Treating Fungal Infections In Patients With Wounds

Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

Fungal infections can exacerbate the already compromised environment of lower extremity wounds. These expert panelists discuss treating fungal infections in wound care patients, offering insights on oral treatments, topical therapies, and the potential of lasers.

Q:

Do you treat fungal skin and nail disease in lower extremity wound patients?

A:

For Brent Haverstock, DPM, the decision to treat is based on whether he feels the infection is contributing to the wound. He notes that a large number of his patients who present with lower extremity wounds are quite compromised medically and have onychomycosis. Some of his patients also present with features typical of a mycotic skin infection such as a region of chronic erythema with associated pruritus. Dr. Haverstock says such patients often demonstrate the classical moccasin distribution on the plantar aspect of the foot. If Dr. Haverstock suspects a mycotic infection in the wound, he will culture by sending a piece of tissue from the wound.

   Bryan Markinson, DPM, says most of his wound patients have diabetes or vascular insufficiency. In this population, he says neglected fungal infections of the skin result in skin breaks that can be a portal for infection by bacteria, which can greatly complicate matters. Therefore, Dr. Markinson aggressively treats tinea infections.

   Similarly, Kazu Suzuki, DPM, CWS, has found that fungal skin and nail disease contribute to foot ulcers and amputations. He has amputated many toes and feet over the years because of the injuries caused by dystrophic fungal nails or tinea pedis. When it comes to patients with diabetes and/or peripheral arterial disease, Dr. Suzuki says interdigital tinea pedis or severe skin fissures exacerbated by tinea pedis can be dangerous as they can lead to skin breakdown, cellulitis and limb-threatening infection.

   Noting that wound care patients are no different than any patient with a fungal infection, John Mozena, DPM, treats the infection before it spreads to other areas of the body or to other people. He always offers patients treatment for their fungal infection depending on its severity. His treatment options include topicals, orals, laser fungus ablation, nail removal and conservative therapy.

Q:

Do you obtain a fungal or yeast culture when treating fungal skin and nail diseases?

A:

Dr. Mozena points out controversies over culturing fungal infections, asserting that many podiatrists believe their clinical experience is adequate in making a diagnosis. Furthermore, he notes that fungal cultures are only 75 percent reliable and can give a false positive or negative result in many cases.1

   Dr. Mozena notes that patients are reluctant to pay for a test that is unreliable. He adds that the most reliable tests, periodic acid Schiff (PAS) and polymerase chain reaction, are very expensive. With that said, he still offers testing to every patient using oral antifungal or laser treatment, and lets patients decide whether they would like a culture taken or not.

   Before Dr. Haverstock begins therapy, he obtains a KOH and fungal culture. If the KOH examination is positive for fungal hyphae and he is concerned that this is affecting the progression of wound healing, Dr. Haverstock will proceed with therapy.

   However, Drs. Suzuki and Markinson do not routinely culture. Dr. Suzuki feels taking a medical history is often sufficient to exclude diseases such as psoriasis and other conditions that mimic fungal skin and nail disease.

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