Bullosis diabeticorum: a treatment conundrum

Bullosis diabeticorum is an infrequent but significant complication of diabetes Mellitus most commonly affecting the hands and feet. These rapidly developing bullous lesions mostly occur in patients with long standing diabetes and neuropathy. The pathophysiology of this condition remains unknown. Despite reasonably low rates of occurrence this complication potentially has significant and serious ramifications for foot health and creates a treatment conundrum. This case study demonstrates the serious nature of seemingly innocuous presentations in management of the diabetic foot. A 76-year-old man presents to the high-risk foot clinic for treatment of a suspected Charcot foot. He has a complex medical history, which includes Type 2 diabetes, hypertension, congestive cardiac failure, hypercholesterolemia, and Gastro-esophageal reflux disease. The patient undergoes various testing to aid in diagnosing a Charcot foot, such as skin temperature testing, X-ray and bone scans. Fortunately he was not diagnosed with a Charcot foot. During a routine follow-up consult he presents with clear, serous filled blisters which have spontaneously appeared. They are in non weight-bearing areas, and the patient does not recall any trauma to the area. The blisters appear consistent with bullosis diabeticorum. There are no set criteria for appropriate treatment of blistering in these cases. Treatment options were to either leave blisters intact or de-roof them, and their treatment raises many questions. Intact blisters were left intact to maintain a sterile field; broken blisters were de-roofed to prevent infection as per normal protocol for any form of blister management. The healing outcomes were compared, with no significant difference noted. However, after healing was achieved, the patient returned to the clinic, weeks later, with another episode of blistering. The patient recalled a similar history to the first episode, with no traumatic injury to the site, and the blisters occurring overnight. The same treatment protocol was followed. However, on this occasion, the blisters did not heal as successfully, and the patient developed osteomyelitis, and subsequently suffered multiple digital amputations as a result. This case demonstrates that successful wound care can be difficult on a patient with diabetes and associated complications, such as neuropathy, peripheral vascular disease, and an increased susceptibility to infection

Partial nail avulsion: habit or evidence based?

Onychocryptosis is a relatively common condition that can cause significant pain and discomfort. Partial nail avulsion (PNA) with phenolisation is a straightforward procedure performed by podiatrists on a daily basis. The procedure has shown a high rate of efficacy and low recurrence rate, and can be performed on high risk patients with close post-operative monitoring and those with concomitant infection. PNA with phenolisation of the nail matrix is a non-invasive procedure that does not require the use of an operating theatre and can be carried out in the podiatrist’s rooms. Pre-operative measures do need to be taken, a local sterile field should be set up and the toe and forefoot should be scrubbed. Once the procedure has been completed healing can be expected in 4-8 weeks. The PNA procedure has been taught to undergraduate podiatrists since the late 1970’s and has developed many small variations in how the procedure is carried out. Variations vary from pre-operative management (type of antisepsis used), phenolisation time (reported to be between 1 to 5 minutes), type of post phenol irrigation (saline, isopropyl alcohol or no irrigation) and post-operative dressing regimen. These variations however are usually operator dependant and based on personal experience. Post-operative management of PNA wounds have attracted a lot of interest, with the use of different dressings (provodone-iodine impregnated gauze and paraffin gauze) and topical medicaments (manuka honey, intrasite gel) aimed at increasing the healing rate and reducing the rate of infection, but quantitative analysis of the colonisation of the wound bed shows a bacterial count of zero after the use of phenol. The case of the phenolised wound is an interesting one, an acute wound that heals by secondary intention and freely discharges for 2-4 weeks postoperatively. After the application phenol and the destruction of all microbiological matter the post-operative focus should be in nurturing the recolonisation of the nail bed. Wounds that have a high as well as a low bacterial count have been shown to have an effect healing rates, but no studies have investigated the microbiological behaviour of a phenolised PNA wound