The Foot Clinic Northampton 07925 085889

Fungul Infections

   The story of the Dermatophyte Test Strip - Ivan Bristow PhD  &  Michelle Score BSc (Hons)    

                   February 1, 2019                                                              

It’s always good to have new innovations in podiatry and when something does come along that can revolutionise practice its always exciting. Back in 2014, we were reading an article which was published in the British Journal of Dermatology (1). The article caught our attention because it discussed a development in the diagnosis of dermatophyte nail disease. Having been frustrated by the difficulties of ascertaining an accurate diagnosis with current methods an alternative was certainly welcome. The current clinical podiatry standard of diagnosing fungal nail infection just by clinical appearance was at best was insufficient and at worst, unethical.

The 2014 published study from a Japanese research group compared the test strip with conventional microscopy and culture from 165 nail samples. The results were impressive showing a very high sensitivity rate of 98%. Moreover, the advantages of the test were appealing to us as clinicians. Taking just five minutes to reach an accurate diagnosis with no need for high levels of technical skill? This would be great for a podiatrist, we thought. A second paper was then published which really confirmed its use. In a study of 222 nail samples, the dermatophyte test strip outperformed traditional microscopy showing high levels of accuracy (2).

Having read these articles, we were keen to obtain some samples to try out this test to see if it had a place in the podiatry clinic. Obtaining these was not straightforward but eventually, through a colleague overseas, we were able to obtain some. Needless to say, the product transformed our practice. When patients came in with a dystrophic nail, for the first time ever we were able to test the nail to check for dermatophytes instead of guessing. Having this new tool was also a learning experience. It was surprising that when we tested our ourselves using visual inspection versus the test strip, we were getting the diagnosis wrong around 25% of the time. Now patients could receive a diagnosis and begin treatment at the same appointment with no three-week wait as the samples did not have to go to the lab and of course, no disappointment when they came back a month later saying the lab specimen was negative.

At this point, we realised that the test kit was something special which should be in any clinic diagnosing and treating nail problems. So we brought the test into the UK and Ireland for clinical use. Since that time, it has been introduced throughout hundreds of podiatry clinics throughout the UK and continues to grow. For the first time, podiatrists can now reliably and quickly test for dermatophyte nail infection and increase their business. No more guessing and no more costly laboratory samples. In addition, this is a unique product which means a podiatry clinic can establish itself offering something which is not currently elsewhere. Most importantly, it also meets the guideline set by NIHCE (3) and the British Association of Dermatologists (4), namely that fungal nails should be properly diagnosed before any treatment is commenced – maintaining high clinical and ethical standards.

References:

1.    Tsunemi Y, Takehara K, Miura Y, Nakagami G, Sanada H, Kawashima M. Screening for tinea unguium by Dermatophyte Test Strip. Br J Dermatol. 2014;170(2):328-31.

2.    Tsunemi Y, Hiruma M. Clinical study of Dermatophyte Test Strip, an immunochromatographic method, to detect tinea unguium dermatophytes. The Journal of Dermatology. 2016;43(12):1417-23.

3.    National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Fungal Nail Infection: National Institute for Health and Care Excellence; 2013 [cited 2014 April 2014]. Available from: http://cks.nice.org.uk/fungal-nail-infection#!scenariorecommendation.

4.    Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists’ guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014;171(5):937-58.

Posted 16 weeks ago

Dry Skin

   Emollients – key to maintaining foot health - Ivan Bristow PhD, Podiatrist    

                   October 21, 2019                                                           

Dry skin is very common. Around 29% of working age adults have it, rising to nearly 90% of people aged 80 or over (1).  It is one of the most common things that we see in clinic, but it often goes undiagnosed and untreated. It has many causes but what are the effects of dry skin and how can we best manage them?

The skin is the largest organ of the body and is also the main barrier between the internal environment and the outside world protecting against a range of threats such as bacteria, virus and fungi. Most of this protection comes from the outer most layer of the epidermis – the stratum corneum.

In healthy skin, the epidermis can be visualised as a brick wall with the skin cells being the bricks and the lipids produced by the skin being the mortar – holding the bricks together with an almost watertight seal. The bricks, are skin cells manufactured in the lowest level of the epidermis, the basal layer, which are modified as they ascend the layers to reach the outermost layer, the stratum corneum, in around 25 days or so. The mortar - skin lipids are produced from the breakdown of a molecule called filaggrin which degrades to a range of lipids (natural moisturising factors – NMF’s)  which are expelled from the stratum granulosum onto the cells coating them in a waterproof layer which retains the skins moisture. The drier the skin becomes the less filaggrin is produced and so less lipid is released. Thus, creating a downward spiral of skin health. Consequently, small cracks appear in the skin and it becomes vulnerable to bacterial and fungal infections (2) along with irritants and potential allergens.

So, what are the main causes of dry skin? For most sufferers, the cause is physiological and not pathological i.e. the way we live rather than any given disease. Factors include:

  • Over-bathing or showering
  • “Hot” showers
  • Use of shower gels, soaps and cleansers (often containing SLS and similar agents) which remove the skins natural lipids
  • Soaking the skin
  • Insufficient rinsing of soaps and gels
  • Vigorous drying
  • Humidity – central heating and air conditioning
  • Sun exposure

Each time the skin is bathed, particularly if a shower gel or soap is used, removal of the skins NMF’s occurs, and a period is required for natural skin recovery to occur. Consequently, it’s a game of catch up for the skin leading to dryness. The skin recovery time increases with age probably explaining why dry skin is more prevalent in the older age groups. With showering comes another risk, particularly for the feet and legs. When soaps and gels are applied, gravity means they may run down the legs but rarely are the legs and feet properly rinsed after a shower, meaning the product remains on the skin provoking and prolonging further dryness in these areas.

In addition, there are a range of known medical disorders which can cause or exacerbate dry skin:

  • Skin disorders – psoriasis, eczema, fungal infections etc.,
  • Diabetes
  • Peripheral vascular disease
  • Anaemia
  • Thyroid disorders
  • Side effects of common drugs – statins

Statins are taken by many of our patients – their job is to lower cholesterol which they do very well. Unfortunately, cholesterol is a building block required in the manufacture of skin lipids so patients on these drugs are more likely to have dry skin problems (2).

Dry Skin and the Feet

Tinea pedis or dry skin?

Dry skin on the feet can be asymptomatic for the patient but is characterised by scale, redness, tightness, itching or occasionally dry fissuring. Tinea pedis is a great mimic of dry skin and so should be ruled out as a possible differential diagnosis. Two weeks daily application of a suitable antifungal such as clotrimazole (Canesten®) or terbinafine cream (Lamisil®) is a simple way to determine if a fungal infection is present on the skin. If the dry skin dramatically improves it suggests the cause was fungal in origin.

Treatment of dry skin

The mainstay of treatment is the regular application of an emollient to the feet. This is something which can be easily stocked and sold in the clinic. As a common condition, you can be assured that there will be a need for this by patients. So, which one do you stock? It is important to stress there is still no consensus on what the most effective emollients are (3). Which emollient is best for your patients is really down to patient choice (3, 4).

The skin on the foot has a very thick epidermis on the plantar area and for the most part is in a shoe for considerable periods of the day so additional factors need to be considered. Firstly, the foot being a cooler, distal area is generally best suited to heavier ointment-based preparations (usually labelled as “balms” or “heel balms”) which have a more occlusive effect than creams but potentially this can be a problem with socks and footwear. Patients may be best advised to apply lighter products such as a cream when they are more active keeping the more potent, heavier ointments for use in the evenings or overnight.

Figure 1 : A fingertip unit = 0.5 gram of product (5)

Urea preparations and other humectants

A humectant is a chemical which is able to draw and hold water – like a sponge. Emollient products with an added humectant have a stronger moisturising effect on the skin. Typical humectants include urea and lactic acid.  Many of the preparations aimed specifically at the foot contain urea as the discerning ingredient with concentrations ranging from 5% to 40%. It is important to appreciate the chemistry of urea as its concentration dictates its chemical properties:

Percentage of Urea

Effect

1 - 20%

Emollient, humectant

20% – 30%

Mild to moderate keratolytic

40%

Moderate keratolytic

Proteolytic

Consequently, higher concentration containing preparations are best avoided in patients with poor tissue viability.

Research has also shown that regular urea application to the skin has additional properties (6) which make it particularly suitable for use on the feet. Firstly, with regular use it can thin epidermis without affecting the skin barrier function making it ideal for use on the plantar surface and on callused skin. In addition, it promotes the body’s natural production of filaggrin which in turn, increases the skins ability to produce more natural moisturising factors.

Key Points : Emollients

  • There is no evidence-based consensus of what the best emollient is.
  • Patient choice is key.
  • Emollients are best applied after bathing or washing when the skin is damp for maximal effect.
  • Pump applicators may be more economical for regular patient use than tubes of products.
  • A fingertip unit (see Figure 1) of emollient in an adult is roughly 0.5 of a gram – around 4 g a day is required for a pair of dry feet.
  • A single “shot” of a pump dispenses around 1 gram of emollient so two “shots” should be enough for one application to two feet.
  •       A urea containing product has added benefits for use on the foot.
  •       The percentage content of urea dictates the properties of the emollient.

References

1.            Augustin M, Kirsten N, Körber A, Wilsmann-Theis D, Itschert G, Staubach-Renz P, et al. Prevalence, predictors and comorbidity of dry skin in the general population. J Eur Acad Dermatol Venereol. 2019:e-print ahead of publication.

2.            Mekic S, Jacobs LC, Gunn DA, Mayes AE, Ikram MA, Pardo LM, et al. Prevalence and determinants for xerosis cutis in the middle-aged and elderly population: A cross-sectional study. J Am Acad Dermatol. 2019;81(4):963-9.e2.

3.            British Dermatological Nursing Group. Best practice in emollient therapy. Dermatol Nurs. 2007;6(2):s1-s19.

4.            Moncrieff G, Cork M, Lawton S, Kokiet S, Daly C, Clark C. Use of emollients in dry-skin conditions: consensus statement. Clin Exp Dermatol. 2013;38(3):231-8.

5.            Finlay AY, Edwards PH, Harding KG. “Fingertip unit” in dermatology. Lancet. 1989;2(8655):155.

6.            Bristow IR. Urea - the gold standard for emollients? Podiatry Now. 2016;19(10):20-3.

Further Reading

Bristow, I. R. (2012). “Emollients and the foot.” Podiatry Now: S1-S8.

FREE Download full paper

Moncrieff, G., M. Cork, S. Lawton, S. Kokiet, C. Daly and C. Clark (2013). “Use of emollients in dry-skin conditions: consensus statement.” Clin Exp Dermatol 38(3): 231-238.

FREE Download full paper

Posted 16 weeks ago
Posted 16 weeks ago

Chiropody Clinic Northampton

Please note the Clinic is still open if you need us.

Ring 01604 422772

Posted 17 weeks ago

COVID-19 Update

During the CoronaVirus outbreak we will be open if you are in pain.

Ring Isobel on 07925 085889 anytime, she will ring back if not available.

Posted 18 weeks ago

Opening during COVID-19

We are open if you need Podiatry treatment. Ring Isobel on 07985 085889

Posted 19 weeks ago

We will be open Saturday 21st March if you require treatment before everything is in lockdown. Ring Isobel on 07925 085889

Posted 20 weeks ago

Hello everyone. Just to let you know we are open. If you require an appointment ring us on the numbers listed. If you are experiencing a cough, shortness of breath and fever please follow the government advise and self isolate. Some people who have symptoms of Coronavirus have experienced sore throats, aching joints together with headaches. We if you want us to can check your temperature at the clinic.

D.Fox Registered Podiatrist.

Posted 21 weeks ago

Please be aware that if you are a smoker you should quit now. Smokers are at more risk from coronovirus complications. See your Pharmacist for help.

Posted 22 weeks ago

Ingrowing Toenail Treatment

               Ingrown toenail                                                          

An ingrown toenail is a common problem where the nail grows into the toe. It can be painful, but there are things you can do to ease the pain.

Check if you have an ingrown toenail

You usually get an ingrown toenail on your big toe. But you can get them on any toe.

Your toe can also get infected.

Signs of an infected toe include:

  • pus coming out of it
  • you feel hot or shivery

How to treat an ingrown toenail at home

If you go to a Podiatrist Chiropodist they’ll usually suggest you try these things first.

               Do  

           
  •              
  •            soak your foot in warm water 3 to 4 times a day for a few days – this softens the skin around your toe and stops the nail growing into it    
  •              
  •            keep your foot dry for the rest of the day    
  •              
  •            wear wide, comfortable shoes or sandals    
  •              
    •            take paracetamol or ibuprofen to ease the pain    
    •      

                   Don’t  

             
    •              
    • do not cut your toenail – leave it to grow out    
  •              
  •            do not pick at your toe or toenail    
  •            do not wear tight, pointy shoes    

  • If it is still painfull give me a ring on 01604 422772 to make an appointment.

    Posted 23 weeks ago