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The Pathogenesis of Nail Unit Dystrophy - Here it is Dennis

Discussion in 'General Issues and Discussion Forum' started by blinda, Apr 3, 2012.

  1. blinda

    blinda MVP

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    Hi Dennis,

    First, please excuse my tardiness in getting this off the ground. Also, I wouldn`t describe an article published in 2006 as many years old.

    I`m not interested in a mudslinging match either, so please do not take any constructive criticism as a personal attack. Before you mailed me the article I undertook a cursory search for it and found a link to it on this forum;


    I figured that as you had already provided a link, you wouldn`t mind others having access to the article in question.
  2. blinda

    blinda MVP


    Your post in the above link, in addition to the published article, raises a couple of issues, which I would very much like to discuss.

    First, I am in complete agreement with your sentiment that biomechanics and footwear should be examined in cases of trauma induced nail pathology. As an appendage of the skin, abnormalities may be the result of;

    1. Local traumatic (environment, footwear, mechanical) factors
    2. Generalized skin (infection) disease
    3. Systemic (congenital, hereditary or acquired) disease
    4. Tumours
    5. Drug side effects/reactions

    You are also correct (ish) in stating that many toenails clinically diagnosed as “fungal produce sterile biopsies”. The main reason for negative results for pathogenic dermatophytes after culture is inappropriate tissue samples taken by the practitioner. The most proximal part of infected nail and associated subungual tissue, where the tinea is active and plenty of it, has to be harvested for an accurate path lab diagnosis, not nail `clippings`. Even so, it is important to recognise that isolation of fungus from a dystrophic nail does not prove that it is the cause of the dystrophy, as your article highlights. However, a dystrophic nail is susceptible to colonisation by fungus, which can further damage the nail. So, yes other factors do have to be considered, but I`m not convinced that we “need a biomechanical box to put our toenails in".

    In another post you made on the same forum here;


    You said; “I maintain that more “fungal toenails” need a bunionectomy, an orthotic, or a bigger shoe than they need Lamisil or a laser. I think that EBM and the literature proves me correct long-term”. Now, that`s quite a jump from recognising that micro-trauma is a predisposing factor to dystrophy associated with tinea. Would you really perform a bunionectomy instead of recommending/prescribing anti-fungal therapy, where a positive diagnosis has been established?

    As I said before, I do agree with much of what is written in the article “The Pathogenesis of Nail Unit `Dystrophy` - Treating the mycotic infection alone will not always be enough for clinical success”. Indeed, a thorough assessment of medical history, physical and foot function is essential, and if required, further investigation before an appropriate treatment plan can be formulated.

    You make a valid point with regard to the term `nail dystrophy`, although the literal translation of dystrophy is bad in `formation` not necessarily `growth`. In most cases it is the whole nail apparatus, not just the plate, which is involved. That is, the nail bed, plate, matrix, sulci and nail folds, that appears malformed. This can be due either external, internal or both factors. However, I cannot agree with your assertion that; “We now know that hypertrophy rarely, if ever, occurs in the context of a malformed nail”. This is news to me and I would appreciate references to support these statements. It is true that the term `hypertrophy` is not strictly accurate to describe a thickened nail. That is why the dermatological term of onychauxis is more appropriate. To state “in the overwhelming majority of thickened or otherwise malformed nail structures, the nail plate itself is largely unremarkable. It is pathologic hyperkeratinisation of the nail bed that causes the clinical changes that we refer to as `nail plate hypertrophy`” is simply untrue. Hyperkeratosis of the nail bed may cause apparent thickening, whereas changes in the matrix result in real thickening of the nail. Nails are transparent plates of keratin, generated mostly by the proximal and distal matrix. Microscopically, the nail plate and nail bed fit together in a tongue-in-groove arrangement. Hence, any thickening of the nail plate (e.g. dermatophyte infection, which proliferate in Keratin), will result in the loss of contour. I would consider nail plate thickening and loss of contour as remarkable.

    Another point I wholeheartedly concur with, is that in the majority of cases of onychomicosis, the nail apparatus is first compromised by an unrelated condition (external or internal), thereby providing infectious elements (or opportunistic pathogens) a route of entry, i.e. infection is secondary to a damaged nail apparatus. Therefore, resolution of the infection of a malformed nail will not necessarily change the appearance to that of a `normal` nail. Clinical and mycological cure of infection can be obtained with a variety of anti-fungal treatments, however around a quarter of patients will subsequently suffer re-infection or recurrence. Therefore, as you stated, the key is management of the dermatophyte infection and addressing the conditions which initially compromised the integrity of the nail apparatus.

    I am confused by your use of the terms `pathologic keratinization` and `hyperkeratinisation`(which is a disorder of cells lining the inside of a hair follicle) in relation to your proposed classification of these as `precursor lesions`. The nail plate IS the result of keratinisation within the matrix. See here; http://www.derm-hokudai.jp/shimizu-dermatology/pdf/01-10.pdf

    Or, are you referring to the nail isthmus? See here; http://www.ncbi.nlm.nih.gov/pubmed/18032949

    IMO, `Keratinization`, is not an improvement on dermatological classification/terminology. Whilst we`re on the subject of terminology; I felt that describing dermatological nomenclature as “antiquated”, “misnomers” and “inappropriate” demonstrated a lack of appreciation for the necessity of diagnostic description and classification of skin disease. Diagnostic labels and descriptive classification in dermatology terms have developed for good reasons. They provide a framework for diagnosis and clinical decision making by recognition of disease signs and symptoms. Your proposed re-classification of nail dystrophy into 4 types of `keratinization`, does not appear to achieve this. Neither does it provide a recognised working label, or offer a prognosis and/or clinical information to determine which treatment modalities are most suitable for the array of aetiologies presenting as nail dystrophy.

    I understand that the crux of the article is to advertise your foot typing system, (which I have no intention of debating with you) as some forms of nail dystrophy are certainly exacerbated/caused by foot function, shape and wear by increased stress and subsequent trauma on the nail apparatus. However, I have to admit that your concluding sub-heading Breaking away from mainstream medicine, did not sit well with me. To accuse dermatologists and family practitioners of “clinging to anti-fungal agents as silver bullets” for nail dystrophy, regardless of cause, and “such professionals know little about the management of common causes of onychodystrophy... even less about the contributions of `precursor lesions`(which i cant fathom out either) is more than a tad insulting. Personally, I feel that my patients benefit from a inter-professional approach to lower limb pathology, and I fail to see how "It could only benefit our profession to further set ourselves apart among medical professionals", but that`s just me.

    G`night for now
  3. Belinda:

    Your dermatology knowledge is "sick". Excellent posting.:good: I am impressed!!:drinks
  4. I concur. And am equally impressed with your street talk Kevin. For shizzle.
  5. drsha

    drsha Banned

    "A woman's flattery may inflate a man's head a little; but her criticism goes straight to his heart, and contracts it so that it can never again hold quite as much love for her".
    Helen Rowland

    Although I do find your comments sophisticated, I do not find them critical at all. In the worst case, we will redefine the terminology that Dr Bakotic and I used in our article and broaden the applications of our work to a wider than podiatry audience.
    I see that as very valuable.

    In reading your posting quickly, I can relate to the areas where your questions are very appropriately raised and I will respond to all of them.
    However, I am most flattered by the fact that for the most part, you are either in agreement or complete agreement with the content and direction of our classification system and its applications.

    Please accept the fact that it is the Passover Holiday for me and The Easter Holiday for my wife and family and so I must ask for your indulgence to allow me to respond in kind to your posting early next week.


    Attached Files:

  6. blinda

    blinda MVP


    My thanks are in relation to your courteous reply and describing my comments as `sophisticated`. It is not my intention to either flatter or disparage you personally.

    Also, please note that my admission of; “I happen to agree with much of what is stated within, in particular the title "Treating the mycotic infection alone will not always be enough for clinical success" caught my attention”, should not be misquoted, nor taken out of context. I am not, nor have I stated that I am, “in agreement or complete agreement with the content and direction of [y]our classification system and its applications”. I have highlighted a few pertinent points that have been made in your article, but I fail to see the usefulness of your proposed classification system over current diagnostic/descriptive classification in dermatology terms and most certainly do not agree with the suggested direction of breaking away from mainstream medicine.

    I look forward to your response, in particular your clarification on (and your definition of) keratinization and why this should be perceived as a precursor lesion, in addition to justifying the requirement of a new classification for nail malformation.

  7. footboy25

    footboy25 Member

    I do see a fair amount of what I diagnose as onychomycosis get cultured by me-and come back as onychodystrophy WITHOUT fungal involvement.Causes:pointed shoes?Hallux limitus/extensus?
  8. blinda

    blinda MVP

    Hi Footboy,

    So, am I understanding you correctly; you send samples of subungual and nail plate tissue to the pathology lab for microscopy and culture. Then, 8 weeks later, the lab report states "onychodystrophy" as the cultured pathogen? Which lab do you use?
  9. David Smith

    David Smith Well-Known Member


    Sharp girl! Impresses the hell out of me!

  10. Ian Linane

    Ian Linane Well-Known Member

    Got to say that I quite enjoyed this thread so far.
  11. Blinda:

    I wonder why he hasn't replied to you, now 5 weeks later when he promised to reply in a few days? Probably because fungal toenails have nothing to do about his favorite subject: Functional Foot TypingTM blah blah blah.
  12. David Smith

    David Smith Well-Known Member

    Hey with Belinda in th edriving seat, dermatology is the new biomechanics, interesting and fresh.:cool:

    So Bel with that in mind I will start a new thread looking at skin lesions and their diagnosis.

    Cheers Dave Smith
  13. If its free from barefoot runners and orthotic salesmen, I'm SO in.
  14. drsha

    drsha Banned

    My overall critique of your critique of my article is that for the most part:
    1. you agree with it
    2. I believe some of your criticism is wrong and am defending it
    3. Some of your critique is your opinion vs. mine but not about the bulk of the article
    4. Some of your critique is a fabrication or fantasy that makes you a poor critic

    My responsive critique of your critique is that you act as thought you have never looked at many types of dystrophic toenails under microscopy when developing your opinions.
    This is probably similar to you never having foot typed a patient as you draw your conclusions about FC/WB.

    Happy Springtime
  15. blinda

    blinda MVP

    I must have missed the "grown up" part. Nevermind.
  16. Anthony S

    Anthony S Active Member

    Is it normal to critique a critique? I thought one rebutted a critique.
  17. Anthony S

    Anthony S Active Member

    I could not find the article, could somebody make a link?

    The closest I could find was this.

    "In 2006, Brad Bakotic and I published an article in Podiatry Management entitled “The Pathogenesis of Nail Unit Dystrophy” introducing a new classification system for diagnosis dystrophic toenails. This case seems to be the pure repetitive microtrauma version (Class III) requiring more biomechanical and shoe adjustment care than a laser.

    When functional foot typing® is applied, your patient will be diagnosed as a flexible forefoot type which has a primary FHL and a secondary functional hallux extensus as described in the article. Dr Bakotic continues to use this classification system to this day when reading his nail samples. As the biomechanics consultant to his lab, I work with DPMs to apply biomechanics to predominantly 1st and 5th toenail disease as in this classical case."

    So I'd not say this
    "I understand that the crux of the article is to advertise your foot typing system, (which I have no intention of debating with you)"

    Was exactly a FLAGRANT lie.

    If someone could sum up for me in 5 words or less, is the outcome of the article that these insoles treat fungal nails?
  18. blinda

    blinda MVP

    The link to the article was embedded in a forum, which I originally made a link to, here;
    However, it would appear that you can no longer freely access said article. I am not at liberty to post a copy, but if you ask Dennis nicely, he may email you a copy.

    5 words? Dennis, re-classification, unrecognised medical terminology.

    Oh and Dennis, I never have and never will be your "Dear".
  19. Anthony S

    Anthony S Active Member


    So the message is that lots of fungal nails are in fact not fungal nails, that they need orthoses to treat them, that stj neutral orthoses won't, but others will.

    And I'm guessing these other orthoses are his, is that about right?
  20. blinda

    blinda MVP


    You`ll have to decide that for yourself (I`m sure he won`t mind sending you a copy), as I still have no intention of discussing functional foot typing with Dennis. In fact, I`m done with discussing anything with him. His posts reveal not only a lack of understanding basic podiatric dermatology, but also the inability to debate in a professional manner.

  21. drsha

    drsha Banned


    drsha@foothelpers.com for a copy..no problem.

    I'll you be the judge as to whether the article mentions orthotics, mine or otherwise and as to Belinda's bias, she ends the debate without acknowledging that her facts dermatologically, were not accurate.

    Some things never change.

    I'll be glad to hear your critique.

  22. blinda

    blinda MVP

    There really is no point in continuing this discussion, Dennis. You evidently don`t understand podiatric dermatology. Or bias. Or what a straw man argument is. Let it go.

    Don`t think I`m being mean,
  23. drsha

    drsha Banned


    I found this online.

    The Japanese update of my last presentation at the ADA,Click and scroll down:


    no advert? no foot typing.

    email me for the reference if you wish.
    Blinda is trying to poison me personally rather than confront the facts..

  24. If only....
  25. I love my ignore list! Thanks for that Craig!!

  26. drsha

    drsha Banned

    Kevin: If your posting is accurate and not a joke, Dr Craig Payne has created an ignore list that is available to selct members of The Podiatry Arena that you are using to censure my posts.

    Is the icon a gun or an Atom Bomb mushroom?.

    Even more telling is your need to expose its existence and gloat about it publicly.

    I'm assuming that htere is a select group that Craig is favoring as I a senior member of The Arena, and have not been offered this option.

    As far as this thread goes, ignoring me does not change the fact that Blinda was wrong in her comments about dystrophic toenails including the fact that toenail plate hypertrophy is not the main source of thickening in dystrophic nails as she asserted.

    Her lack of knowledge fueled by your ignorant support of it reveals a flaw in your ability to appraise and validate evidence.

    The Ignore list is a dangerous, totalitarian form of censorship that has no place on what is being promoted as an open forum.

    Shame on you Craig!.
    You should resign as the editor.
  27. [​IMG]

  28. Craig Payne

    Craig Payne Moderator

    Confucius once said, when in a hole its often a good idea to stop digging.
    Everyone is welcome to read about you making another fool of yourself here.

    Can I suggest that you should be asking yourself why so many members here want to put you on their ignore list and not want to read what you are writing.
  29. drsha

    drsha Banned

    You mean like a Catholic wanting to ignore a Buddhist or Muslim or Jew?

    Or American politicians ignoring the 47%? Or?

    I was brought in guilty before being proven and that has never changed.

    You have not delivered much high level, valid and applicable evidence (all you do is call for it from others) and that goes against the power of any of your arguments.

    You are entrepeneurial with this site, it generates profits, you are profit oriented in life, you are out of the standard box.

    You have other goals and aspirations in life like taking care of the twins that motivate you. How do you all know what I am thinking and meaning and "cruxing".

    What makes me so different from the rest of you?

    Oh and yes, I have stated (and am willing to back it up in person, that I am a better clinician than some (or many of you) because you spend so much of your time drawing and diagramming and waiting for pain and suffering while I am focused on prevention, performance enhacnement and quality of life upgrading that you have no time for.

    Your reaction to that was amazingly, "we are all peer practitioners and how dare I say that I was better than anyone else?

  30. Do we really have to endure these constant immature diatribes from this madman with such an obsessive inferiority complex?
  31. Craig Payne

    Craig Payne Moderator

    You mean the $143.60 that the site made last month? It did not cover all the expenses.
  32. More like a parent, striving to avoid the persistent and shrill complaints of a petulant child.

    Seriously. This isn't funny any more. You made a fool of yourself (and not for the first time). The graceful move there would be to apologize, have a laugh about it (who's never made a mistake?) and learn from it. Not compound it.

    For one thing, you don't know when to stop!

    Let it be! If you're so certain that there is a conspiracy and that the arena is packed with "inferior" clinicians, why are you still here?! I can't begin to understand.

    Let me paint it as clearly as I can. Craig is not the editor, he is the owner. He made this site, which we all enjoy, and which has done more to bring podiatric minds together than perhaps anything else in the history of the profession. He has invested countless hours and continues to do so to bring us this arena for the use of the profession.

    To come in here and start calling him names and insulting him like that is like being invited into someones house then crapping on the carpet. To demand he steps down is like being invited into someones house then demanding they leave.

    This is Craigs house. If you don't like it, the door is there. If you want to stick around, a little respect for your host, who in spite of considerable number of requests, has refrained from banning you out of hand, would be seemly. The man you demonize and insult is the closest thing you have to a supporter.

    As Bill suggested, if you wish to start your own forum, to put the work into building it, then you may set whatever rules you please.
  33. While strolling along the internet, this book cover somehow seemed appropriate for this thread....

    ....I just couldn't resist this one.....
  34. drsha

    drsha Banned


    As much as you are so correct, your critique is one sided.

    I did apologize, it wasn't enough. So I reacted as childishly as The Arena did.

    Next time, be men and women enough to realize we all make mistakes, forgive and forget, grow up and act like colleagues.

    That would be my advice to you.

    and Live and Let Live.


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