Tuesday, November 2, 2010


Dyshidrosis is a disorder of the skin that is characterized by small blisters on the hands and/or feet. It is also known as pompholyx, podopompholyx, cheiropompholyx, acute vesiculobulbous hand eczema, and dyshidrotic eczema.

Most commonly the condition presents on the fingers and toes, in particular it may be present on the lateral sides of the digits. Dyshidrosis is a pruritic, or itchy, condition, particularly when it is located on the sides of the digits. It typically begins as a number of small, tense blisters, which are deep seated in the skin. Over time these small blisters may coalesce into larger blisters, but do not commonly rupture. However, if the vesicles do rupture, this may lead to secondary bacterial infections.

It was previously believed that dyshidrotic eczema was caused by faulty sweat glands, which led to the name “dyshidrosis”. However, this hypothesis has been refuted due to the evidence that shows that the vesicular lesions are not in fact related to the eccrine sweat glands.

It is commonly accepted now that dyshidrotic eczema is a multifactorial disorder, which is commonly related to other skin conditions and precipitating factors. In particular, atopic diathesis (such as hay fever, eczema, asthma, and allergic sinusitis) has been shown to be present in as many as 50% of patients with Dyshidrosis.

While excessive sweating may not cause it, dyshidrosis has historically been linked to an excessive output of sweat. However, cases reported of dyshidrosis without hyperhidrosis (excessive sweating) dispute the causation. It is possible that dyshidrosis is linked to anxiety, stress, and frustration, which may cause outbreaks or exacerbate the symptoms.

An association with nickel sensitivity has also been reported. Systemic exposure to high levels of nickel may be from foods that are high in nickel, such as cocoa, chocolate, whole grains, and nuts. Diets that restrict intake of these foods have been shown to reduce the number of outbreaks of dyshidrotic eczema.

Chemical and mechanical irritants have also been indicated as a cause of dyshidrotic eczema outbreaks. This may include things such as keeping the hands and feet damp, using strong soaps or detergents on the hands and feet, exposure to latex or other materials that cause documented allergic reactions, such as bandages, skin tapes and plasters. Dyshidrosis may also be seen in correlation with fungal and/or bacterial infections of the feet. There has also been a well-documented inheritance pattern and genetic predisposition to dyshidrotic eczema.

Dyshidrotic eczema is diagnosed by first ruling out a number of other possible diagnoses. This may include infection, allergic reaction, blistering disease such as pemphigus vulgaris, and a number of other dermatological conditions.

Treatment of dyshidrosis is largely symptom based, and many cases will clear spontaneously within several weeks. Topical steroids are often used to reduce itching, and oral steroids are occasionally used in cases of intense outbreak. When blisters are present, draining of the blisters may be appropriate, as well as using compression bandages with drying agents such as Burow solution. A number of other treatments have been used experimentally, such as Botox injections, UV-A light therapy, Nickel chelators, and a number of oral medications.

Other therapies include diet modifications to avoid exacerbating foods, as well as behavioral modifications to avoid irritating substances. Allergy testing may be indicated for patients with a known or suspected allergy to certain substances.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.Winter Haven, FL 33881
Phone: 863-299-4551

Monday, September 27, 2010

Nail Changes in Systemic Disease

(Hutchinson’s Sign in melanoma)

An important aspect of the clinical exam for podiatrists is the careful examination of the toenails as well as the fingernails. A variety of systemic diseases can appear in both the hands and feet, and analysis can often lend itself to revealing an underlying systemic condition. The following is a brief list of some of the changes to the nail and fingers and toes, as well as the underlying conditions associated with the changes.

  • Nail Clubbing – This is a condition that is caused by a thickening of the soft tissue beneath the proximal portion of the nail plate (the area closest to the knuckle, or the distal interphalangeal joint). A specific finding of nail clubbing is to put the two index fingers next to each other, with the nails facing each other. If the distal interphalangeal joints of the two fingers touch, and the distal end of the nails do not come in contact with each other, it may indicate clubbing of the digits. Nail clubbing is most commonly associated with pulmonary disease, such as emphysema, cystic fibrosis, lung abscess, pulmonary fibrosis, and bronchogenic carcinoma. It is also commonly seen in inflammatory bowel disease, celiac disease, and cirrhosis of the liver.

  • Nail Pitting – Most commonly associated with psoriasis, nail pitting is a series of small, punctate depressions in the nail. It is caused by a defect in the layering of the nail plate as it grows out of the nail matrix. Nail pitting may also be seen in systemic diseases such as Reiter’s syndrome, connective tissue disorders, sarcoidosis, and pemphigus. A localized dermatitis may also cause nail pitting, if it disrupts the normal growth of the nail plate.

  • Koilonychia – Also termed “nail spooning”, koilonychia gives the nails a spoon-like appearance, with a central depression of the nail plate. It may be due to repeated chemical exposure or trauma to the nail, but is also associated with a variety of systemic conditions. Hemochromatosis and iron-deficiency are two of the conditions that the clinician should be suspicious of when koilonychia is found. Koilonychia can also be a normal variant in the infant child, which usually resolves with age.

  • Onycholysis – This is a separation of the nail plate from the underlying nail bed, most commonly at the distal end of the nail, and usually caused by trauma, warts, onychomycosis, or as a finding of psoriasis. However, in the absence of these explanations, it may be associated with hyperthyroidism. When onycholysis is seen in hyperthyroidism, the condition is termed “Plummer’s nails”.

  • Leukonychia – Any whitening of the nail in a random, non-linear pattern may be termed leukonychia. It is a very common finding in the nails of both children and adults. Many people will have several white spots on one or more nails, that grow out with time. These are benign lesions that are of no consequence, are believed to be caused by random microtrauma to the nail matrix. A whitening of one or more nails in a linear fashion that parallel the lunula (the half-moon shaped lighter portion at the proximal end of the nail) may indicate a number of systemic disease, and should be evaluated by a physician.

  • Longitudinal Linear Lesions – Darkened lesions that run longitudinally along the nail should always be shown to a clinician. Benign lesions must be distinguished from melanoma, which can be seen growing underneath the nail plate. Unexplained darkening in a longitudinal pattern along the nail plate should be considered malignant until proven otherwise with a biopsy.

This is simply a brief listing of some of the changes seen in the nail and surrounding tissues associated with a variety of systemic diseases. Always let your doctor know of any recent changes to your nails.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551

Friday, August 6, 2010

Dog Eats Toe, Saves Owner’s Life

Strange news from Grand Rapids, Michigan today as a Jack Russell terrier saved its owners life after gnawing off the man’s big toe.

Yes, you read that correctly.

Forty-eight year old Jerry Douthett’s dog, Kiko, sniffed out an infection that had been growing in Jerry’s toe for several months. The wound had been the result of a small sliver that Douthett had attempted to remove himself by cutting at it with a knife. What ensued was a serious infection that would swell greatly over time, and eventually would spread to the underlying bone.

Douthett’s wife, a registered nurse, recognized the infection as possibly related to diabetes, and urged her husband to seek medical attention. After weeks of delay, Jerry would finally be forced to heed this advice.

The canine-amputation resulted in a hospital visit that would uncover Jerry’s type II diabetes, as it was undiagnosed at the time. Doctors removed what was left of the gnarled and infected toe at the hospital.

Kiko had been sniffing at the wound for quite some time, but was finally able to rid his owner of the infected toe when Jerry came home from a bar. Jerry had drank several beers and margaritas, and fell fast asleep upon arrival. Jerry would wake up later to a missing toe and pool of blood in his bed.

"The toe was gone," said Douthett. "He ate it. I mean, he must have eaten it, because we couldn't find it anywhere else in the house. I look down, there's blood all over, and my toe is gone."

What Kiko was able to sniff out is unfortunately a fairly common situation in the diabetic foot. A loss of pain sensation in diabetic peripheral neuropathy can allow someone to have a serious foot infection without much pain. This is also what would help Kiko chew off the toe without causing too much pain. Combined with the diminished immune system of the diabetic patient, this sets up a dangerous situation.

Now that Douthett is out of the hospital, he has sworn off drinking and is trying to take better care of his health. This starts with working to control his diabetes.

For diabetic patients, it is crucial that they check their feet for open wounds or areas that look like the skin is breaking down. These areas can quickly become infected. For a person with diabetes, something as simple as a hangnail could turn into a big problem. Jerry Douthett learned this in a difficult way.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551

Thursday, July 22, 2010


Rickets is a softening of the bones in a child, sometimes referred to as childhood osteomalacia. It is caused by a decrease in calcium absorption, most commonly due to a decrease in activated vitamin D.

Vitamin D is an essential component of calcium metabolism in the body. Activated vitamin D allows for the absorption of calcium from our diet. Without it, much of the ingested calcium in our diet passes through the intestines without being absorbed and utilized by the body.

The activation of vitamin is a complex reaction that is activated by UV light, in particular UV-B from the sun’s rays. A certain amount of exposure to sunlight is required to generate activated vitamin D everyday. In an adult, it takes approximately 15-20 minutes of direct sunlight on non-protected fair skin to generate approximately 10,000 IU of vitamin D everyday.

In children, however, the amount of time required to activate an appropriate amount of vitamin D is unknown and is difficult to measure. Factors such as age, skin tone, body mass, geographical location and season will all play a role in altering the total. In children, 400 IU of vitamin D are required daily to prevent Rickets and to maintain a healthy level of calcium in the body. It has been shown that children with darker skin pigmentation may require 5-10 times as much sunlight exposure as fair skinned children to activate the daily requirement of vitamin D.

Children aged 3-18 months are at a particularly high risk for the development of rickets, because their bones are growing rapidly at this point in development. High risk groups include children that are strictly breastfed, children with darker skin pigmentation, and children with very limited exposure to sunlight.

In developed countries like the United States, the incidence of Rickets is extremely low (approximately 1 in 200,000 will develop the condition). However, in the developing world, it remains as one of the more common conditions attributable to malnutrition. A lack of vitamin D in the diet is to blame; foods rich in vitamin D include eggs, butter, fish liver oils, fortified milk, and oily fishes such as tuna, herring and salmon.

Symptoms of rickets are due to a lack of calcium, most notably the skeletal deformities that result from the softening of the bones. This includes the classic bow-legged appearance of the tibia and femur, cranial and spinal deformities, and costochondral swelling (swelling along the ribs at their attachment with the cartilage, also known as “rachitic rosary”). Other symptoms include muscle weakness, growth disturbances and failure to grow, dental problems, bone pain, and an increase risk of fractures.

The Indoor Air Quality Act of 1989 reported that Americans spent roughly 93% of their day indoors, which only further compacts the problem of limited sunlight exposure and the development of rickets. Due to the modern lifestyle of developed countries, as well as campaigns to limit sun exposure due to its influence on developing various forms of skin cancer, it is predicted that the incidence of rickets may rise in the future. This has already been observed in Western countries.

Treatment of rickets may be multi-faceted, but includes supplementation with activated vitamin D as the mainstay. Increased exposure to sunlight may be recommended in some cases, though the risk of skin cancer from over-exposure warrants a word of caution. In cases where skeletal deformity has developed, accommodative bracing, orthotics, and other devices may be used.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551

Tuesday, March 16, 2010

Ingrown Toenails

Ingrown toenails can be an excruciating experience. They happen when the nail grows into the skin around the toe, and can lead to a tremendous amount of pain, or even infection.

The best way to avoid getting an ingrown toenail is to cut your nails straight across, without rounding off the corners. When the corners of a toenail are trimmed, they have a tendency to grow back into the skin.

If you have diabetes, nerve damage to the legs and/or arms, or are otherwise prone to infections, do NOT try treating an ingrown toenail yourself. This can lead to serious complications. If you fall into this category, you should consult with your podiatrist or primary physician immediately.

If you’ve got an ingrown toenail and it’s starting to turn red, or if there is pus coming out of the skin, it is most likely infected already. In this situation, your doctor may prescribe antibiotics, as well as trim out the offending nail border. This can be done in several different ways.

Often, a podiatrist may cut out the entire border of a nail. This is especially done in situations where an ingrown toenail is a recurring event. By removing the entire border of the nail, the chances of the nail growing back into the skin are very low.

When the entire border of the nail is to be removed, your doctor will first numb the area with a local anesthetic. This is to ensure that you have no pain during the procedure. The procedure is fairly quick, and it involves cutting into the nail and removing a small piece.

The root of the nail is often removed as well. The idea behind removing the root of the nail is that this is where the nail grows from. If the root of the nail is gone, then the nail will not be able to grow into the skin. Thus, the problem of the ingrown toenail is solved.

Many people have a problem with recurring ingrown toenails. The key is to prevent infection. Infection of an ingrown toenail is known in the medical community as a paronychia. Paronychia is usually a problem that will go away with treatment, but can evolve into a more complicated situation if left untreated. This is particular true in someone with a compromised immune system, such as a diabetic patient.

In the diabetic patient, the immune system is not functioning at full capacity. The same may be true for patients that are on oral steroids for rheumatoid arthritis or other systemic disease. For these patients it is especially important to seek treatment right away.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551

Thursday, January 7, 2010

Varicose Veins

Podiatrists are known to treat the foot and ankle and leg. To the average person, it seems like the typical problems a podiatrist is limited to are bunions and warts. The common conception is that their expertise is confined to the foot in the areas of the muscle, bone and skin.

However, podiatrists are well-versed in many aspects of the foot, ankle and leg – nervous system disorders, musculoskeletal pathologies, dermatopathologies and vascular anomalies! Varicose veins are one such anomaly that is quite common in the population.

What are veins? Veins are a type of blood vessels that take the blood from different parts of the body TO the heart. They only function in ONE direction. The one-way direction is due to the one-way valves that are within the vessels. Varicose veins arise when the valves are malfunctioning. When a valve stops working properly, blood which was destined to the heart starts to flow back towards the legs (or other extremities). The blood is now going in the opposite direction it was supposed to be going! As a result of this backward blood flow, pressure in the veins starts to rise and causes varicose veins! Varicose veins are essentially veins that are receiving so much pressure that the start to expand and engorge. The elastic properties of the vein allow for it to expand due to pressure and it thus it protrudes out of the skin.

There are a variety of risk factors which can cause the veins to start swelling due to the pooling of blood.

A. Family history is one factor – you may genetically have valves that are incompetent;

B. Occupation – standing on your feet for greater periods of times increases venous pressure

C. Obesity

D. Pregnancy

E. Age – with increased age, vessel function starts to deteriorate

Varicose veins are not usually painful but you may feel a deep ache in the area. Swelling and discoloration may also be noted in the area of the engorged veins. The color starts out reddish and may turn to brown with time. The most common complaint is the fact that these veins just look ugly! If untreated, skin erosions can occur; this may progress to venous stasis ulcers which have a poor ability to heal! If you find that you do have varicosities, don’t hesitate to see your podiatrist! They have the knowledge and expertise to guide you to a solution and prevent this medical condition from becoming worse!

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551

Tuesday, January 5, 2010

Small Girls and Tall Heels!!

Every little girl has tossed on a pair of her mom’s high heels, doused herself in red lipstick, put on a string of pearls and topped off her ensemble with a floppy oversized hat! It is one thing to play dress up; however, it’s another thing when infants or little girls are seen wearing high heels for any period of time!

Many women are already well-aware of the damaging effects of heels on the feet. Heels themselves are a hazard for walking because they alter your center of gravity. In addition, all of your body weight which is meant to be distributed evenly across your feet is now on the ball of your foot. The ball of your foot is not designed to bear your weight and does not function well in terms of shock absorption. So the impact of the forces from the ground and the body weight from above leading to pain called metatarsalgia!

Other conditions that can occur with heels are Morton’s neuromas, corns, calluses, bunions, and hammertoes. The damaging effects of heels are not just limited to feet either! Heels affect your posture by pushing your hips and spine out of alignment! The knees are also prone to injury because heels place additional force on the inside of your knee! The calf muscles may shorten and tighten as a result of excessive contraction needed to adjust to the angle of high heels.

Many podiatrists are concerned with the advent of celebrity moms dressing their children in high heels and being seen in public. High heels are ill-advised in adults and the implications on children can be even more devastating. The bones of a child are not yet fully-formed or fully-calcified; bone formation in the foot in particular partly relies on how the forces are transmitted. The wearing of high heels alters these normal forces and can affect the normal ossification pattern of the bones! And remember, foot problems will not be the only problems that will arise from wearing high heels too early. Knee, hip and back problems can occur due to the change in the body’s center of gravity as a result of high heels. These are not problems young children should ever have! One way to AVOID these musculoskeletal problems is to delay wearing heels as long as possible! Talk to your podiatrist about the implications and possible complications of wearing high heels at any age!

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551