Dermatophyte resistance - on the rise.

Dermatophytes are group of filamentous fungi which have adapted to living on the skin of humans and other animals. In the last decade, reports have emerged from Asia of new dermatophyte strains showing resistance to the commonly used antifungal agent terbinafine and others. The spread of these resistant strains has been noted in many other countries globally. Little is known about the mechanisms or management of this emerging problem. Urgent research and changes to current practice are required if the spread of the infection is to be contained and managed effectively.

Independent prescribing in the UK: insights from the Department of Health Allied Health Professions Medicines Project team.

BACKGROUND: The UK medicines legislation was amended ten years ago (2013) to allow podiatrists and physiotherapists independent prescribing rights, the first of the allied health professions to do so. Non-medical prescribing formed one part of a broader policy agenda promoting role flexibility in response to the challenge of an ageing population and the need to maintain effective health provision in the face of a contracting workforce. AIM: The aim of this study was to outline the experiences of the Department of Health AHP medicines project board team in working towards independent prescribing for podiatry and physiotherapy, with a particular focus on the challenges encountered. METHODS: In depth, open-ended interviews were conducted with eight of the core members of the project team, drawn from those individuals who served throughout the duration of the project (2010-2013). Included were the former Department of Health Chief and Deputy Chief Allied Health Professions Officers; the Department of Health Engagement and Communications Officer; representatives of the Health and Care Professions Council; the Medicines and Healthcare products Regulatory Agency; the Council of Deans of Health; the Royal College of Podiatry and the Chartered Society of Physiotherapy (The team also included the representative of the Allied Health Professions Federation. However, as that representative is also a researcher in this study, he has recused himself from any role as a participant.). Data were transcribed and subject to a thematic analysis. RESULTS: A complex picture of the project emerged revealing a range of obstacles and challenges, including inter-professional role boundary tensions and negative prior assumptions about the two professions. Success hinged upon the adoption of a dual strategy involving submission of a robust case of need focused on patient benefit coupled with the careful management of professional expectations. Underpinning theory from the sociology of the professions offers a supportive explanatory framework for understanding the relationships between the various stakeholders involved. CONCLUSIONS: Ultimately, success depended upon aligning the project aims with healthcare policy through a clear focus on patient benefit. Balancing competing professional and policy demands through a continual emphasis on improved patient care laid the foundations for future projects by other allied health professions.

Microwave therapy for the treatment of plantar warts.

BACKGROUND: Plantar warts, or verrucae plantaris, are common lesions causing considerable pain during weightbearing activity. Although current treatment modalities have low success rates, microwave therapy has been introduced as a promising intervention. This study aimed to determine the effectiveness of microwave therapy for the treatment of plantar warts and to determine the clinical factors associated with plantar wart resolution. METHODS: A retrospective analysis of 150 plantar warts from 45 patients treated with microwave therapy was undertaken. Binomial regression was conducted to explore clinical characteristics (age, gender, immunosuppression, impaired healing, multiple vs single wart, location of lesion, lesion diameter) associated with lesion resolution. RESULTS: Of the total 150 plantar warts treated with microwave therapy, 125 (83.3%) warts resolved and 25 (17%) warts did not resolve. The mean (SD) total treatment sessions for resolved lesions was 2.8 (1.0). Decreasing age (P = 0.046) was the only clinical characteristic associated with resolution. CONCLUSIONS: This retrospective study has shown that plantar warts may be resolved with two to three sessions of microwave therapy, which may be more successful in younger populations.

The treatment of plantar warts using microwave-A review of 85 consecutive cases in the United States.

BACKGROUND: Plantar warts (verrucae plantaris) are a common source of pain for patients and are often refractory to treatment. Previous work has shown a high clearance rate of verrucae using a surface-based microwave device (Swift®). AIMS: To assess the efficacy, defined as the complete visible clearance of warts, in patients with verrucae plantaris receiving microwave treatment. PATIENTS: We undertook a retrospective review and identified records of 85 patients who underwent a course of microwave treatment at a single US-based podiatry centre. Efficacy was analyzed on the basis on intention-to-treat. RESULTS: In patients who received ≥1 session there was a complete clearance rate of 60.0% (51/85) (intention-to-treat; 59 patients completed treatment, 26 lost to follow-up) and 86.4% (51/59) per treatment completion; no significant differences in clearance rates of children and adults were observed (61.0% [25/41] vs. 59.1% [26/44]). There were 31 patients who received three sessions of microwave therapy with a clearance rate of 71.0% (22/31) as per intention-to-treat (27 patients completed treatment, 4 lost to follow-up). An average of 2.3 sessions (SD: 1.1; range: 1-6) was required for the complete clearance of plantar warts. Complete clearance was also observed in some patients with recalcitrant warts following additional treatment sessions (42.9% [3/7]). A significant reduction in wart related pain was reported for all patients undergoing treatment. Some patients continued to report a reduced amount of pain post-therapy compared with pretherapy. CONCLUSIONS: Microwave treatment of verrucae plantaris appears to be a safe and effective procedure.

Paediatric Cutaneous Warts and Verrucae: An Update.

Cutaneous warts are common lesions in children caused by the Human Papilloma Virus (HPV) and for most lesions spontaneously resolve within months of the initial infection, regardless of treatment. The infection is most prevalent in the second decade of life affecting over 40% of children. Studies have demonstrated wart virus carriage on normal skin is higher in children with active lesions and family members. Subtypes HPV 2, HPV 27, HPV 57 and HPV 63 are particularly common in paediatric populations. Warts arising on the plantar surface of the foot (verrucae) can be particularly problematic owing to the location. They may interfere with daily activities causing pain and embarrassment. Plantar lesions have been shown to be more resistant to treatment than warts elsewhere on the skin. Systematic reviews and studies conducted over the last decade have demonstrated little evidence of innovation or effective improvements in treatment of recalcitrant lesions over the last 30 years. However, newer modalities such as immunotherapy (using injected vaccines) and hyperthermia using microwave treatment may hold promise in improving the treatment of these common and therapeutically frustrating lesions.

Successful Treatment of Hard Corns in Two Patients Using Microwave Energy.

Corns are a common foot problem accounting for nearly half of all problems seen within podiatry and chiropody clinics. Hard corns are concentrated areas of hyperkeratosis within the stratum corneum, typically found on the weight-bearing (plantar) surfaces of the feet. For many patients, they are a source of pain and have been shown to negatively affect a patient's activity and quality of life. Most of the currently available treatments are short-lived in their effectiveness, with corns frequently being recurrent, requiring repeated visits to remove the painful lesions. The use of handheld microwave devices indicated for surface applications has demonstrated effectiveness in clearing recalcitrant plantar warts and significantly reducing the pain associated with them. The authors report 2 cases of patients with persistent and painful plantar corns who underwent microwave treatment of their plantar corns with a successful, lasting reduction in pain levels after the intervention. Further work is required to fully assess the potential of this treatment modality in the management of painful plantar corns.

The mystery of the COVID toes - turning evidence-based medicine on its head.

The recent and rapid emergence of COVID-19 infection has led to a flood of publications describing all aspects of the disease and its presentation. The appearance of chilblain-like lesions, in children and young adults has particularly caught the attention of healthcare professionals with an interest in the foot. With such a novel infection, demand for information is high at a time when evidence is scarce. Consequently, there has been a renaissance in the publication of case studies. This type of research, previously relegated from many mainstream journals, as a low level source of evidence, has permitted the rapid reporting, publication and dissemination of much needed clinical data which can be used as a foundation to inform further research and investigations about a new global infection.

Microwave therapy for cutaneous human papilloma virus infection.

BACKGROUND: Human papilloma virus (HPV) infects keratinocytes of the skin and mucous membranes, and is associated with the induction of cutaneous warts and malignancy. Warts can induce significant morbidity and disability but most therapies, including cryotherapy, laser, and radiofrequency devices show low efficacy and induce discomfort through tissue destruction. Microwaves are readily capable of passing through highly keratinised skin to deliver energy and induce heating of the tissue in a highly controllable, uniform manner. OBJECTIVES: To determine the effects of microwave on cutaneous HPV infection. MATERIALS & METHODS: We undertook a pilot study of microwave therapy to the skin in 32 consecutive individuals with 52 recalcitrant long-lived viral cutaneous warts. Additionally, we undertook a molecular characterisation of the effects of microwaves on the skin. RESULTS: Tissue inflammation was minimal, but 75.9% of lesions cleared which compares favourably with previous studies showing a clearance rate of 23-33% for cryotherapy or salicylic acid. We show that microwaves specifically induce dendritic cell cross-presentation of HPV antigen to CD8+ T cells and suggest that IL-6 may be important for DC IRF1 and IRF4 modulation to enhance this process. CONCLUSION: Keratinocyte-skin dendritic cell cross-talk is integral to host defence against HPV infections, and this pilot study supports the concept of microwave induction of anti-HPV immunity which offers a promising approach for treatment of HPV-induced viral warts and potentially HPV-related cancers.

The Successful Use of a Novel Microwave Device in the Treatment of a Plantar Wart.

Plantar warts, caused by the human papilloma virus (HPV), are a commonly encountered condition presenting in clinic. In adults, an array of various therapies exists, frequently with modest results particularly with plantar lesions. Microwaves have had limited uses for medical purposes. Recently a new portable microwave device has been approved for the treatment of skin lesions. Prior research has demonstrated immuno-stimulatory effects against HPV infection. We report the application of a novel portable medical microwave unit to treat a long-standing plantar wart which had failed to respond to other treatment modalities.

Rapid Treatment of Subungual Onychomycosis Using Controlled Micro Nail Penetration and Terbinafine Solution.

Onychomycosis continues to be a common and intractable problem in adults, often responding poorly to topical treatment due to limited drug penetration of the nail plate. Improving penetration has been attempted previously by chemical and physical means with some success. The authors present three cases of toenail onychomycosis treated topical terbinafine 1% solution using controlled micro-penetration of the nail using a novel intelligent nail drill system which is able to drill nail plate without penetrating the delicate nail bed beneath. The cases illustrate how the device has been successfully employed to deliver the anti-fungal drug directly and rapidly to the site of infection with minimal side effects or complications, whilst maintaining the nail integrity.

J Drugs Dermatol. 2016;15(8):974-978.

Melanoma of the Foot.

Melanoma is a rare form of skin cancer that is responsible for most skin cancer deaths globally. Tumors arising on the foot continue to be a particular challenge. Patients present later and lesions are frequently misdiagnosed, leading to more advanced disease with an overall poorer prognosis then melanoma elsewhere. In order to improve early recognition, this article reviews the clinical features of the disease along with published algorithms. Emerging assessment techniques such as dermoscopy are also discussed as tools to improve clinical decision making. Contemporary drug therapies in the treatment of advanced disease are also discussed.

The effectiveness of lasers in the treatment of onychomycosis: a systematic review.

BACKGROUND: Onychomycosis is a common nail pathology which has proven to be a treatment challenge to healthcare professionals. Antifungal drugs have been the mainstay of therapy for many years. Recently, laser technologies have been introduced as a treatment for onychomycosis avoiding the disadvantages of systemic and topical drug therapies, offering a rapid treatment for an often persistent nail condition. The purpose of this study was to review published evidence regarding the effectiveness of laser technologies in the treatment of onychomycosis. METHODS: The primary question for this review was "what evidence is there for the use of lasers in the treatment of onychomycosis"? A systematic literature search of published papers indexed on Pubmed and Web of Science® was undertaken in June 2014 for original, published research. The primary outcome measures for efficacy were mycological cure and clearance of the affected nail (clinical cure). RESULTS: This review returned a total of twelve eligible published studies evaluating the use of lasers in the treatment of onychomycosis. Two were randomised controlled trials, four were comparative design studies (with no placebo/control groups) and the remainder were case series. The level of evidence was generally low level reflecting predominantly small sample size and lack of control groups. The results from studies were conflicting and follow up periods for patients in studies were generally short. Many studies excluded patients with severe or dystrophic onychomycosis. CONCLUSIONS: The evidence pertaining to the effectiveness of laser treatment of onychomycosis is limited and of poor methodological quality. Future studies using a randomised controlled trial designs with larger study populations and clear procedures are required to permit a full evaluation of this emerging technology.

Pitted keratolysis: a clinical review.

BACKGROUND: Pitted keratolysis is a bacterial infection that affects the plantar epidermis. Despite the condition being reported in many countries affecting both shod and unshod populations, there is little guidance for clinicians providing evidence or best practice guidelines on the management of this often stubborn infection. METHODS: Using a structured search of a range of databases, papers were identified that reported treatments tested on patients with the condition. RESULTS: Most of the literature uncovered was generally of a low level, such as case-based reporting or small case series. Studies were focused mainly on the use of topical antibiotic agents, such as clindamycin, erythromycin, fusidic acid, and mupirocin, often in combination with other measures, such as hygiene advice and the use of antiperspirants. From the limited evidence available, the use of topical antibiotic agents shows some efficacy in the treatment of pitted keratolysis. However, there is currently no suggestion that oral antibiotic drug therapy alone is effective in managing the condition. CONCLUSIONS: Currently, there is no consensus on the most effective approach to managing pitted keratolysis, but a combination of antimicrobial agents and adjunctive measures, such as antiperspirants, seems to demonstrate the most effective approach from the current literature available.

Dermatology within the UK podiatric literature: a content analysis (1989-2010).

BACKGROUND: Although dermatology, as a medical subject, has been a facet of the training and education of podiatrists for many years, it is, arguably, only in recent years that the speciality of podiatric dermatology has emerged within the profession. Some indication of this gradual development may be identified through a content analysis of the podiatric literature in the UK, spanning a 21 year timeframe. METHOD: 6 key professional journals were selected for content analysis in order to provide a picture of the emergence and development of podiatric dermatology over a period extending from 1989 to 2010. Both syntactical and thematic unitization were deployed in the analysis, revealing both manifest and latent content. Categories were devised using a prior coding, a codebook produced to define relevant concepts and category characteristics, and the coding scheme subject to an assessment of reliability. RESULTS: 1611 units appeared in the 6 journals across a 21 year timeframe. 88% (n = 1417) occurred in one journal (Podiatry Now and its predecessors). Modal categories within all journals included course adverts (n = 673), commercial adverts (n = 562) and articles by podiatrists (n = 133). There was an overall rise from 40 per annum in 1989, to over 100 in 2010. A wider range of dermatological topics were addressed, ranging from fungal nail infections to melanoma. CONCLUSIONS: It is evident from this analysis that there has been an increasing focus on dermatology as a topic within the main podiatric journals in the UK over the last 21 years, primarily reflecting a rise in commercial advertising and an increase in academic dermatology related publications. Whilst earlier publications tended to focus on warts and fungal infections, more recent publications address a broader spectrum of topics. Changes in prescribing rights may be relevant to these findings, as may the enhanced professional and regulatory body requirements on continuing professional development.

The Treatment of Verrucae Pedis Using Falknor's Needling Method: A Review of 46 Cases.

Human Papilloma Virus (HPV) related verrucae pedis persist, seemingly evading host immune surveillance, yet sometimes disappear with inflammation. The absence, or reduction, of a cellular immune response may explain why verrucae treatments are not uniformly successful and treatment can be difficult even in immune-competent individuals. Little investigation has been undertaken into the potential benefit and efficacy of needling verrucae, a treatment modality causing HPV infected keratinocyte destruction in addition to inducing an assumed enhanced immune response. A review of clinical practice is presented, reporting the treatment method and results of data collected from a retrospective review of 45 patients. Thirty-one (69%) cases demonstrated complete resolution of verrucae following needling treatment. Three patients demonstrated reduction in size and pain whilst 11 showed no improvement. No adverse events were noted. Needling may have a place in the management of verrucae pedis in an adult population but a large scale study utilising objective measures and a control intervention would provide more detailed efficacy data along with a greater understanding of the effects of this treatment on long term immunity.

Clinical guidelines for the recognition of melanoma of the foot and nail unit.

Malignant melanoma is a life threatening skin tumour which may arise on the foot. The prognosis for the condition is good when lesions are diagnosed and treated early. However, lesions arising on the soles and within the nail unit can be difficult to recognise leading to delays in diagnosis. These guidelines have been drafted to alert health care practitioners to the early signs of the disease so an early diagnosis can be sought.

Development of a practical guide for the early recognition for malignant melanoma of the foot and nail unit.

BACKGROUND: Malignant melanoma is a rare but potentially lethal form of cancer which may arise on the foot. Evidence suggests that due to misdiagnosis and later recognition, foot melanoma has a poorer prognosis than cutaneous melanoma elsewhere. METHODS: A panel of experts representing podiatry and dermatologists with a special interest in skin oncology was assembled to review the literature and clinical evidence to develop a clinical guide for the early recognition of plantar and nail unit melanoma. RESULTS: A systematic review of the literature revealed little high quality data to inform the guide. However a significant number of case reports and series were available for analysis. From these, the salient features were collated and summarised into the guide. Based on these features a new acronym "CUBED" for foot melanoma was drafted and incorporated in the guide. CONCLUSIONS: The use of this guide may help clinicians in their assessment of suspicious lesions on the foot (including the nail unit). Earlier detection of suspicious pedal lesions may facilitate earlier referral for expert assessment and definitive diagnosis. The guide is currently being field tested amongst practitioners.

Dermoscopy as a technique for the early identification of foot melanoma.

Malignant melanoma is the most common primary malignant tumour arising on the foot. Where improvements in the prognosis have been observed for patients with melanoma elsewhere on the skin, pedal lesions are still frequently delayed in presentation through neglect or misdiagnosis. Detection of foot melanoma relies on the health care practitioner's skills and observations in recognising early changes. Recent publications have documented the use a dermoscopy as a tool to improve recognition of such suspicious lesions. This paper reviews current literature with a special emphasis of its potential applications on plantar and nail unit melanoma. Data from these studies suggest that the technique is a useful and significant adjunct to clinical examination, which ultimately may lead to earlier recognition of this aggressive tumour.

Acral lentiginous melanoma of the foot and ankle: A case series and review of the literature.

BACKGROUND: Acral lentiginous melanoma (ALM) is an uncommon, cutaneous malignant tumour which may arise on the foot. Its relative rarity, atypical appearance and late presentation frequently serve as poor prognostic indicators. METHODS: At a tertiary skin tumour centre, a retrospective review was undertaken of all patients diagnosed with the tumour at the level of ankle or below. RESULTS: Over a six year period, 27 cases (20 female, 7 male) were identified with positive histology confirming the disease. The age ranged from 35-96 years of age (mean 62.7 years). The majority of the cohort were white (59%) with plantar lesions (62%). 33% of patients were initially were diagnosed incorrectly. The average time taken from the point of recognition, by the patient, to the lesion being correctly diagnosed was around 13.5 months. CONCLUSION: Earlier diagnosis of ALM requires education at both a patient and practitioner level.

Non-ulcerative skin pathologies of the diabetic foot.

Many of the complications of the diabetes are well studied but robust research documenting the cutaneous effects of the disease remains sparse. Various studies have suggested that the majority of patients with diabetes will suffer a skin disorder during the course of their disease and for some, the skin changes may even precede the diagnosis of diabetes. Cutaneous pathology of the diabetic foot and lower leg can arise as a result of the direct or indirect effects of diabetic complications. The most common manifestations include fungal and bacterial skin infection, nail disease and diabetic dermopathy. Other less commonly observed conditions include diabetic bullae, necrobiosis lipoidica diabeticorum (NLD), granuloma annulare and reddening of the soles. For many of the less common disorders, there is little in the way of effective treatment. However, much can be done in the clinical setting in the management of the more common manifestations such as bacterial and fungal infection. Fungal infection, in particular, although relatively inconspicuous, is a very common foot problem and if left untreated can threaten tissue viability in the diabetic foot leading to secondary bacterial infection and cellulitis. Management of fungal disease is often considered difficult due to high relapse and re-infection rates, although by introducing a combination of therapies including mechanical and pharmacological the success in treating this stubborn condition can be greatly improved.