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What are indications for referral for foot disorders? what disease states?
-**If foot becomes PAINFUL/INFLAMED
Kids w/ CONGENTIAL MALFORMATIONS or specific DISEASE STATES affecting feet (
-DECREASED CIRCULATION and limb SENSITIVITY
-INCREASED risk of serious infections
-**Peripheral vascular disease:
-Decreased circulation and oxygen perfusion
-Decreased wound healing
Tell me a bit about minor foot disorders- what increases risk? common foot disorders?
-Nearly 75% of americans will experience at one time
-Regular exercise INCREASES risk
-Common foot disorders:
-Corns, calluses, bunions, ingrown toenail
Tell me a bit about Corns-Cause? also called? appearance? types? what type is more painful?
-Localized THICKENING of STRATUM CORNEUM
-Occurs when skin attempts to PROTECT ITSELF AGAINST FRICTION or PRESSURE
-Also called "CLAVUS"
-Typically yellowish gray RING w/ HARD CENTER CORE surrounded by INFLAMED skin
-HARD Corn: OCCURS on WEIGHT BEARING PART of feet (BOTTOM feet)
-SOFT Corn: OCCURS on NON-WEIGHT BEARING PART of feet (TOP/SIDES of feet or BETWEEN toes)
-MORE PAINFUL than hard corns
-Macerated due to perspiration-soft appearance
Tell me a bit about calluses- what happens to the skin? often found where?? size? appearance?? formed from what?
-BROAD, relatively EVEN THICKENING OF SKIN w/ INDEFINITE BORDERS
-Often found on HEEL, TOES, BALL, and SIDES of FEET
-Size ranges from couple mm to several cm, TYPICALLY LARGER THAN CORNS
-RAISED and YELLOW, w/ NORMAL "SKIN PATTERN"
-Formed from FRICTION and CONTINOUS PRESSURE
-Typically only PAIN w/ pressure
Whats the pathophys of corns and calluses- Increased activity of what?
-INCREASED MITOTIC activity OF BASAL CELL layer SECONDARY to increased friction and pressure
-Produces a THICKER LAYER of SKIN on outside
-Mitotic activity DECREASES BACK TO NORMAL ONCE FRICTION/PRESSURE IS RELIEVED-eventually causing the lesion to disappear
What are some non-pharmacologic tx for Corns and Calluses-Goals?
-Goals of tx:
-REMOVE corns and calluses
-**Daily SOAKING in WARM water
-**PUMICE STONE or EMERY PAPER ONCE/wk
-**ELIMINATING SOURCES of pressure and friction
-**CUSHIONING gel pads, orthotics, toe splints
-AVOID "bathroom surgery"
Tell me pharmacologic therapy for corns and calluses- what to ALWAYS DO before medication? tell me a bit about salicylic acid? conc? moa? causes area to what? vehicles?
-**SOAK AREA IN WARM WATER FOR 5 MINS, dry area then apply medication
-**Salicylic acid (0.5-40%):
-**MOA: Keratolytic: DISSOLVE KERATIN (protein that MAKES MOST corns/calluses)
-Causes area to SWELL, SOFTEN, MACERATE, THEN DESQUAMATE
-Comes in COLLOID, PLASTER/PAD (**MAY WORK FASTER), GEL
Tell me Salicylic acid counseling- encourage what first? apply where-why? exclusions for self-tx? dont use on what? avoid in what age? and duration of tx for success?
-Encourage ELIMINATION OF PRIMARY CAUSES that cause corn/callus
-Apply ONLY to CORN or CALLUS (CORROSIVE ingredients)
-Exclusion for self-tx: DIABETES OR POOR CIRCULATION
-**DONT USE ON:
-WARTS on GENITAL areas, MUCOUS membranes, FACE, or if HAIR is GROWING OUT
-Kids <12 yrs
**TAKES SEVERAL DAYS/MONTHS FOR REMISSION
Tell me a bit about bunions- also known as what?? more common in-why? due to what? presentation-symptoms, often has what, whats goin on with big toe?
-Also known as "HALLUX VALGUS"
-MORE COMMIN IN WOMEN: secondary to HIGH-HEELS/other NARROW-TOED footwear
-Due to CHORNIC PRESSURE/BONE MALFORMATION
-Typically asymptomatic- can be painful
-RED, TENDER, SWOLLEN
-OFTEN HAS CALLUS
-LIMITED MOBILITY of big toe
-"Bunionnettes" can DEVELOPE on the LITTLE toe
When to refer bunions-disease states? lack of improvement in how many weeks?
-DIABETES or POOR CIRCULATION
-IMPAIRMENT-physical or mental
-HISTORY of RHEUMATOID ARTHRITIS and/or DEVIATION of a GREAT TOE (due to bunion)
-LACK of improvement AFTER 2 weeks of self-tx
-LESIONS : bleeding, purulent, extremely painful and debilitating
Tell me bunion tx-Goal? wear what kind of shoes? OTC? when to refer? last resort?
-Goals: DECREASE PAIN, IRRITATION , PREVENT progression
-Comfortable shoes: enough room for toes
-PROTECT from irritation: NON-MEDICATED GEL CUSHIONS, MOLESKIN
-OTC pain relievers for SHORT TERM
-REFER if not resolved in 2-3 wks
-Surgery LAST RESORT:
-Used when bunions cause FREQUENT pain and INTEREFERE w/ daily activities
Tell me a bit about tired, aching feet (sports-related injuries)- RICE? OTC?
-PROPER footwear is key
**RICE: rest, ice, compression, elevation
-SHORT TERM USE ONLY:
-Ibuprofen (max of 3.2 g/d)
-Naproxen (Max of 1.25g/d)
Tell me a bit about blisters-Prevention-4? tx-barriers? what if blister ruptures?
-PROPER FITTING SHOES
-MOISTURE WICKING SOCKS
-**COVER w/ BARRIER:
-TINCTURE of BENZOIN or FLEXIBLE COLLOIDION (new skin bandage)
-HELPFUL PRIOR to exercise-DECREASE PAIN and PROMOTE HEALING
-**Antibiotic ointment if blister RUPTURES (NEOSPORIN)
Tell me a bit about ingrown toenails- what happens? appearance? What can occur if skin is punctured? prevention?
-Nail IMBEDS INTO SKIN at CORNER of toe
-Typically red, swollen, painful
-Infection can occur if skin is punctured
-AVOID POINTED TOE FOOTWEAR
-CUT TOENAILS STRAIGHT ACROSS
-Keep toenails MODERATLY LONG
-CHECK FEET OFTEN
What are tx of ingrown toenails?
-**Apple cider vinegar:
-ANtiseptic + anti-inflammatory
-soak for up to 20 mins/daily, dry thoroughly
-**Lift the nail:
-using WAXED DENTAL FLOSS or COTTON
-**Dr. Schools ingrown toenail pain reliver (SODIUM SULFIDE 1% GEL)
-RELIEVE PAIN by SOFTENING nail/HARDENING nail BED
-apply BID x7d
-APPROVED for >12yrs
-Surgery to remove part of or all of nail
Tell me a bit about Tinea pedis-"athlete's foot"- caused by what? affects what? risk factors? complication? symptoms??
-Caused by dermatophytes: trichophyton, microsporum, epidermophyton
-Superfical infections that affect hair, skin, and nails
-MALE > female
-WET, WARM temp, HUMID ENVIRONMENT
-SHARING bed LINENES or CLOTHES w/ someone who has fungal infection
-**symptoms: RED, ITCHY, CRACKED skin, sometimes BLISTERS
When to refer tinea pedis- disease states? involvement of what?
-Unsuccessful OTC tx, FREQUENT RECURRENT infections
-Signs of SYSTEMIC INFECTION (fever, malaise)
-Diabetes, Peripheral vascular disease, immunocompromised
-Widespread, major inflammation
Tell me a bit about tinea pedis- what are the 3 types? most common? signs? what is also known as mocassin type? what is the one with a foul oder?
-Originate BETWEEN TOES, often starting between the 4th and 5th toe
-Skin is MACERATED and erythematous "BOGGY"
-INTENSE PRURITIC and BURNING
-Also called "MOCASSIN type"
-Fine, diffuse PLANTAR SCALING
-Often ASYMPTOMATIC, AFFECTS BOTH FEET
-INTENSE PRURITIS and FOUL ODER common
-Vesicles and pustules
Tell me a bit about Tinea Pedis prevention- what kind of footwear? educate patient about what? communal showers/saunas? dont share what?
-Keep FEET DRY and CLEAN
-CHANGE SOCKS regularly
-ALTERNATE pairs of SHOES
-**Give opportunities to be EXPOSED TO AIR:
-BAREFOOT or SANDAL
-WEAR SANDALS for communal showers, saunas, public pools, locker rooms
-Utilize MOISTURE-WICKING socks
-DO NOT SHARE shoes, towels
tell me Tinea Pedis tx- goal? OTC-primary agents, sig??
-SYMPTOM RELIEF, TREAT infection, PREVENT reoccurrence
-CLEAN AREA well w/ SOAP and PAT DRY
-Antifungals creams- **PRIMARY AGENTS
-Thin layer applied TID x2-4wks
-Powders and aerosols
Tell me the Tinea Pedis- antifungals OTC, good for what kind of skin? avoid use on what kind of skin? sig? fungistatic or fungicidal?
-**Clotrimazole 1% (Lotrimin AF CREAM)
-**Miconazole 2% (Lotrimin AF SPRAY or POWDER)
-Good for DRY, SCALY or MACERATED skin:
-AVOID USE ON SEVERELY CRACKED/IRRITATED AREAS
-May see improvement in 2 wks
-Use **products TID x4wks, NOT JUST WHEN SYMPTOMS RESOLVE
-Mild burning/skin irritation
Cont. of Tinea pedis OTC tx-Tolnaftate; approved for what? good for what kind of skin? powder contains what? MOA? sig for prevention? tx?
-Tinactin CREAM, SOLN, and SPRAY
-Lamisil AF defense spray powder
-Approved for BOTH PREVENTION and TX
-Good for DRY SCALY LESIONS
-Powder contains TALC to ABSORB moisture
-Prevention: Apply once or TID
-Tx: Apply TID x4wks
Cont. tinea pedis-OTC- Terbinafine: sig? moa? Tx what? also available as-CI?
-Lamisil AT cream, spray
-Tx INTERDIGITAL tinea pedis:
-Use TID x1wk
-Longer durations (4wks) may be more effective
-Tx BOTTOM and SIDES of feet: apply TID x2wks
-Also available as ORAL AGENT by Rx:
-Tx last 4-6 wks
-**CI: w/ CrCL <50 and ACTIVE LIVER DISEASE
Tell me a bit about OTC tinea pedis-Butenafine; moa? indicated for what? sig?
-Indicated for INTERDIGITAL tinea pedis
-Apply TID x1wk OR once daily x4wks
-**Undecylenic acid power, cream ,solution 8-25%:
-Apply TID x4wk
Tell me a bit about Tinea pedis OTC- aluminum salts-Ex, MOA, use for what, follow up with what? soak for how long, when is too long? dissolve how many packets in how much water?
-Aluminum Salts (20-30%)
-Burrows soln, Domeboro
-ASTRINGENT and ANTI-INFLAMMATORY (NOT ANTIFUNGAL)
-useful FOR WET "BOGGY" LESIONS and BLISTERS
-DRY OUT lesion- FOLLOW UP w/ ANTIFUNGAL tx
-Soak foot for 20 mins 2-3 times/d x3-7d
-Dissolve 1-3 packets in 16 oz warm water
-Discard soln after each use
-**DO NOT SOAK more than 30 MINS
-Soak and clean cloth in burrows soln
-APply cloth loosely to affected area for 20 mins
-Repeat as needed
-Discard soln after each use
Key points in topical antifungals- what delivery system is most effective? what are less effective? what are ingredients to keep feet dry?
-SOLN and CREAMS MOST EFFICIENT AND EFFECTIVE delivery agents
-SPRAYS and POWDERS-LESS EFFECTIVE
-Useful in combo therapies
-Good PREVENTATIVE agents for new/recurring infections
-Cornstarch or Talc power: Good astringents to keep feet dry.
Tell me some Rx topical products
-**Clioquinol 3% + HCT 0.5-1% cream/ointment:
-2-4 times daily x4 weeks
-**Naftitine (naftin) gel/cream 1-2%:
-Approved FOR INTERDIGITAL TINEA ONLY
-**Oxiconazole (Oxistat) cream/lotion:
-Once-twice daily x1month
-**Suliconazole (Exelderm) cream 1%:
-**Luliconazole (Luzu) cream 1%:
-daily for 2 weeks
what are some Rx oral agents? which ones are strong CYP inhibitors and pgp inhibitors? moderate cyp inhibitors?
-**Ketoconazole and itraconazole: strong CYP450 inhibitor and pgp inhibitor
-**Fluconazole and terbinafine: moderate CYP450 inhibitor
Tell me a bit about Onychomycosis- is what? risk increases with what? nail signs? complications? tx options? what is the main tx option-efficacy?
-DIFFICULT to tx: nails grow slowly
-Risk increases w/ AGE
-DISCOLORATION-darkened can be debris under nail
-DISTORTED in SHAPE
-SECONDARY SKIN INFECTIONS
-PERMANENT nail DAMAGE
-NAIL REMOVAL (nail avulsion): chemically/surgically
-Topical antifungals: NOT EFFECTIVE USED ALONE
-Oral antifungals are a MAINSTAY
-clinical cure rates range from 10-60%
What are Onychomycosis OTC tx-Fungal Nail revitalizer- what does it do? composed of what? does it tx?
-**Fungal Nail revitalizer:
-IMPROVE nail APPEARANCE
-REDUCE nail DISCOLORATION, SMOOTHEN ROUGH AND THICK nails, MOISTURIZE brittle nails
-Composed of CALCIUM CARBONATE and UREA
Sig: Apply cream to nail, scrub w/ brush for at least 1 min, wash and dry, use daily for 3 weeks
**DOES NOT TREAT!!
Tell me Onychomycosis Rx tx-Ciclopirox- MOA? sig? allow how many hrs before bathing? clean with what? ADRs? best used with what?
-**Ciclopirox (penlac) 8% nail lacquer:
-MOA: INHIBIT FUNGAL TRANSMEMBRANE TRANSPORT
-Sig: APPLY to affected nail QHS x48 weeks, allow AT LEAST 8 hrs before bathing, CLEAN nail w/ ALCOHOL q7d
-ADRs: well tolerated, some mild irritation
-BEST IF USED TOGETHER WITH ORAL AGENT
TEll me other Onychomycosis Rx tx- ADRs? Efficacy?
-Efinaconazole (Jublia) 10% soln: apply daily x48wks
-Tavaborole (kerydin) 5% soln: apply daily x48 wks
-Overall LOW adverse effects BUT ALSO LOW CURE RATES
Tell me a bit about Onychomycosis tx: terbinafine (lamisil)- MOA? pulsed dosing? duration of therapy-fingernails/toenails? DDI? ADRs? inhibits what kind of CYP?
-**FIRST LINE ORAL TX
-INHIBIT SQUALENE EPOXIDASE (FUNGICIDAL)
-Dosing: 250 mg po daily
-Pulsed dosing-NOT FDA APPROVED
-Duration therapy: fingernail = 6 weeks ; Toenails = 12 weeks
-MODERATE CYP 2D6 inhibitor
-DDI: beta-blocker, SSRI, TCA, Anti-arrhythmic, WARFARIN
-ADR: GI UPSET, HA, rash, Dizziness, ELEVATED LFTs, dysgeusia
Tell me Onychomycosis Rx tx: Itraconazole (SPoranox)- MOA? continous dosing? pulse dosing? duration of therapy-fingernails/toenails? DDI? inhibits what kind of CYP?
-SECOND LINE ORAL TX
-MOA: INHIBIT ERGOSTEROL SYNTHESIS (FUNGISTATIC)
-Continuous dosing: 200 mg/d
-Pulse dosing: 200-400 mg/d for 1 week/month
-Duration of therapy: fingernails- Pulse dosing-8wks; continous dosing-6 wks; Toenails: 12 weeks
-Strong CYP 3A4 inhibitor:
-DDI: benzos, calcium channel blockers, statins, PPIs, warfarin
-ADRs: GI upset, elevated LFTs and TRG, hypokalemia
Tell me a bit about Onychomycosis Fluconazole (diflucan)- Approved? MOA? dosing? what tests are taken before these antifungals are used? counsel on what? when to get labs?
-SECOND LINE ORAL TX
-NOT FDA approved for Onychomycosis
-MOA: AFFECT ERGOSTEROL SYNTHESIS (Fungistatic)
-Dosing: VARIES; typically 100-300mg/wk
-Duration of therapy: fingernails: 3-6 months; toenails: 6-12 months
-Moderate inhibitor of CYP 2C9, 2C19, 3A4:
-DDI: benzos, CCB (calcium channel blockers), Statins
-**FOR TERBINAFINE, ITRACONAZOLE, FLUCONAZOLE- get LFT and CBC at BASELINE;
-Counsel on DARK URINE + LIGHT STOOLS, gets labs ON WEDNESDAY NOT MONDAYS
Tell me a bit Onychomycosis rx- Griseofulvin- efficacy? limitations? take with what kind of meal?? DDI? what does it do to CYPs? ADRs?
-OLDER AGENT W/ LOW EFFICACY AND HIGH RELAPSE RATES
-NARROW antifungal SPECTRUM and LONG TX DURATIONS
-Admin w/ FATTY MEALS to INCREASE abs
-CYP INDUCER: DDI: OC, barbs, warfarin
-ADRs: Photosensitivity, RASH, Gi upset, CNS effects
How do you prevent reoccurence- encourage what? avoid what?
-Encourage compliance w/ tx
-Keep feet cool and dry
-Wear adsorbent socks
-Discard old shoes
-wear footwear (sandals, flip flops) in communal showers, saunas
-AVOID ARTIFICIAL NAILS/NAIL POLISH
-NOT CLIPPING NAILS TOO SHORT
What are some Complementary/alternative meds (CAM)? 6
-**Tea trea oil (melaleuca):
-MIXED DATA in tx of TINEA PEDIS: high conc. are MORE LIKELY EFFECTIVE than lower
-Also used for Onychomycosis:
-100% tea trea oil applied w/ cotton ball TID x6months
-efficacy: 18% efficacy rate after 6 months
-**Oregano oil (thymol):
-Apply to affected nail w/ cotton swap TID
-May be used simultaneously with tea tree oil
-Made from plants in the SUNFLOWER family
-APply to affected nail every 3rd day for 30 days. then TIW for 30 days, then Once weekly for 30 days
-3month duration therapy
-Oil formulation applied 3x/d
-MAY BE USEFUL for tinea pedis
-Cured most fungal SKIN infections in 1-4 weeks
-Typically a gel or cream containing AJOENE
-Ajoene: component of garlic believed to have antifungal properties
-Chopped or crushed garlic may be applied to affected nail for 30 mins daily
-MAY BE USEFUL in tx tinea pedis
-**VIcks vapor rub:
-May improve nail appearance
-LITTLE EVIDENCE TO RECOMMEND
-Contain menthol, eucalyptus oil, camphor, thymol = active against several fungi
What are some dietary changes that can help? what supports nail regrowth? what prevents brittle nails? what reduces inflammation in nail beds/lubricates/moisturizes nails? what is essential for nail health and bone health?
-Probiotics: capsules, FERMENTED foods, yogurt
-Protein: support nail regrowth
-Iron: prevent brittle nails
-Essential Fatty acids:
-reduce inflammation in nail bed and lubricate and moisturize nails
-Calcium: nail and bone health
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