Toenail onychodystrophy of the diabetic foot

Description

A 54-year-old diabetic female patient with type 2 diabetes of 7 years’ duration presented with pain in her big toe. She had previously sustained foot ulceration several times and hence worried for recurrence. On examination she had a laminated, thickened, dark yellow toe nail of an extremely rare structure (figure1).

Figure 1.

Laminated, thickened, dark yellow toe nail.

Onychodystrophy, which is a widely used term referring to nail deformities, has historically been linked with several genetic syndromes.¹ Additionally, it may be associated with fungal and nonfungal infections, various non-infectious inflammatory dermatological diseases, benign and malign neoplasms and systemic drug use.² None of these conditions was present in our patient. Onychodystrophy is also common among diabetic patients with poor peripheral circulation and/or peripheral neuropathy. It may have severe implications in the diabetic foot and may be the initial cause for several wounds.³ Excessive thickening and deformities of the nails may result in an accumulation of debris beneath the nail which may predispose to bacterial growth. Additionally improper shoes may press on the nails and may become the site of ulceration following repeated microtrauma. Once onychodystrophy occurs, it is rather challenging to manage these deformities. Hence, the care of toe nails in the diabetic foot is as important as any other aspects involved in ulceration. Close follow-up and timely interventions may prevent the occurrence of such deformities.

Learning points.

• Toe deformities may be the initial cause for several diabetic foot wounds.

• Toe care is as important as the care of the rest of the foot in diabetic patients.