From the Guidelines
The patient should be advised to schedule a prompt evaluation by a dermatologist or podiatrist within 1-2 weeks to determine the cause of the dark spot on the left big toenail and multiple erythematous areas on the right foot. The dark spot on the toenail might represent subungual hematoma (blood under the nail from trauma), fungal infection (onychomycosis), or potentially subungual melanoma, which requires urgent attention 1. The erythematous areas on the right foot could indicate cellulitis, tinea pedis (athlete's foot), contact dermatitis, or other inflammatory conditions. Until professional evaluation, the patient should keep both feet clean and dry, avoid tight footwear, and document any changes in appearance or symptoms. They should not attempt to treat the nail with over-the-counter medications before diagnosis. If the erythematous areas are itchy, a non-prescription antifungal cream like clotrimazole 1% applied twice daily may provide temporary relief if fungal infection is suspected. However, definitive diagnosis often requires clinical examination, possibly with nail clippings for fungal culture, dermoscopy of the nail, or in some cases, biopsy of concerning lesions. Early evaluation is important as skin and nail conditions are easier to treat when addressed promptly. Additionally, the patient should be educated on proper foot care, including daily washing and drying of the feet, use of emollients to lubricate dry skin, and cutting toenails straight across 1. The patient's current instruction to maintain good foot care and monitor the spot on the left foot is appropriate, but further guidance on foot care and evaluation by a specialist is necessary to prevent potential complications. The prescription of medical shoes and insoles is also a good measure to prevent further foot problems, as it is recommended to wear properly fitting footwear to prevent foot ulcers 1.
From the Research
Patient Assessment and Diagnosis
- The patient presents with a dark spot on the left big toenail, which may be indicative of onychomycosis, a fungal nail infection 2, 3, 4.
- The presence of multiple erythematous areas on the right foot suggests a possible fungal or bacterial infection 5.
- A thorough diagnosis, including direct microscopic examination, histopathologic examination, or fungal culture, is necessary to confirm the presence of onychomycosis 3, 4.
Treatment Options
- Oral antifungal therapies, such as terbinafine or itraconazole, are effective treatments for onychomycosis, but may have significant adverse effects 3, 6.
- Topical antifungal therapies can be considered for mild to moderate onychomycosis, but may have limited effectiveness due to poor nail penetration 3, 5.
- Surgical removal of the toenail may be an option, but the patient has declined this treatment 2.
Patient Education and Follow-up
- The patient should be instructed to maintain good foot care, including regular cleaning and drying of the feet, to prevent the spread of infection 2, 5.
- The patient should be advised to monitor the spot on the left foot and contact the healthcare provider if any signs of infection develop, such as increased redness, swelling, or pain 2, 5.
- Regular follow-up appointments should be scheduled to assess the patient's condition and adjust treatment as necessary 6, 5.
Additional Considerations
- The patient's age and potential comorbidities should be taken into account when selecting a treatment option 6.
- The patient's preferences and lifestyle should also be considered when developing a treatment plan 6.
- The use of medical shoes and insoles, such as the prescribed Apex X520M and size 13.0 insoles, may help to reduce pressure and discomfort on the feet 2.