dark granulated crusting on infected toes of noncompliant patient with diabetes

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Hi all

Below are pictures of the foot of an Asian gentleman, 40 years old who, on Wednesday, his 1st appointment with me, presented with very painful toes esp right foot. He also had millimetres of hair, dirt and fibre on the plantar surface with macerated hyperkeratosis underlying the dirt.

He reported that he stopped work because of the pain and because his toes bleed if he does heavy work.Some toes were dressed and the patient reported that the hallux right had bilateral PNA in May at a local NHS Podiatry dept. He reports the he returned for 1st redressing and then had been redressing at home since.

Speaking to the NHS clinic - They confirmed the PNA history als He has a history of ingrown nails and diabetes 1 and is classified as at risk by the clinic due to possible mental health issues whereby he does not return for follow ups and personal foot hygiene is very poor, he denies diabetes but it is confirmed by his GP as is his difficult behaviour in terms of attending appointments.


The lesser toes 2,3,4 left and right had paronychia and most of the nail edges were ingrown. The most striking feature was the dark and golden granulated crusting which at first sight resembled gangrene but the crusting was removed to reveal fairly intact skin. The nail groove bled when disturbed and the eponychium and adjacent skin of the hallux was very dark and bled easily. The toes were exquisitely painful to pressure applied.

Dorsal pedal pulses were strong but post tib pulse not palpable, capillary refill a little slow but difficult to asses due to skin pigment. The digital dorsal skin was particularly dark and had the preulcerative appearance and signs of ischaemia except that cyanosis was hard to distinguish.

After he feet were cleaned and debrided on the plantar surface, crusting removed and the nail spikes removed and the wounds irrigated and dressed he was referred to GP. He was booked to return for review on Saturday but he cancelled.

The dark and golden crusting is something I have never come across before and can anyone enlighten me as to what it is and its cause? I know I might be looking a bit dim here but a moment's embarrassment is better than a lifetime of ignorance