Nail and Skin Disorders of the Foot

KEYWORDS Onychomycosis _ Onychocryptosis _ Subun ual tumors _ !inea pedis KEY "O#N!S
!he dermal layers of the foot alon $ith the nail possess properties that make the foot %ulnerable to an array of disorders& !hese maladies are uni'ue to the foot because of the e(treme contact stresses it endures as $ell as the re ular use of foot$ear) $hich maintains a moist en%ironment& !his damp climate allo$s for opportunistic infections and maceration of the skin& !he foot is also prone to %ascular disease i%en its distance from the heart and ascendin %enous draina e&

!he dermal layers of the foot alon $ith the nail possess properties that make it %ulnerable to an array of disorders& !hese maladies are uni'ue to the foot because of the e(treme contact stresses it endures as $ell as the re ular use of foot$ear) $hich maintains a moist en%ironment& !his damp climate allo$s for opportunistic infections and maceration of the skin& !he foot is also prone to %ascular disease i%en its distance from the heart and ascendin %enous draina e& !his article re%ie$s common conditions that afflict nail and dermal tissue of the foot&
N*#+ D#SORDERS

Nail disorders include disease that can be common and innocuous to subtle yet lethal& #n this article $e discuss some of the common disorders afflictin the nail and its supportin structures and a fe$ conditions that should al$ays be on the physician,s differential& !he anatomy of the nail on the toe is similar to that of the fin er& !he nail is constructed of keratini-ed s'uamous cells& !he nail plate is a ./layered keratin shield that protects the distal pulp of the di it dorsally& #t also acts to enhance the 0/point discrimination at the tip of the di it& #t is enerated chiefly from the erminal matri() $hich in%ol%es tissue linin the in%a inated socket at the pro(imal aspect of the nail plate& !he nail plate ro$s at a rate of 1 to 1&2 mm per month& !he erminal matri( i%es rise to the more superficial layers of the nail& !he nail is also created in part by the lunula and the sterile matri() the former eneratin the middle portion and the latter interdi itatin and supportin the deep surface& !he lunula is the $hite half circular structure deep to the nail plate and is the distal e(tent of the erminal matri(& When sur ically ablatin the nail) it is essential to e(cise the erminal matri( and lunula entirely to pre%ent remainin nail ro$th& !he eponychium is the area of the fin er 3ust pro(imal to the nail plate and includes the cuticle& !he cuticle is the distal ed e of the eponychium that lies o%er the nail at the pro(imal aspect and acts as a seal to the root of the nail&!he sterile matri( is a thin tissue 3ust deep to the nail plate) $hich is adherent to not only the nail plate but also the deeper distal phalan(& 4ecause of the intimate relationship bet$een the sterile matri( and the distal phalan() crush in3uries that cause distal phalan( fractures also cause lacerations to occur at the sterile matri(& !he nail plate can be dissected a$ay from the nail plate in the case of a subun ual hematoma and can be painful because of the pressure on the sterile matri(& !he lateral ed es of the nail plate are rolled into the tissue of the fin er called the paronychium& !his structure is prone to infection $hen it is disrupted due to trauma& #t can also be in%ol%ed in the case of onychocryptosis) commonly referred to as an in ro$n nail& !he distal nail plate is bordered by the hyponychium& !he hyponychium creates a seal bet$een the nail plate and the deeper) sensiti%e sterile matri( at the onychodermal band or solehorn& !he distal phalan( possesses a distal tuft that supports the sterile matri( and the ad3acent nail plate&
Onychomycosis

*mon the most chronic and common conditions at the nail is onychomycosis or fun al infestation of the nail& !his affects appro(imately 56 to 1.6 of indi%iduals 7Fi s& 1 and 08& !his fun al infestation leads to a thickened and brittle nail that is cosmetically disfi urin ) particularly in middle/a ed and elderly indi%iduals& Functionally) it also can limit foot$ear and catch $hen pullin socks o%er the foot& !he nail is discolored and can ha%e $hite and yello$ components& !he dermis surroundin the nail is also hyperkeratotic& Rarely) this disorder can affect children and the hands& Risk factors include diabetes) family history) trauma) male se() ad%anced a e) tinea pedis) smokin ) prolon ed $ater e(posure) and immunocompromised hosts& !he disorder is caused by a cast of fun al species) most commonly dermatophytes such as !richophyton rubrum and !richophyton menta rophytes& +ess fre'uently) this infection can be caused by nondermatophytes and 9andida species&

Fi & 1& Onychomycosis 7From :ay R) 4aran R& Onychomycosis; a proposed re%ision of the clinical classification& < *m *cad Dermatol 0=11>52758;101?@0A&8

Fi & 0& Onychomycosis&

Breat care must be taken $hen treatin diabetic indi%iduals because the dysmorphic nail may add contact stresses to the surroundin skin yieldin a nonhealin ulceration& "rofessional nail care and close obser%ation of these patients is necessary to a%oid reater complications& !reatment can be limited to obser%ation $ith periodic nail care& Cedical mana ement of this disorder is frustratin & *ntifun als must be taken for prolon ed periods& Oral treatments may cause or an dama e and may interact $ith other medications& Relapse risk is also hi h after medical mana ement& !opical re imens are also a%ailable> ho$e%er) they are less effecti%e) and the treatment time is reatly increased& 9urrent DS Food and Dru *dministration@appro%ed re imens include 9iclopiro( lac'uer daily for EF $eeks> riseoful%in) 2== to 1=== m daily until cleared> itracona-ole) 0== m daily for 10 $eeks> and terbinafine) 02= m daily for 10 $eeks& !erbinafine is the most effecti%e treatment $ith cure rates around A56& Rarely) nail plate e(cision and matricectomies are performed if a nail poses a risk to surroundin soft tissues& !reatment may also be symptomatic) such as debridement of the nail and partial or total nail a%ulsion to a%oid catchin $hile donnin foot$ear&
"aronychia

aronychia is a common infection in%ol%in the paronychium or lateral nail fold& !his disorder is most common at the hallu( in men in their third decade of life&!his occurs $hen the nail fold or cuticle is traumati-ed allo$in for bacterial or anisms enter and cause a pyo enic infection& Cost fre'uent microbes include Staphylococcus aureus> ho$e%er) Streptococcus pyo enes) "seudomonas) "roteus) 9andida) and oral flora may also be suspect& :erpetic $hitlo$ is a type of paronychia caused by herpes simple( %irus& Risk factors include pickin soft tissues about the nails) han nails) and trauma durin pedicure& !hese can lead to a subun ual abscess) chronic paronychia) cellulitis) and osteomyelitis or to a felon if not treated& Dia nosis is made by physical e(amination& !he paronychium andGor cuticle are typically erythematous and painful $ith purulent draina e emanatin from the 3unction of the nail plate and skin fold& Cana ement includes Epson salt soaks if abscess is not suspected& #f an abscess is disco%ered on e(amination) simple local incision and draina e is performed lea%in the $ound open to drain& *ntibiotic re imen should co%er skin flora and patho ens that the indi%idual may be e(posed to such as "seudomonas in case of prolon ed $ater contact& "atients should be instructed to a%oid future trauma to the cuticle and paronychial folds by trimmin back han nails $ith fin ernail clippers&
Onychocryptosis

#n ro$n toenails or onychocryptosis is an e('uisitely painful condition that is caused by a prominent lateral ed e of the nail plate Fi & .) $hich leads to dermal breakdo$n $ith inflammation at the lateral nail fold and) if not treated appropriately) to a pyo enic infection& !his disorder occurs typically in males a es 12@E=& 1= Onychocryptosis is insti ated by either aberrant anatomy at the paronychiumGnail 3unction) by improper nail care) or by cro$din of the toes in cramped foot$ear& !hese allo$ for the nail ed e

to be dri%en deep $ithin the periun ual tissue causin inflammation& 11 Nonoperati%e mana ement is $arranted in early sta es of onychocryptosis) includin carefully liftin the sharp nail ed e from the lateral nail fold and suspendin the nail plate $ith a small piece of cotton& *n indi%idual may find this easiest after soakin the feet or bathin ) $hen the nail fold is softened& With an acute painful episode) a metatarsal block $ith local anesthetic can be performed and the nail trimmed locally and ele%ated& #f simple e(cision of the nail spike is performed) it is necessary that the patient be in meticulous nail care to a%oid recurrence of the in ro$n nail&1=

Fi & .& Onychocryptosis&

#n the case of chronic onychocryptosis) a partial nail plate a%ulsion and partial ablation of the erminal matri( 7matricectomy8 is indicated Fi & E& !his is accomplished by performin a local block) splittin the nail plate lon itudinally 0 to . mm from the affected corner of the nail $ith a%ulsion of this se ment and either ablation or e(cision of the erminal matri(& *blation is completed $ith topical phenol or electrocautery& * recent 9ochrane re%ie$ found that ablation of the erminal matri( $ith phenol $as more effecti%e than partial sur ical e(cision& !he authors also concluded that sur ical mana ement of chronic onychocryptosis $as more effecti%e than nonoperati%e treatment& 9omplete remo%al of the nail plate and ablation of the erminal matri( may be $arranted in cases of recurrent onychocryptosis& First/ eneration cephalosporins are typically prescribed postoperati%ely for A to 1= days& "re%ention is encoura ed by proper nail care by cuttin the nail perpendicular to the a(is of the toe) lea%in the lateral and medial ed es of the nail plate to e(tend beyond the distal e(tent of the lateral nail fold&
Subun ual :ematoma and Sterile Catri( +acerations

!rauma to the sterile matri( of the nail is a common occurrence& !hese are simple to mana e in the office or in an emer ency department settin & Dsually subun ual hematomas and lacerations to the sterile matri( occur $hen the distal aspect of the phalan( sustains a %iolent compressi%e force) such as droppin a canned food item on an unshod foot& *lthou h uncommon) one must al$ays consider subun ual melanoma in the differential of a darkly pi mented lesion deep to a nail& * eneral rule is that if the subun ual hematoma in%ol%es reater than 2=6 of the subun ual space $ithout fracture of the tuft of the distal phalan() remo%al of the nail plate and primary repair of the sterile matri( is indicated) as there is a hi h likelihood of laceration& * recent re%ie$ refuted this claim and found that most patients $ithout fracture and subun ual hematoma reater than 2=6 reco%ered $ith fe$ nail deformities $ith simple trephination& Failure to repair the matri( laceration can lead to a deformed nail that may not adhere normally to the matri(&

Fi & E& 7*@B8 !reatment of onychocryptosis& 7From 9ou hlin C<) Salt-man 9+) *nderson R4& Cann,s sur ery of the foot and ankle& "hiladelphia; Saunders) an imprint of Else%ier #nc> 0=1E&8

!rephination is $arranted in subun ual hematomas that are painful& !hey reduce pain by decompressin the subun ual space and limit pressure necrosis of the sterile matri( in an acute settin & #t is essential that radio raphs are taken of the affected di it to rule out a tuft fracture of the distal phalan( before proceedin & !rephination is performed by makin a small burr hole $ith a stout hypodermic needle 71F or 0= au e8) scalpel) a small biopsy punch) or a disposable battery/po$ered cautery de%ice& Numerous de%ices and methods ha%e been described to perform this procedure& !he hole created should only penetrate the nail plate to allo$ for e%acuation of the hematoma& !rephination $ith a small 0/mm biopsy punch is optimal) as it is atraumatic to the underlyin matri( and a%oids cauteri-ation of the blood $ithin the hematoma to allo$ for more effecti%e draina e& #f a distal phalan( fracture on radio raph is present $ith a subun ual hematoma) this constitutes an open fracture) $hich necessitates ur ent debridement) irri ation) and repair& !he administration of antibiotics is debatable& Some sur eons elect to treat $ith intra%enous antibiotics in the acute settin and others $ould ar ue that thorou h debridement and irri ation only are necessary& 9efa-olin in most cases is the preferred choice $ith clindamycin bein a suitable alternati%e in case of sensiti%ity to cephalosporins& *ntibiotics are typically administered immediately after the disco%ery of an open fracture& Our preferred techni'ue is to administer intra%enous antibiotics and update tetanus prophyla(is as soon as possible& We then perform a metatarsal block $ith 16 lidocaine and =&026 bupi%acaine) $hich are in3ected dorsally at the le%el of the distal metatarsal directed plantarly to block the common di ital ner%es and their proper di ital branches to the affected toe after cleansin the skin $ith alcohol pads& Benerally) 1= m+ of solution is used& !he foot is then prepared $ith either chlorhe(idine or po%idone iodine solution& We prefer to use a sur ical scrub brush as this is applied& * sterile field $ith to$els is then created& We find it helpful to then create a small tourni'uet $ith a rolled up fin er from a sterile sur ical lo%e or a "enrose drain tied o%er the pro(imal aspect of the di it& !he nail is carefully ele%ated $ith a pair of tenotomy scissors directed distal to pro(imal) under and parallel to the nail plate& !he nail plate is then ele%ated by placin the blades of the scissors in a closed fashion bet$een the layers and spreadin the scissors apart in a entle fashion to release the sterile matri( from the undersurface of the nail plate& 9aution must be used) as this can cause iatro enic laceration to the matri(& !his is continued under the entirety of the nail plate to the erminal matri( and to the lateral e(tent of the nail plate& #t may be necessary to release the tissue dorsally bet$een the nail plate and the eponychium or cuticle pro(imally to the erminal matri(& !his dorsal release is also performed in the same fashion by spreadin apart the tenotomy scissors after placin them in a closed fashion bet$een the tissue layers& !he nail should then be free and the nail plate can be rasped $ith a small hemostat and remo%ed& !he underlyin sterile matri( is then irri ated $ith at least 1=== m+ of sterile saline in an unpressuri-ed fashion& !he sterile matri( is then inspected and debrided of small free pieces of bone and hematoma& !he lacerated ed es of the sterile matri( are then re/appro(imated $ith 2@= chromic ut suture anatomically in an interrupted fashion& *ny other lacerations about the toe are then closed $ith E@= nylon suture in an interrupted fashion& #t is then necessary to place somethin bet$een the dorsal and deep layers of the erminal matri(& * %ariety of materials can be used to place in the erminal matri( includin intra%enous drip chamber or foil from petrolatum au-e packa in to name a fe$& We prefer to use the nati%e nail plate as a spacer to pre%ent adhesion at the erminal matri(& !he nail plate is debrided of any soft tissue and cleansed if necessary& "ro%isionally) the nail is replaced and marked for suture placement& We then use a E@ = or .@= nylon suture to secure the nail plate& !he suture is placed . to E mm pro(imal to the eponychium and into the space bet$een the opposin erminal matri( layers $here the nail plate resides& !he suture is then placed superficial to deep at one corner of the pro(imal aspect of the nail and then deep to superficial throu h the other corner of the nail& !he suture is then placed deep to superficial throu h the eponychium and the opposite corner of the toe to create a mattress suture throu h the nail plate& !his suture is later cut and the nail plate is allo$ed to fall off after the ne$ nail be ins to ro$ and the sterile matri( laceration has healed& We dischar e patients $ith a 2/ to A/day supply of first eneration cephalosporins orally or clindamycin& Wound care includes keepin the foot clean and dry and performin daily or t$ice/daily dry dressin chan es&
SD4DNBD*+ !DCORS Blomus !umor

* tumor that is sensiti%e to temperature fluctuation is patho nomonic for a lomus tumor& Blomus tumors are rare) representin 1&26 of beni n soft tissue tumors of the e(tremities) and typically affect the hands in A26 of cases& !hey occur bet$een a es .= to 2=& !hey ori inate from the lomus body) a thermore ulatory apparatus at the distal di it& !hese lesions present as a triad of pain) point tenderness) and temperature sensiti%ity& !hese masses are typically $orked up $ith ma netic resonance ima in sho$in the location of the mass& !he ma netic resonance ima e appearance is dark on !1 and bri ht on !0& Casses ha%e a

characteristic purplish hue to rey/pink and are 1 to 0 mm in diameter&E(cision of the mass is $arranted for pain relief& Recurrence rate is bet$een E6 and 126&
Subun ual E(ostosis

Subun ual e(ostoses are beni n lesions that lift the nail from the sterile matri( and impede the patient from donnin foot$ear& !hese masses are uncommon and typically occur in the third and fourth decades of life& !he reat toe is in%ol%ed A26 of the time> ho$e%er) subun ual e(ostoses can occur on any di it& !he etiolo y is thou ht to be an incitin trauma or infection that initiates reparati%e mechanisms $ithin the distal phalan( $here metaplasia leads to an abnormal bony ro$th& 9linically) the lesion appears as fullness beneath the nail& Radio raphically) they ori inate from the dorsal surface of the distal phalan(& !reatment includes e(cision $ith repair of the nail and sterile matri(& !he recurrence rate is bet$een 56 and 106&
Subun ual Osteochondroma

* mimickin lesion to subun ual e(ostosis is an osteochondroma& Osteochondroma at the distal phalan( occurs in men) usually around the second decade of life& !he presentation is similar to subun ual e(ostosis) althou h the mass ori inates near the physis at the pro(imal aspect of the distal phalan(& *nother ma3or difference bet$een the 0 lesions is that the osteochondroma possesses a hyaline cartila inous cap in $hich the subun ual e(ostosis possesses a fibrocartila enous cap& !reatment is the same&
Subun ual Celanoma

Subun ual melanoma is a se%ere %ariant of mali nant melanoma $ith a subtle presentation& !his disorder represents 16 of melanoma cases and carries a 156 to F=6 sur%i%al rate at 2 years& Subun ual melanoma is most often found in *frican and *sian patients& Dp to 0=6 of subun ual lesions are amelanotic) makin the dia nosis challen in &5 Cedian a e at presentation is in the si(th to se%enth decades of life and does not ha%e a se( preference& 0)5 Dia nostic clues include :utchinson,s si n) or the e(tension of melanotic pi ment into the nail folds& 0 +on itudinal melanonychia) $hich is a dark lon itudinal stripe at the nail) may also be a clue to dia nosis> ho$e%er) this may be present in other beni n processes& !reatment is contro%ersial& #t is unclear $hether local e(cision) includin Cohs micro raphic e(cision) %ersus $ide e(cision is most ad%anta eous) althou h there is a trend to$ard partial di it/sparin sur ery& !he key to sur%i%al is prompt dia nosis and treatment&
*cral Celanoma

*cral Celanoma is another mimickin lesion that is potentially fatal that resembles a simple subun ual hematoma) ulcerations) or other beni n skin lesions& "ractitioners must ha%e a hi h le%el of suspicion to disco%er these lesions) as they do not occur typically in li htly pi mented indi%iduals $ith a history of hi h le%el of sun e(posure&
SK#N D#SORDERS 9ellulitis

9ellulitis is most often the result of breaches in skin inte rity and is associated $ith risk factors such as obesity) %enous insufficiency) diabetic foot ulcers) or lymphatic disruption from prior sur ery Fi & 2& 9linical presentation includes areas of edema) $armth) tenderness) and redness& *lon $ith the clinical presentation) laboratory %alues of complete blood count) erythrocyte sedimentation rate) and 9/reacti%e protein should be obtained& 4lood cultures and $ound cultures) if an open $ound is present) may be necessary& Oral and intra%enous antibiotic therapy is administered accordin to the causati%e or anism) $hich is most commonly ram/ positi%e bacteria& First/line therapy is medical) and initial antimicrobial a ents should include co%era e of Streptococci and Staphylococci in the settin of trauma&

Fi & 2& 9ellulitis&

!inea "edis

!inea pedis is a superficial fun al infection that affects the plantar sole and the interdi ital spaces of the foot& 9ommonly kno$n as athletes, foot) the disorder affects indi%iduals $ith increased contact $ith s$immin pools) athletic shoes) and sports e'uipment and) to a lesser de ree) those $ith depressed immune function& 9linically) this condition presents in the form of interdi ital) moccasin) and %esiculobullous chan es& #nterdi ital tinea pedis is the most common form $ith the appearance of macerated skin $ith fissures and often erythema 7Fi & 58& Coccasin tinea pedis presents as scalin pla'ues $ith a mildly erythematous base on the heels) soles) and lateral aspects of the feet) $hereas %esiculobullous lesions ha%e the appearance of %esicules $ith multiple blisters $ith erythema& *lthou h interdi ital tinea pedis is caused by ! rubrum) more a ressi%e forms of tinea are caused by ! menta rophytes $ith pain) erosions) foul odor) macerations) and fissures commonly in con3unction $ith a superimposed bacterial infection& Dia nosis is often based on clinical e(amination in combination $ith microscopic e(amination of potassium hydro(ide skin samples of the lesion border that $ill appear as multiple) branched) septate hyphae& !reatment of tinea pedis in%ol%es topical medications $ith the oals of eradication or inhibition of the ro$th of the fun al infection& !opical antifun al medications such as a-oles) allylamines) and thiocarbamates are effecti%e in the treatment of interdi ital tinea pedis& Oral terbinafine has been reported to ha%e reater efficacy than a-ole medications& #f erythema secondary from bacterial infection is present) treatment may also in%ol%e an oral antibiotic& Coccasin and %esiculobullous tinea pedis can be more resistant to topical therapy that is more effecti%e a ainst interdi ital tinea pedis) ho$e%er) may re'uire more a ressi%e systemic antifun al treatment& !hese treatments carry the risk of hepatoto(icity& Oral or systemic mana ement must be combined $ith other conser%ati%e treatment in the form of antimoisture socks) antifun al po$ders) and proper shoe ear in public bathrooms) yms) and sho$ers& !his mana ement is ad%ised to pre%ent recurrence secondary to fun al spores that are pre%alent in moist en%ironments&

Fi & 5& #nterdi ital tinea pedis is the most common form $ith the appearance of macerated skin $ith fissures and often erythema&

Herrucae Hul aris

Herrucae are a particular type of %irus that cause $arts on the plantar aspect of the foot& !he %irus is usually caused by the human papilloma%irus) particularly types 1) 0) and . Fi & A& 9linical presentation includes hyperkeratosis) callous lesions on the plantar aspect of the foot $ith focal tenderness on direct palpation or upon $ei htbearin in shoes& 4ecause of the hyperkeratotic appearance of the lesions) they are often dismissed as callous secondary to biomechanics of the foot> ho$e%er) upon debridement) the lesions re%eal pinpoint hemorrha in or punctate black dots that are thrombosed capillary %essels& !reatment for %errucae consists of destructi%e therapies includin cryotherapy $ith li'uid nitro en) local curetta e) and electrodessication& !opical treatments such as salicyclic acid preparations) podophylloto(in) retinoids) sil%er nitrate) and immunotherapeutic a ents 7s'uaric acid dibutylester8 ha%e also been described& 0A Oral cimetidine has been found to be effecti%e alone or in combination $ith topical medication& 0? *lthou h topical) oral) and destructi%e treatments are effecti%e) recurrence of this condition is common&

Fi & A& Herrucae Hul aris&

"orokeratosis

"orokeratosis is a skin disorder that commonly presents on the plantar aspect of the foot $ith hyperkeratosis and a clear isolated lesion $ith central depression and raised rolled borders that are painful on $ei htbearin Fi & F& !his condition $as first described by !aub and Steinber in 1?A=& !hey described the lesion as a hyperkeratotic lesion that $as closely related to eccrine lands of the foot) typically found o%er pressure points on the plantar aspect& !heir relation to the eccrine land has been disputed& #t $as most commonly found in adults and in $omen A26 of the time& .1 !he lesion possesses a hyperkeratotic plu that penetrates deep into the foot& Dnlike %errucae) it does not contain capillaries that i%e the characteristic pinpoint bleedin durin debridement& !reatments $ith hi h success rates include e(cision of the painful lesion $ith a I12 scalpel blade) sclerosin a ents such as 06 to E6 alcohol solution $ith local anesthetic) and cryotherapy&

Fi & F& "orokeratosis&

SDCC*RY

Disorders of the dermis and the nails on the feet are common& Despite the simplicity of the skin and nail disorders of the foot) they can be debilitatin and impact the patient,s ability to ambulate and perform acti%ities of daily li%in & Dia nosis in most cases is confirmed on physical e(amination alone& Dili ent care of skin and nail disorders can pre%ent further patholo y in%ol%in the deeper structures of the foot and allo$ the patient to fully participate in their usual acti%ities&