextension, or excessive bending of the toe upwards in relation to the foot.

The injury occurs when the athlete’s cleat gets ‘stuck’ in the turf surface while the body is moving in a forward direction. This motion forces the big toe to extend, abnormally, before the cleat can release itself from the surface. This hyperextension can induce an overstretching of the plantar ligaments, a partial tear, a complete tear, and even cause damage to the big toe joint if it becomes compressed during the injury. Almost immediately pain becomes evident to the player, but professional athletes tend to play through pain until it’s absolutely unbearable. However, this pain is usually accompanied by swelling and difficulty in bending the toe, realized when the athlete removes his or her cleat after a game.

The tenants of any injury apply to treating Turf Toe: RIICE: Rest, Ice, Immobilization, Compression and Elevation. Rest and Immobilization will prevent further injury to the plantar ligaments in addition to giving them a chance to repair themselves. Ice, compression bandaging of the toe and elevation will help decrease swelling and subsequently decrease pain to the joint. Of course, non-steroidal anti-inflammatory drugs such as Ibuprofen can be utilized to decrease pain and help control inflammation as well. Athletes are typically encouraged to keep off their toe/foot for at least 3 days, after which partial weight bearing in a rigid soled shoe, to prevent motion at the joint, can be attempted

It is always wise, when a Turf Toe injury is possible, to be evaluated by a Podiatrist. X-rays can help rule out damage to the joint and physical therapy will help get the athlete back to their game in no time! It is likely that with return to activity, protection of the toe will be exercised through taping and shoe accommodations to keep motion to a minimum. Obviously, depending on the extent of damage, more time away from the game may be necessary to allow for adequate healing, but at the professional level, those athletes are looking at a maximum of three weeks on the sidelines. Too early a return to activity can lead to further damages to the joint, including arthritis and eventual loss of motion, so caution should always be exercised!

Next week, I’ll be discussing muscle pulls and tears including those most commonly suffered in professional athlete: the hamstring, and achilles tendon.

Think R.O.D.

Over the last three weeks we’ve been discussing the most common complications to affect the diabetic patient in the lower extremity. Diabetic neuropathy with circulatory compromise and increased plantar foot pressures all contribute towards an increased risk of diabetic ulceration in such patients.

I’ve given you many helpful tips for decreasing your risk of developing each of those three complications, and again I’ll reiterate that prevention is your best option! However, despite your best efforts, if you do develop a “neuropathic ulcer,” you will be facing an uphill battle in getting that ulceration to heal. This week I hope to help you identify signs and symptoms of an ulceration that needs immediate treatment, increasing your chances of healing that area quickly.

First and foremost, you should understand what I mean when I say “neuropathic ulcer:” this is an ulceration found in an area of the foot where you lack sensation such that the causative agent (whether a foreign object or friction) went undetected by you. Treatment begins with recognition of the ulceration at home during your daily foot checks. Once you’ve identified a break in the skin or ulcerative area, you should immediately call your Podiatric Physician for an appointment. This last step is very important, no matter how large or small the area of ulceration may be, because these wounds have a history of quickly deteriorating.

Now, if the area in question is discovered on a Friday after your Podiatrist’s office has already closed for the weekend, there are some signs and symptoms you need to be on the lookout for. These signs/symptoms will help you determine if you need to seek immediate treatment at an Emergency Room, or if you are able to wait it out until Monday. In deciding this, think ROD: Redness, Odor, Drainage.

R = Redness: If the skin surrounding the ulceration is extremely red, hot and swollen, this is a cause for concern. Even more emergent is recognition of red “streaking” from the area of ulceration up towards the core of the body. Streaking is a sign of infection that is penetrating the lymph system and needs immediate attention. As an aside, if you are having any symptoms of a systemic infection, such as fever, chills, nausea or vomiting, you are also in need of immediate treatment.

O = Odor: If the area smells fruity or has an unbearable odor associated with it, this may be an indication of local infection across the base of the wound. If this is the only symptom, what you should do is clean the area with warm soap and water, dry it completely and place a clean dry bandage over the area, to be changed each day until you’re able to see your Podiatrist. If this odor is associated with systemic symptoms, excessive redness or streaking and alarming drainage, you are in need of immediate treatment.

D = Drainage: If there is green or thick yellow drainage coming from the area, typically associated with an odor, you need to be seen immediately. This is a definite sign of local infection, and one that may spread quickly, so it’s important to seek medical attention.

As a disclaimer, if you are unsure that your wound meets any of these criteria, my advice would be this: go to the Emergency Room. It’s better to be reassured that everything is okay than to miss an ulceration that’s quickly deteriorating. In addition, if the ulceration seems to be changing for the worse and digressing quickly, you should also seek immediate treatment.

Decreasing You Risk of Ulceration

Over the last two weeks we’ve been discussing diabetic complications of the lower extremities; an important topic in terms of raising awareness and helping you to prevent or slow progression of such complications. This week, I want to focus on the function of the foot in the diabetic population and again, how prevention is your best option for decreasing your long-term risk of complications.

In the diabetic population, equinus is the overwhelming commonality between patients suffering from plantar wounds associated with diabetic neuropathy. Equinus, to explain it simply, is a lack of dorsiflexion, or ability to raise the foot at the ankle joint past 90 degrees (neutral position). The ankle and foot function best in gait when dorsiflexion at the ankle is at least 10 degrees past the neutral position. When this is decreased, excess pressure is placed on the plantar forefoot throughout gait, and increased pressures automatically lead to an increased risk in ulceration.

Patients develop equinus from a lack of flexibility in the musculature of the leg, namely the calf. Whereby, dorsiflexion becomes decreased because it is those muscles in the calf that are responsible for lifting the foot above that neutral position during gait. If those muscles are tight or contracted, which occurs in patients who don’t stretch or exercise on a regular basis, equinus and increased forefoot pressures result.

Increased pressures in any area of the foot create a major risk in the diabetic patient, and such pressures can also be induced by tight fitting shoes, open-toed sandals that rub between the toes, and areas of friction along bunion prominences or on the tops of contracted digits (hammertoes) in closed-toed shoes. The reason increased pressures are such a risk is that in places of friction, typically not felt by the neuropathic diabetic patient, a pre-ulcerative lesion may develop. The area goes undetected, unless you’re religiously checking your feet on a daily basis for new lesions (which you should be doing!), and the pre-ulcerative lesion turns into a wound.

Again, you are faced with the issue of non-healing secondary to poor circulation (which we discussed last week), such that the nutrients needed for wound healing carried by the blood have difficulty getting to the area. In addition, if you have not addressed the issue of equinus or the problem shoes that created the initial friction, you’re bound to have problems in the future, even if you’re able to heal this time around. So what can you do? Again, the answer is prevention!

There are two important ways in which you can take control of the deforming forces of equinus and increased pressures placed on the foot:
1. Stretch – By stretching the musculature in your calf and increasing the flexibility around the ankle joint (decreasing your equinus), you will greatly decrease pressure placed on the plantar forefoot and decrease your risk of ulceration. There are several exercise, that are easy to do:
a. Wall Stretch: With your feet shoulder width apart, one foot in front of the other, place your hands on the wall in front of you. Keeping the back leg straight and the front leg bent slightly at the knee, lean into the wall. You should feel a light stretch in the calf of the straight leg. Hold this for 20-30 seconds, take a 15 second break and repeat 10 times. Then switch front and back feet, so that you can stretch the opposite side. Again, hold for 20-30 seconds, repeating 10 times.
b. Heel Drop: This exercise will require a set of stairs with a railing available for balance. Place the balls of both feet on the step, knees straight and allow the heels to suspend off the step and drop down below the level surface via your body weight. You should feel a light stretch in the calf of both legs. Hold this for 20-30 seconds, take a 15 second break and repeat 10 times.
2. Invest in a pair of diabetic shoes – Especially important for those patients with diabetic neuropathy, but important for any diabetic patient. Diabetic shoes have a custom molded insert with a wide and deep toe box. The insert is made from a mold of your foot and alleviates all areas of pressure on the plantar foot. The wide and deep toe box allows the foot room within the shoe, preventing areas of friction on boney prominences. Diabetic shoes essentially alleviate all friction areas, thus decreasing your risk of pre-ulcerative areas and ultimately of developing an open wound.

As you can see, the power again remains in your hands when it comes to decreasing your risk of complications associated with diabetes! With diet and exercise, controlling your blood glucose levels, managing your co-morbidities and preventing areas of pressure in the foot, you’ll be well on your way.