Proceedings of the Fifth SKIN SPECTRUM SUMMIT

SSS-2019 02-10-20_Layout 1 2/12/2020 5:18 PM Page 24
KELOIDS,
MYCOSIS
24 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
Controlling onychomycosis
and toe web bacteria
Dr. Gary Sibbald
In his presentation at Skin Spectrum Summit in Toronto, Dr. Gary Sibbald
spoke about preventing diabetic foot ulcers by first outlining
treatment for onychomycosis and toe web bacteria.
“The average wear and tear in the foot for someone who lives an average
lifespan is the equivalent of walking 115 thousand miles,” said Dr. Sibbald.
It is no surprise, then, that 75% of the population experiences foot pain at
some point, said Dr. Sibbald.
Many other physical ailments can first manifest in the foot, he said. Those ailments
include arthritis, peripheral vascular disease, cardiac disease and diabetes.
“A foot out of alignment results in discomfort and pain in the ankle, the knee,
the hip and the back,” he said.
For patients with diabetes, 85% of amputations begin with a foot ulcer, said
Dr. Sibbald. For this population, an onychomycosis infection can be especially
concerning.
“In a population of persons with diabetes, 1 per cent of them have gangrene,”
said Dr. Sibbald. For those with diabetes and onychomycosis, 5% have gangrene,
he said.
He noted that 2% of persons with diabetes and a foot ulcer will develop gangrene.
If they have diabetes, a foot ulcer and onychomycosis, the incidence goes
up to 6%.
When taking a nail clipping for culture, the most important part is to get the
subungual debris, said Dr. Sibbald.
“This is really where most of the fungus is. About 30 per cent can be falsely
negative on culture, so you may need three cultures. But if we see a KOH [test]
with fungal filaments, that’s enough,” he said.
There are 22 different conditions that can mimic fungus, Dr. Sibbald said. He
offered a piece of advice for identifying tricky cases.
“The most important pattern is distal streaking where it’s wider distally than
proximally,” he said.
If unsure about the diagnosis, he recommends 1% hydrocortisone powder
and antifungal cream.
Dr. Sibbald also talked briefly about bacteria between the toes. The tightest
toe web is typically between the fourth and the fifth toe, he said.
In patients with diabetes, this can become a problem area for bacterial and
fungal infections, so he recommends
checking in this area first before going
proximally to check the others.
“Bacteria, specifically Staph and
Strep, can get in. That causes lymphangitis
and subsequent cellulitis,
and these people end up in emergency
departments,” he said.
He recommends using 10% povidone-iodine
on this area by applying it
with a cotton applicator.
“It’ll control gram-positive, gramnegative
and anaerobic bacteria; it
will treat dermatophyte fungus,
yeast and viruses. This is a way to
keep that space clean,” he said. He
also recommends breathable
footwear for patients with this condition
Dr. Gary Sibbald