Macerated fungal foot care question

[flightdoc09]

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Not asking for medical advice, more so for CME.

I'm an ED doc, had a patient with a relatively large body habitus and pain on the soles of his feet. I can PM pics if anyone wants to see, but my diagnosis based on smell, appearance, and the stains on his socks is that it was likely maceration and skin breakdown from a combination of fungal infection and always wearing socks with probably sweaty feet.

He had been given nystatin ointment by wound care that he had been applying daily for several months without any improvement, and gradual worsening. I figured he needed to dry his feet out, but also needed something antifungal. So I ended up prescribing tolnoftate powder - which is something I dont think I've ever prescribed before, at least for nothing with open fungal wounds.

Again, I can PM pics if anyone would like to see, but wondering how you would normally treat something like this. Would clotrimazole or nystatin trap moisture? Is tolnaftate as potent as those two?

Thanks.

 

[Feli]

... I figured he needed to dry his feet out, but also needed something antifungal. So I ended up prescribing tolnoftate powder ...

You solved your own problem. I use miconazole powder (Zeasorb or generics) typically.... but yeah, you need an OTC antifungal powder (spray is also ok between toes and for shoes... basically dries into powder), air out the skin. You might occasionally also need PO abx if the fissures/wounds are infected. But it's basically same principle of people who wear a knee/elbow brace ever day: the skin gets macerated and prone to yeast/tinea infect.

The antifungal creams are better for the normal/dry skin with typical tinea erythema/xerosis. They can make maceration worse.

...and refer to the nearest UpperLine podiatry for fellowship trained ongoing foot and nail care. They think they will be doing total ankle implants, but this stuff is 100x more common. 🙂

 

[deleted1244881]

OTC Domeboro is a fantastic astringent to dry out macerated skin as well…. Especially for chronic fungal or pseudomonal involvement! I usually have patients mix it up in a bottle with water and spray it on.

 

[BeaverBlade]

skip the topicals as the main treatment and go to oral antifungals when it’s serious enough you’re concerned about infection. Otherwise just keep it dry. And yes abx when necessary

 

[air bud]

skip the topicals as the main treatment and go to oral antifungals when it’s serious enough you’re concerned about infection. Otherwise just keep it dry. And yes abx when necessary

Yeah I don't even mess with clotrimazole if the patient is a reasonable candidate for 6 weeks of oral terbinafine

 

[flightdoc09]

You solved your own problem. I use miconazole powder (Zeasorb or generics) typically.... but yeah, you need an OTC antifungal powder (spray is also ok between toes and for shoes... basically dries into powder), air out the skin. You might occasionally also need PO abx if the fissures/wounds are infected. But it's basically same principle of people who wear a knee/elbow brace ever day: the skin gets macerated and prone to yeast/tinea infect.

The antifungal creams are better for the normal/dry skin with typical tinea erythema/xerosis. They can make maceration worse.

...and refer to the nearest UpperLine podiatry for fellowship trained ongoing foot and nail care. They think they will be doing total ankle implants, but this stuff is 100x more common. 🙂

Thanks, exactly the answer and info I was looking for.

OTC Domeboro is a fantastic astringent to dry out macerated skin as well…. Especially for chronic fungal or pseudomonal involvement! I usually have patients mix it up in a bottle with water and spray it on.

Never heard of it. Googling it, it looks like it's used similarly to calamine lotion? I'll try to learn more about it.

skip the topicals as the main treatment and go to oral antifungals when it’s serious enough you’re concerned about infection. Otherwise just keep it dry. And yes abx when necessary

Yeah, good idea. I guess my only concern would be starting on something that requires liver checks. Though a few weeks probably not a big deal I would imagine.

 

[air bud]

Thanks, exactly the answer and info I was looking for.


Never heard of it. Googling it, it looks like it's used similarly to calamine lotion? I'll try to learn more about it.


Yeah, good idea. I guess my only concern would be starting on something that requires liver checks. Though a few weeks probably not a big deal I would imagine.

6 weeks and normal ALT AST is fine. The whole LFT thing is over blown. It is 2x before it's a problem. 1 drink a day is fine and make sure EMr doesn't give any major drug contraindications

 

[Feli]

OTC Domeboro is a fantastic astringent to dry out macerated skin as well…. Especially for chronic fungal or pseudomonal involvement! I usually have patients mix it up in a bottle with water and spray it on.

T

 

[dtrack22]

starting on something that requires liver checks.

It doesn’t though

 

[Toenail]

I would try painting the foot daily with betadine and if the skin doesn’t improve then would consider dermatology evaluation.

 

[deleted1244881]

I would try painting the foot daily with betadine and if the skin doesn’t improve then would consider dermatology evaluation.

Why not biopsy (if needed) and treat yourself? This is rudimentary stuff that shouldn’t require derm referral IMO.

 

[BeaverBlade]

good TFP question on what you guys are doing for suspected cancerous lesions though. Derm referral or biopsy in your office? I don’t see a lot of these so when I get something I refer not sure if that’s lame or best interest of patient. I’m sure I could do a shave or punch biopsy just fine but derm does 20+ a day so

 

[deleted1244881]

good TFP question on what you guys are doing for suspected cancerous lesions though. Derm referral or biopsy in your office? I don’t see a lot of these so when I get something I refer not sure if that’s lame or best interest of patient. I’m sure I could do a shave or punch biopsy just fine but derm does 20+ a day so

100% biopsy yourself. But when it comes to definitive care, that might require derm/gen surg referral for Mohs excision, sentinel lymph node biopsy, etc.

I biopsy at least one or two wounds a month at the wound care center. So many patients have chronic non-healing ulcers that no one has ever biopsied (which is a bit disturbing).