From the Guidelines
The best course of action for this 53-year-old male patient is to seek prompt medical evaluation from a dermatologist or primary care physician. The multiple red areas on the right foot could indicate various conditions ranging from infection to inflammatory disorders, while the dark spot on the left big toenail might be a subungual hematoma (blood collection under the nail) or potentially a more serious condition like melanoma. The physician should perform a thorough examination, possibly including dermoscopy of the toenail to distinguish between benign blood collection and melanoma 1.
Key Considerations
- If confirmed as a subungual hematoma with recent trauma history, treatment may involve monitoring or, if painful, nail trephination (creating a small hole in the nail to release pressure) 1.
- For the red areas, treatment will depend on diagnosis—potentially topical antifungals like clotrimazole twice daily for 2-4 weeks if fungal, antibiotics if bacterial, or corticosteroids if inflammatory 1.
- Photographs should be taken to monitor changes over time.
- This dual presentation requires professional assessment as self-diagnosis could miss serious conditions like melanoma, which has a higher mortality rate when diagnosis is delayed 1.
- Diabetes should also be ruled out as it increases risk for foot complications 1.
Additional Recommendations
- The patient should be advised on proper foot care, including keeping the feet clean and dry, trimming toenails straight across, and avoiding sharing personal care items 1.
- The use of medical shoes and insoles, as prescribed, can help reduce pressure on the feet and prevent further complications 1.
- Regular follow-up appointments should be scheduled to monitor the patient's condition and adjust treatment as necessary 1.
From the Research
Patient Presentation
- The patient is a 53-year-old male presenting with multiple red areas on the right foot and a dark spot on the left big toenail, possibly indicating subungual hematoma.
- The patient denies pain related to the left big toe.
Diagnosis and Treatment
- The dark spot on the left big toenail may be a sign of onychomycosis, a fungal infection of the nail unit 2, 3, 4.
- Onychomycosis can be caused by dermatophytes, such as Trichophyton rubrum and Trichophyton mentagrophytes, and can lead to discomfort, reduced quality of life, and risk of complications in patients with comorbid conditions 2, 4.
- Treatment options for onychomycosis include oral antifungal agents, such as terbinafine and itraconazole, and topical antifungal agents, such as efinaconazole and tavaborole 2, 4, 5.
- The patient declined surgical removal of the toenail, and was instead advised to maintain good foot care and monitor the spot on the left foot for signs of infection.
Management and Follow-up
- The patient was instructed to maintain good foot care and to contact the healthcare provider if any signs of infection develop.
- The patient was prescribed medical shoes and insoles to help manage the condition.
- A follow-up appointment was scheduled for 30 days to monitor the patient's condition and adjust treatment as needed.
- Community nurses can play a crucial role in managing skin and nail dermatophyte infections, including onychomycosis, by addressing poor adherence and other possible causes of treatment failure, and suggesting lifestyle changes that reduce the risk of antifungal failure, infection, and relapse 6.