Healthy Feet & Lower Legs - dermatologyupdate.com · Dorsalis Pedis or Posterior Tibialis 23 Check...
Transcript of Healthy Feet & Lower Legs - dermatologyupdate.com · Dorsalis Pedis or Posterior Tibialis 23 Check...
Healthy
Feet & Lower Legs
R. Gary Sibbald, MD, M.Ed, D.Sc (Hons), FRCPC (Med, Derm), FAAD, JM
Professor of Public Health & Medicine
University of Toronto
Director of International Interprofessional Wound Care Course & Masters of Science - Public Health (Prevention & Wound Care)
Clinical editor Advances in Skin & Wound Care
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Dr. Sibbald’s Potential Conflicts of Interest:Unrestricted educational grant from Valeant Pharmaceuticals
to develop the Healthy foot ScreenClinical Editor- Advances in Skin & Wound Care
Company/ Agency Paid Lecturers
Advisory Board Members
ResearchParticipants
Systagenix/ Acelity √ √ √
Mölnlycke √ √ √
RNAO- Registered Nurses Association of Ontario
√ √
Galderma √
Leo √
Hollister √ √ √
Health Point/ Smith & Nephew √ √
Valeant √ √ √
Abbott/ Abbvie √ √ √
MH-LHIN, MHLTC, HQO = Province of Ontario Government
√ √
Eli Lilly Canada Inc. √
Ferris Manufacturing Comp √
Objectives
Participants will:
Discuss the
Simplified 60 sec. screen for high risk diabetic foot
Promote foot health
Review the development and
validation of a quick efficient
foot screen for all patients
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Focus on Prevention:
60 Second Screening
•History
•Inspection - abnormalities
•Palpate pulse
•Deformity
•Monofilament testing
(4 out 10 negative)
After Inlow 60 sec exam
Available at www.diabeticfootscreen.com
www.WoundPedia.com
• Any 1 positive result indicates high risk status
→ patient referred to diabetic foot centre for
follow up, education on foot care and foot
wear, and plantar pressure redistribution as
necessary
• Adopted by the Ministry of Health for use
throughout Guyana, South America
& around the world through the
IIWCC
Tool for High Risk Diabetic Foot: Validation & Clinical Pilot: Simplified 60 Second Diabetic Foot Screening ToolM. Gail Woodbury, R. Gary Sibbald , Brian Ostrow, Reneeka Persaud, Julia M. Lowe
Published: June 29, 2015-Open Access- Impact Factor 10.14
Major Amputations at Main Referral Hospital, Guyana
Risk Months Mean
St.
dev
95%
CI T test
Before
DFC 42 7.95 3.99 1.24 P <
0.0001After
DFC 42 4.14 2.36 0.73
48% reduction from pre-project levels
48 limbs saved each year =
192 limbs to July 2012
68% reduction in monthly proportion of DFU
despite 75% increase in DFU admissions
Lowe, Sibbald. Ostrow et al. PLOS Med April 2015Open Access IF= 10.14
PLoS Med. 2015 Apr; 12(4):
The Guyana Diabetes and Foot Care Project
Why is Foot Health Important?
75% of populations will experience foot pain
The foot contains 26 bones, 133 joints, 107 ligaments, and 19 muscles
The average wear and tear on a foot is equivalent to the distance a person covers in a lifetime, which is about 115,000 miles.
Physical ailments can first manifest in the foot:
diabetes
arthritis
peripheral vascular disease
cardiac disease
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http:// www.wellnessmag.com/
article/feet-how-important-are-they
A foot out of alignment cam result in discomfort
and pain to the foot, ankle, knee, hip, and back (e.g. Reflexology)
Why
• 90% of patients are not people with diabetes – some are and not yet diagnosed!!
• Produce a simple and rapid-to-use clinical screening tool
• Detect common foot abnormalities, including onychomycosis
Study Design
• Develop, pilot, validate and produce a novel foot screening tool
• Methodology based on criteria for reliability testing of Donner and Eliasziw (1987)
& principles similar to those in Woodbury et al. (2015); a pilot
& validation study of a novel simplified 60-second foot screen
Development and validation of a
healthy foot screening tool8
• Donner, A. and Eliasziw, M. (1987), Sample size requirements for reliability studies. Statist. Med., 6: 441–448. doi:10.1002/sim.4780060404
• Woodbury MG, et al. Tool for Rapid & Easy Identification of High Risk Diabetic Foot: Validation &
Clinical Pilot of the Simplified 60 Second Diabetic Foot Screening Tool.
• Santanelli, di Pompeo d’Illasi F, ed. PLoS ONE. 2015;10(6):e0125578. doi:10.1371/journal.pone.0125578.
Elements of the Healthy Foot Screen
1. Known diabetes mellitus type 1 or 2 (perform simplified
diabetic 60-second screen)
2. Smoking status
3. Symptoms of neuropathy (perform simplified diabetic 60-
second screen)
4. History of previous foot ulcer or amputation
5. Signs of toenail fungal infection or inflammatory changes
6. Abnormal toe webs
7. Bottom of foot dry
8. Significant bony abnormality
9. Foot pulse palpable
10. Pitting edema of feet/ankles
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Global Diabetes Tsunami10
IDF Atlas 5th edition diabetes
prevalence (age 20-79)
Guyana
South
America
15%
Year Persons with Diabetes Comment
2011 365 million • 4.6 million DM related deaths annually
• Spending on DM 465 million US
2030 552 million • 50% increase
• Additional 398 million at high risk
75% of people with diabetes now live in
low-and middle-income countries
4th leading cause of death
1. Known diabetes type 1 or 2
Higher Incidence of Gangrene + Foot Ulcers
in Patients with Diabetes and Onychomycosis
1% 2.2%0.6%
4.8%6.2%
1.2 %0
1
2
3
4
5
6
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Gangrene Foot Ulcer Gangrene + Foot Ulcer
Incid
en
ce
(%
)
Without Onychomycosis With Onychomycosis
1.Doyle J, Boyko W, Ryu S, Gause E.. Diabetes. 2000;49(suppl 1): A195-A196.
Onychomycosis Increases Risk of
Developing the Diabetic Foot
International Diabetes Federation. Clinical Practice Recommendation on the Diabetic Foot:
A guide for health care professionals : International Diabetes Federation, 2017.
2. Smoking status
Smoking = Double indemnity
“Every cigarette will decrease the circulation in
the leg or foot up to 30% for an hour or
increase sympathetic” tone for 8 hours”*
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*Cigarette smoking decreases tissue oxygen. –
Jensen JA - Arch Surg - 01-SEP-1991; 126(9): 1131-4
3: Neuropathy
Contextualize Answer: Consider investigations/ patient counselling
Burning, stinging, shooting or
stabbing in either feet
Simplified 60 second screen should be performed in any
person with neuropathy
Symptoms of neuropathy- Consider:
• Diabetes
• B12 deficiency
• Trauma• Thyroid disease
• Toxins- Environmental, Chemotherapy
• Cancer- Growth impinge on nerves
• Kidney disease
Idiopathic
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Types of neuropathy:
Sensory- loss of protective sensation (LOPS)
Autonomic- dry plantar surface, not mocassin
Motor- absent or diminished reflexes
4. History of previous ulcer or amputation
1. Previous Ulceration 2. Previous Amputation
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Indicate a high-risk foot – requires intervention
5. Signs of toenail fungal infection or
inflammatory changes
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Distal and lateral
subungual
Proximal
subungualTotal dystrophic
onychomycosis
Dermatophytoma
Mild Moderate Severe
Photos AK Gupta
Superficial white
onychomycosis caused
by nondermatophtytic molds
Classification of onychomycosis
Inflammatory
changes:
E.g. due to trauma,
psoriasis,
lichen planus
Tinea Investigations
Scraping or nail clipping for KOH examination or
culture and sensitivity
Scraping from the edge of the lesion
Clipping should include the subungal debris
About 20% falsely negative
Reasonable to perform 3 cultures before classed as negative
Can order 1%-1.5% hydrocortisone powder in antifungal cream twice
daily while waiting for the results
(order 100 gms)
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Diagnosis of Onychomycosis confirmed by:
- 1 positive microscopic result for at least 1 toenail + clinical presentation
AND/OR
- Positive culture for fungus
Mycological Cure Rates (Pooled Data)18
55% 54%
70-80%
36%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Week 48
Pro
po
rtio
n o
f Su
bje
cts
Efinaconazole
Itraconazole
Terbinafine
CiclopiroxEF INECO
NAZOLE
CICLOPIRO
X
ITRACONAZO
LE
Sporanox (itraconazole) [package insert]. Janssen Pharmaceuticals Inc, Titusville, NJ; 2012.
Lamisil (terbinafine HCl) [package insert]. Novartis Pharmaceuticals Corporation, East Hanover, NJ; 2012.
Drake LA et al J Am Acad Dermatol 1997;37:740-5
Westerberg DP, et al. Am Fam Physician. 2013;88(11),
TE
R
B
I
N
A
F
I
N
E
Topical Oral Oral Topical
Pathway to the Prevention
and Treatment of Toe Onychomycosis
Detail: III Treatment strategies
1. Elewski B, et al. J Am Acad Dermatol 2013;68(4):600-8
2. Gupta AK, et al. J Drugs Dermatol. 2014 Topical efinaconazole = Jublia, Valeant
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6. Abnormal toe web spaces
4th – 5th toe web
space is most
common site for moisture retention resulting
in skin breakdown; all toe
webs should be checked
If dry, scaly: think fungus
If wet, macerated: think secondary bacterial
infection
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© Sibbald 2012
7. Dry foot
Important to diagnose cause
of dryness
Dryness of foot in a
Moccasin distribution: dryness
extends to sole, heel and sides of
foot - think fungus
Dryness on plantar surface of foot
alone – think neuropathy
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Hammer Toe –
proximal interphalangeal
joint down
Hallux valgus (Bunion)Claw Toe-
metatarsal phalangeal joint up
and interphalangeal joint down
8. Bony abnormalities + associated changes
(pressure, shear/friction)
• Flat foot: loss of plantar arch
• Callus: hyperkeratosis over a pressure point
• Blister: over area of friction or shear
9. Palpable foot pulse
Dorsalis Pedis
or
Posterior Tibialis
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Check the posterior tibial
if dorsalis pedis is negative
http://www.gla.ac.uk/ibls/US/fab/tutorial/generic/sapulse.html
Vascular Supply & Healing Ability
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Palpable Pulse ** >80 mm Hg
Ankle-brachial
pressure index
(ABPI)
>0.5 and <1.3
Audible Hand
Held Doppler
Alavi, Sibbald et.al 2015
Biphasic,
Triphasic
AHHD ABPI > 0.9
Toe pressure >55 mm Hg
Dilated saphenous vein
Superficial varicosities and varicose veins
Lower leg edema
Pigmentary changes of distal leg
Woody fibrosis
Lipodermatosclerosis
Progression of Venous Disease
10. Pitting edema of the foot or ankle?25
Other lesions: Red areas/ blisters or pustules
on the foot
Types of lesions Examples of common abnormalities
Red areas/ blisters or
pustules on the foot
Any change that the
evaluator is unsure of the
diagnosis should trigger
a biopsy referral or
therapeutic trial
Inflammatory
conditions
Infections
Benign Lesions
Pre-malignant /Malignancy
Psoriasis
Dermatitis
Lichen PlanusGouty Tophus
Plantar Fasciitis
Cellulitis
Plantar Warts
Corn or clavus
Morton’s Neuroma
Benign Stucco keratosis (SK)
Actinic keratosis (AK)Cutaneous horn
Basal Cell Carcinoma
Squamous Cell Carcinoma
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• Protocol development and ethics submission
• Preliminary draft of healthy foot screen developed
• Planning committee meeting with interdisciplinary wound care experts & sponsor
• Working draft of healthy foot screen developed
Validation day – 18 patients screened by 11 assessors
Fungal scrapings & bacterial swabs
Feedback from assessors & round table discussion – revised version of screen
• Statistical analysis - reliability scores
• Items with < 0.6 reliability score removed from screen
• Final draft of healthy foot screen produced for piloting
• Piloting of healthy foot screen on 120 patients over 2 months
• Final working version of the healthy foot screen will be produced
Development and validation of a healthy foot screening tool
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Data analysis
28Data entered in SPSS Cronbach’s alpha calculated
Elements with < 0.6 reliability score were removed from screen (highlighted)
Healthy foot screening tool
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Conclusion
A healthy foot screening tool will enable clinicians, especially primary care providers, to identify common foot problems (onychomycosis, infection/ inflammatory lesions, bony abnormalities, vascular insufficiency, etc.)
Early diagnosis and treatment can prevent amputations & result in improved patient quality of life & optimize resource allocation
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My grandchildren
Sophie Grace’s first dress-
6 weeks old
A good big brother
Sophie Grace and Luke Gary
Parking lot 32
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Onychomycosis Is a Common Nail Disease
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6.5
0
10
20
30
40
EstimatedOnychomycosis
Population
Office Visits Diagnosed Patients
Millio
ns
Source: Scott-Levin PDDA. MAT October 2002.
Photograph: collection of A Gupta
Differential Diagnosis of Onychomycosis
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• Disease at other sites
• Nail ridging
• Splitting or thinning
• Loss of nails• Proximal pterygium
Lichen Planus
Eisman et al. BMJ. 2014;348:g1800.
Trauma Image: Alex Lozupone
Afifi et al. Can Fam Physician. 2005 Apr;51:519-25.
American Academy of Dermatology National Library of Dermatologic Teaching Slides.
Psoriasis
• Subungual hyperkeratosis
• Oil drop sign
• Splinter hemorrhages
• Nail pitting
• Psoriatic plaques
• Leuconychia
Trauma
• Abnormal nail
plate shape
• Distal onycholysis
• Often single nail
affected
• Uniform colour
change
Objectives
Participants have:
Discussed the Simplified 60 sec.
screen for high risk diabetic foot
Examined promotion of foot health
Reviewed the development and
validation of a quick efficient foot
screen for all patients
Explored clinical opportunities to
implement foot screening
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Other lesions: Red areas/ blisters or pustules
on the foot
Types of lesions Examples of common abnormalities
Red areas/ blisters or
pustules on the foot
Any change that the
evaluator is unsure of the
diagnosis should trigger
a biopsy referral or
therapeutic trial
Inflammatory
conditions
Infections
Benign Lesions
Pre-malignant /Malignancy
Psoriasis
Dermatitis
Lichen PlanusGouty Tophus
Plantar Fasciitis
Cellulitis
Plantar Warts
Corn or clavus
Morton’s Neuroma
Benign Stucco keratosis (SK)
Actinic keratosis (AK)Cutaneous horn
Basal Cell Carcinoma
Squamous Cell Carcinoma
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