Pie crust toe nails

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I have a 80 year old female presents with "fungal nails" that she states started after seeing a foot doctor at a seniors centre which was a year prior.
I have the biopsied the nails twice, with both times negative for fungus or yeast. The nails flake like pie crust when they are debrided. I have tried various topical anti microbials and cortisones. I would welcome any help with a diagnosis and treatment plan.
I attached a pic.

 

Well, they certainly look fungal to me.

Are you sure you have taken a sample to include the debris underneath the nail? Sometimes if the sample is not taken from the correct area then testing can produce false negatives.

I am not sure where cortisone and antimicrobials figure in the treatment of fungal nails infections?

regards

Catfoot

 

Hi,

Thanks for the pic, always helpful when discussing anything dermy . I`m guessing this pt has diabetes, from the `shin spots` (diabetic dermopathy) on the dorsum? Regardless of whether they have been diagnosed with DM or not, and whilst it is true that fungal infection is probably present, what stands out more is the very obvious compromised vascularity of this foot. Peripheral vascular disease manifests as hair loss, nail and soft tissue dystrophy, mottling and cyanosis, as seen on the distal phalanges here.

In other words, this is a high risk foot. That is, at risk of ulceration and infection. Therefore, you must be incredibly selective in your choice of treatment, particularly if you have decided to apply steroid based topicals (cortisone). As Catfoot stated, I`m not quite sure why you would use cortisone or anti-microbials. Topical anti-fungals, such as imidazoles or 1% terbinafine would be an appropriate course of treatment, although the general appearance of the nails may well not improve, due to the fact that they are friable and dystrophic due to vascular disease.

Hope that helps!

Cheers,
Bel

 

I agree with Bel absolutely. There are a couple of hairs at the base of the hallux, so you may be dealing with microvascular compromise.

I would run her through a P stick test initially and if this is positive refer to a diabetologist via the GP, (but please do it in writing) for more definitive diagnosis. Frankly, I don't think that the nails will ever be "normal" and would suggest that you treat symptomatically with especial reference to footwear etc.

Please let us know the outcome.

Bill Liggins

 

Thank you for your replies.
Yes the samples I provided contained substantial amounts of debris from under what was left of the nails.
Her GP has tried various topical cortisones on flaky keratin covered erythematous areas at the medial and lateral heels.
During the last year, I have prescribed various topical anti fungals including those mentioned. I prescribed a topical anti biotic when a mild ulcer on the hallux nail bed was discovered which healed quickly.
Her pulses are palpable but I will order non invasive vascular studies with PVR's and work her up for diabetes.
She has been using prescribed hybrid custom orthotics for over a year and stable shoe gear with room in the toe box.
I agree that the hallux nail plates may never resolve due to the apparent loss of the proximal nail fold.
Thank you for the replies and I welcome any other suggestions.

 

Just remember that fungal cultures have quite a large false negative rate. So much so, that they are no longer recommended before oral terbinafine is initiated here in New Zealand.
Cheers

 

The Gp has tried various cortisones... does she have psoriasis?
Does she have severe asthma, emphysema?
Her toes are cyantoic, her pulses are palpable but are they mono-phasic? Does she have slight calcification of the arteries? What is her SVPFT / capillary refill time?
It may be any possible fungal infection is being exaccerbated by lack of oxygen/circulation, or due to underlying damage from previous skin condition.

Just my thoughts.

 

I think that should be sought in the primary cause systemic disease. I'm hanging psoriasis or lichen planus. good personal and family history is important
Thanks