Mìžnarodnij Endokrinologìčnij Žurnal (Nov 2016)
Onychogryphosis Complicated with Ingrown Toenail in Patients with Diabetes Mellitus Type 2: Features of a Comprehensive Surgical Treatment and Deviations of Certain Laboratory Parameters
Abstract
Background. The pathogenetic links leading to increased risk of occurrence and development of feet mycosis and onychomycosis in diabetic patients include the cardiovascular and nervous system pathology, glycolysis disorders, resulting in lower energy supply of skin cells and changes in metabolism, skin dysfunction, determining rapid progression and chronic mycosis. Objective: to research certain peculiarities of mycosis-associated pathology and treatment, including surgical removal of nails for patients with onychogryphosis and recurrent ingrown with underlying diabetes mellitus (DM). Materials and methods. During five-year period we examined and treated 38 patients with onychogryphosis. The paper provides the research of the features of the pathological process to create the optimal scheme of complex treatment of patients with abnormal ingrowing of the nail plate with underlying diabetes mellitus type 2. Surgery was performed in 23 patients (14 males and 9 females aged 55–80 years old) with ingrown onychogryphosis and underlying diabetes mellitus, diabetic micro- and macroangiopathy (prospective material, treatment group), and onychogryphosis and recurrent incarnation of toe nail (hallux) and multiple destructive mycotic lesions of other nail plates of both feet. Other 15 people with onychogryphosis of the toe (hallux) and fungus of other nails were included into the control group. The duration of clinically-manifesting nail mycotic process in all studied cases exceeded 5 years. Results. On one side the subungual hyperkeratosis and dermatophytosis caused compression of the central part of the nail, epionychium edges ingrew to periungual walls thus recurrent ingrown nail was formed; on the other side, constant compression caused destruction of the central part of the nail bed; this process is typical for 32 (84.32 %) cases. Conglomerate of nail plate and subungual hyperkeratosis and trichophytosis calcinated completely, forming onychogryphosis with deformation and recurrent nail ingrowth. Mycosis-associated acute purulent pathology was confirmed for 13 patients of treatment group (34.21 % of the total sample; 52 % cases) and, respectively, for 5 patients of control group (13.16 % of the total sample; 30 % cases). Systemic adjuvant pulse therapy with 400 mg itraconazole was applied during two days till the initial surgical treatment and during the first three days of the postoperative period. Remediation of other affected nails in order to prevent mycosis reinfection was carried out with ciclopirox lacquer. Removal of other nails affected by hyperkeratosis with trichophytosis was performed through onycholysis by separate successive stages where certain pulses of therapy were supported with itraconazole. Significant decrease of HOMA-index of β-cell function and increase of HOMA-index of insulin resistance (9.51 ± 1.9 in treatment group and 4.12 ± 1.12 in the control group; p < 0.01) were detected for patients with type 2 DM (treatment group) with multiple onychomycosis and trichophytosis onychogryphosis, with recurrent incarnation of the nail edge. Elevated total cholesterol over 5.18 mmol/l was detected for all patients of the basic group, i.e., 7.28 ± 0.07 mmol/l, and 5.45 ± 0.12 mmol/l for the half of the control group; there is also confirmed the deviation of laboratory parameters of low and high density lipoprotein cholesterol. Conclusions. We believe that preference should be given to less traumatic removal of nails through onycholysis, particularly after such treatment the diabetic patients had healing time of operative wound (crust formation) equal to 16–23 days (average healing duration was 19 days) and had the indices approaching to those in the control group; indices in the patients with diabetes mellitus and classical nail removal (onicectomia) were 24–30 days (average healing duration was 26 days), indices in the control group were 14–22 days (average healing duration was 18 days).
Keywords
