Treating Difficult Nails In Diabetic Patients

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Continuing Education Course #139 — March 2006

I am pleased to introduce the latest article, “Treating Difficult Nails In Diabetic Patients,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Patients with diabetes face an increased risk of nail disorders such as onychomycosis due to their systemic disease. Given the unique challenges of treating such patients, Peter Blume, DPM, Jared Wilkinson, DPM, and Jonathan Key, DPM, offer a comprehensive overview of diagnosing nail disorders in this patient population. They offer insights on various therapies, including oral, topical and surgical treatments.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site ( roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 92 and successfully answering the questions on pg. 98. Use the enclosed card provided to submit your answers or log on to and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Blume, Wilkinson and Key have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
RELEASE DATE: March 2006.
EXPIRATION DATE: March 31, 2007.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the rationale and methodology for screening diabetic patients for nail disorders;
• review various types of onychomycosis;
• discuss the advantages of debridement and topical therapy in treating onychomycosis;
• compare various oral therapies for onychomycosis;
• discuss the indications for surgical treatments for onychomycosis; and
• assess the potential impact of nail trauma in patients with diabetes.

Sponsored by the North American Center for Continuing Medical Education.

When screening diabetic feet, one should evaluate nail abnormalities including onychocryptosis (as shown above) and onychomycosis.
Here is a nail bed flap exposing the distal phalanx for resection. Exostoses, enchondromas or  osteochondromas may cause a nail deformity.
In some instances, severely deformed and symptomatic nails secondary to onychomycosis may require surgical management. Partial surgical matrixectomies, like the Winograd or Frost procedures, may be options if the situation dictates.
The distal Symes procedure permits removal of the nail bed, matrix, contiguous soft tissue structures and part of the distal phalanx.
Using angiosome principles of arterial-arterial connections can allow one to make safe incisions and raise local flaps to provide adequate coverage of soft tissue.
Using angiosome principles of arterial-arterial connections can allow one to make safe incisions and raise local flaps to provide adequate coverage of soft tissue.
Researchers have described various skin plasties for nail deformities.
Researchers have described various skin plasties for nail deformities.
Researchers have described various skin plasties for nail deformities.
By Peter Blume, DPM, Jared T. Wilkinson, DPM, and Jonathan J. Key, DPM

Due to the nature of the disease, the diabetic patient population has an increased risk of developing nail abnormalities, including onychocryptosis, onychomycosis and other nail structure malformations and injuries. Over one-third of diabetic patients suffer from nail abnormalities and are 2.77 times more likely to have nail mycoses compared to the general population.1
Diabetic patients often develop nephropathy, peripheral neuropathy, retinopathy, cardiovascular disease and impaired circulation, which further exacerbates secondary complications associated with various nail pathologies.2

Due to these sequelae of diabetes and the propensity of developing various nail disorders, the patient with diabetes has a higher risk for complications, including microbial invasion, infection, ulceration and injury. These risks make it important to recognize and treat nail disorders in the diabetic population.3 Mycotic nails can lead to adjacent nail, skin and subungual injury while providing reservoirs for various fungi and increasing the risk of other sequelae and infectious spread.2
The peripheral neuropathy that affects many patients with diabetes may delay recognition and treatment of minor abrasions and lesions. When these abrasions and lesions become infected, it can lead to further ulceration and propagation. Various onychopathies may affect the physical, mental and social health of the patient.4-5

Why It Is Important To Identify Nail Disorders In Patients With Diabetes
Onychomycosis occurs in 5.9 percent of people with diabetes (20.8 million people in the United States) compared to 0.8 percent of people without diabetes.6,7 The secondary infection rate of diabetic patients with onychomycosis is 16 percent compared to 6 percent of those without onychomycosis.6 Patients with diabetes and onychomycosis also have a significantly higher occurrence of gangrene and foot ulceration (12.2 percent) as compared to diabetic patients without onychomycosis (3.8 percent).6
Diabetic foot screenings should include the evaluation of nail abnormalities, including onychocryptosis and onychomycosis. Complications of unmonitored nail disorders could lead to severe complications including ulceration and infection. Podiatric physicians should check for nail bed ulcerations resulting from subungual exostoses, distal osteochondromas and endchondromas. Treatment goals should emphasize prevention and active treatment of onychomycosis and other nail disorders in order to prevent associated morbidities and complications. Treatment options include mechanical intervention, pharmacological therapies and surgical intervention.

Clinicians must first recognize the nail disorders. The clinical symptoms of onychomycosis include onycholysis, hyperkeratosis, brittle nails, paronychial inflammation and color changes.8 Tenderness to palpation directly on the nail plate in conjunction with associated deformity should trigger a radiographic evaluation of the distal phalanx to rule out exostoses, osteochondromas, endochondromas and suspected osteomyelitis in potential cases of nail bed ulcerations.
After ruling out these osseous abnormalities, physicians should identify the causative pathogen. Identification begins with fungal culture or direct microscopy after KOH preparation. Direct visualization determines the presence of hyphal fragments but does not determine the exact organisms. However, results can certify dermatophytic or non-dermatophytic involvement.9 Differential diagnosis of pathogens causing onychomycosis include dermatophytes, non-dermatophytic molds and candidal species. Dermatophyte test media (DTM) can help confirm the clinical diagnosis but the most accurate diagnostic test is a histopathologic examination with periodic acid-Schiff stain (PAS), which has a reported 85 percent rate of accuracy.10

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