As people get older the issues they need to deal with generally increase and one that becomes more of a threat is diabetes. In terms of feet, this risk often manifests itself as ulceration due to pressure, bacteria infection as secondary outcome and possible loss of toe or limb.
In the US it has been established that onychomycosis for diabetics triples the risk of ulceration, infection or gangrene. The effects of diabetes or just being male nearly triple the risk of having onychomycosis and one third of diabetics have a foot fungal condition. The effects of age, smoking, vascular disease or obesity are all associated with onychomycosis. In addition, special consideration is recommended for those with specific conditions such as cellulitis, edema and diabetes.
Podiatrists will identify nail thickening and discolouration with subungual hyperkeratosis as a common diagnosis of onychomycosis. However, studies have indicated that almost half of abnormal nails may not be fungal!
Due to patients with diabetes being generally immunocompromised to some degree they often have slower nail growth rates due to accompanying peripheral arterial disease. This complication can affect the perceived outcome by the patient of the therapy undertaken. Non ablative laser therapies have been shown to be safe and effective for clearing onychomycosis. A recent US study was conducted into the clinical effectiveness of the 1064nm Nd:YAG laser in 32 patients with 57 fungal infected hallux nails and moderate to severe onychomycosis. The study included patients with and without diabetes. It achieved significant improvement in the onychomycosis severity indices, proximal clear zones and overall patient satisfaction.
It is of note that laser treatment of patients with diabetes can lead to significant complications due to the risk of thermal burns. Q switched short wavelength lasers are required for this treatment due to the amount of energy required to permeate the nail plate, reach the nail matrix and provide sufficient energy to deal with the fungus. Therefore heat build up is a consideration during the treatment process to prevent concentrated targeting of the laser on a fixed spot by ensuring pulse duration of nanoseconds with a maximum of 700mj output. Accordingly, severe cases of onychomycosis in diabetics are unlikely to be suitable for laser due to the increase in nail plate thickness requiring higher energy levels to be effective.
Successful treatment of any individual, diabetic or not, includes the periodic professional debridement by a podiatrist. Impaired vision or sensation by patients can acutely increase the likelihood of repetitive injury and secondary infection, so self treatment is unadvisable.
In summary, a combined effort of podiatrist care, recognition of the specific secondary dangers to diabetic patients and a suitable care & aftercare plan are required to deal with the combination of onychomycosis and diabetes.
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