Treating Onychomycosis In Patients With Diabetes

Dr. Armstrong: Diabetes is becoming far more common both in the developed and the developing world. By the year 2025, there will be at least 300 million people worldwide with diabetes. People are living longer with diabetes thanks to many advances in diabetes care and improvement in care by primary, secondary and tertiary care physicians. They are also living longer with complications and one of the most significant complications in diabetes is the diabetic foot.
We know the most common reason for hospitalization among people with diabetes is not for high blood sugar or a stroke or a heart attack — it’s for an infected foot. That encompasses one-quarter of all diabetes-related hospital admissions in the United States. It’s even higher in parts of the developing world.15,16 We also know when these folks are admitted, they are generally not cared for as adequately as we would like them to be. Unfortunately, inadequate assessment of these patients doesn’t start with hospitalization but rather when they are initially assessed by their primary care provider and even their specialist care provider.

This leads me to the issue of appropriately assessing the diabetic foot. We know the most significant factor associated with development of diabetic foot complications is diabetic peripheral neuropathy. There are other issues as well such as dermatologic issues. One of those significant dermatologic complications is onychomycosis. There are interesting data now from Boyko, et. al., that suggest someone presenting with onychomycosis may be at significantly higher risk for development of a diabetic foot ulceration.17 In fact, a patient presenting with onychomycosis is at a 60 percent greater risk for developing a diabetic foot ulcer than someone who presents, for example, with a clean nail bed. If these patients are at risk for this kind of infection, it stands to reason they might be at risk for other complications as well.
Perhaps a modality that strikes at this problem, both when it is there and perhaps even to prevent the problem from recurring, might be very useful. There are a number of various modalities and pharmaceuticals approved to treat onychomycosis. However, I think an appealing modality would be a topical treatment that not only allows the patient to treat the onychomycosis but also facilitates the patient getting down and evaluating his or her feet.

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