What is the best course of treatment for a 54-year-old diabetic male patient presenting with onychomycosis (fungal infection of the nail) of the right big toenail, subungual hematomas (bleeding under the nail) of the right and left 3rd toenails, and an old bloody blister on the right big toe?

From the Guidelines

The best treatment for this 54-year-old diabetic male with multiple foot conditions requires a comprehensive approach, prioritizing the prevention of foot ulcers and management of existing conditions to reduce morbidity, mortality, and improve quality of life. For the onychomycosis of the right big toenail, oral terbinafine 250 mg daily for 12 weeks is recommended as first-line therapy due to its superior efficacy and shorter treatment duration compared to alternatives 1. This should be accompanied by topical antifungal nail solution (ciclopirox 8% or amorolfine 5%) applied daily to the affected nail. For the subungual hematomas of the 3rd toenails, conservative management is appropriate if they're not causing significant pain, including elevation, ice application, and acetaminophen for discomfort. The old bloody blister on the right big toe requires gentle cleansing with mild soap and water, application of an antiseptic solution like povidone-iodine, and covering with a sterile dressing changed daily.

Given the patient's diabetic status, a podiatry referral is essential for professional nail care and regular foot examinations to prevent complications, as emphasized by the guidelines on the prevention of foot ulcers in persons with diabetes 1. Blood glucose monitoring should be maintained throughout treatment, as diabetes can impair healing and increase infection risk. Proper foot hygiene, including keeping feet dry, wearing breathable footwear, and daily inspection for new lesions, is crucial for preventing recurrence and complications in diabetic patients. The patient should be educated on the importance of protecting their feet, washing them daily, and examining them for any signs of ulcers or infections, as recommended by the guidelines 1.

In terms of footwear, the patient should wear shoes that accommodate the shape of their feet and fit properly, and consider using orthotic interventions or extra-depth shoes if necessary, as suggested by the guidelines 1. The use of CeraVe cream for diabetic foot care is also recommended, as it can help to keep the skin moisturized and prevent dryness and cracking. Overall, a comprehensive approach that includes medical treatment, podiatry referral, proper foot hygiene, and patient education is necessary to manage this patient's conditions and prevent future complications.

From the Research

Treatment Options for Onychomycosis

The patient presents with onychomycosis of the right big toenail, subungual hematomas of the right and left 3rd toenails, and an old bloody blister on the right big toe. Considering the patient's diabetic condition, it is essential to manage the onychomycosis effectively to prevent further complications.

• Oral antifungal agents such as terbinafine and azoles have been shown to be effective in treating onychomycosis, with high-quality evidence supporting their use 2.
• Topical antifungal applications, including nail drilling, can also be effective in managing onychomycosis, especially in patients with superficial white onychomycosis or distal-lateral subungual onychomycosis 3.
• Foot care intervention, including daily checks and regular nail care, is crucial in preventing the progression of onychomycosis and reducing the risk of complications in diabetic patients 4.

Management of Subungual Hematomas

Subungual hematomas can be painful and may lead to further complications if not managed properly.

• The patient's subungual hematomas should be monitored closely, and the patient should be advised to avoid putting pressure on the affected toes.
• Topical applications, such as CeraVe cream, can help to keep the skin and nails moisturized and promote healing.

Importance of Foot Care

Regular foot care is essential for diabetic patients to prevent complications such as foot ulcers and gangrene.

• The patient should be advised to check their feet daily for any signs of injury or infection and to seek medical attention immediately if they notice any changes.
• Regular foot care, including nail care and moisturizing, can help to prevent the progression of onychomycosis and reduce the risk of complications 4, 3.