7348 East Brainerd Road , Chattanooga, TN 37421, 423-760-3115

 423-760-3115

      When one hears the word "BIOPSY", visions of cancer cannot be avoided.  One thinks of breast biopsy, for example, and it is hard not to think of cancer as a possible finding.  In the foot, biopsy can take many forms.  There is biopsy of skin, biopsy of deeper soft tissue, fine needle aspiration of cysts and other fluid-filled masses, and in some cases bone biopsy.  Today - we are going to talk about the biopsy of the SKIN and other skin-like structures, such as NAIL or NAIL BED TISSUE.  While biopsy of the skin of the foot is done to rule out potential malignancies, such as basal cell carcinoma, squamous cell carcinoma, and malignant melanoma, there are many other reasons to biopsy.  

     Skin biopsy of the foot can be done to find out why the skin is discolored and/or dry and scaly.  Fungal infections, such as Athlete's foot, are often misdiagnosed.  A red, itchy, and dry/scaly area on the foot is not always fungus!   While dry and scaly red skin on the bottom of the foot, and extending into the web spaces (area between the toes) is probably fungal, there are other causes.  Bacterial infections can infect this area also.  Allergic reactions to things touching the skin (contact dermatitis), atopic dermatitis, psoriasis, eczema, and other non-infectious skin problems are much more common than fungus when the top, or dorsal aspect of the foot is involved.  Parasitic infections, including scabies and creeping eruption (larva migrans) can also cause severe itching, redness, and changes in the skin that may make one think there is a fungus.  Antifungal medications will have NO EFFECT on such conditions.  Making things even more interesting, it is possible to have a fungal infection between the toes that gets SECONDARY INFECTION with bacteria..  In this case, a culture of the drainage, along with a biopsy and/or culture for fungus is very beneficial.  A WOOD'S LAMP or ultraviolet light examination can also help. Skin biopsies in cases of red/itchy/dry skin can save the patient time and money in that a definitive diagnosis is made and there is usually no need to keep switching medications from antifungals - to steroids (cortisone type creams) - to another steroid - to a mixed steroid and antifungal.  You know which medication to use as soon as the biopsy report comes back.

   Skin biopsy can also be done to determine the diagnosis of a skin "tumor" when it is not certain by visually examining it, or when conservative treatment does not work.  Warts, for example, are very common on the bottom of the foot (PLANTAR WARTS).  These are often treated with cryotherapy (freezing), chemical cauterization with acid, electrical cauterization (Hyfrecation) or with a laser.  None of these, however, gives a specimen for microscopic examination.  If a wart-like lesion does not respond to these treatments, or it comes back again and again, a biopsy is indicated.  In many cases, sutures are not needed, expecially if the lesion is small.  Other things can look like warts - such as an IPK (very deep corn), porkeratosis (blocked sweat duct causing a wart like lesion), and foreign bodies (a small splinter or piece of glass can feel much like a wart).  Biopsy of one of these lesions is very helpful in determining the course of treatment.  If a lesion is treated as a wart, for example, and it is actually an IPK or corn, the problem will keep coming back because it is not a problem within the skin.  Such lesions are due to PRESSURE, and can be caused by a bone spur, accessory or extra bone, prominent metatarsal bone, or even the way the foot functions.  People with excessive pronation or flat feet often get a deep corn or IPK beneath the 2nd metatarsal head.  I have seen MANY cases where these were treated as warts - with freezing, acid, surgical removal, even skin grafting, and continual recurrence,  If the lesion had been biopsied, the microscopic exam would have shown that the layer of skin that is thickened is NOT what is seen with a wart, and that all of these treatments are futile.  Using a custom orthotic device or arch support would help to eliminate the pressure, and possibly eliminate the lesion altogether!  

    Bleeding under the nail - often referred to as "Tennis toe" and properly called a SUBUNGUAL HEMATOMA is a very common condition.  This is seen in very active people such as runners, tennis players, and other athletes.  It is due to pressure and friction of the nail against the nail bed or skin under the nail.  On the other hand, it can also be seen on older adults on blood thinners such as Coumadin or even aspirin.  A single traumatic event, such as dropping something on the toe, can also cause hemorrhage under the nail and it gets trapped and cannot come out.  The problem is that while 99+% of these "dark areas under the nail" are BLOOD, it is also possible to get a melanoma under the nail.  Melanomas are very serious, highly malignant lesions, typically non-painful, and cannot always be differentiated from blood just by looking at it.  Doing a punch biopsy, to remove a portion of the nail and some of the nail bed beneath it, is an excellent way to tell if the problem is just blood or a potentially fatal melanoma.  Nail unit biopsy can also be done in cases of suspected nail fungus, where the thickening and discoloration of the nail is not responding to medication, laser treatment, or other conservative measures.  Trauma to the nail can result in thickening and discoloration, and if there is no fungus present, topical antifungakl medication, oral antifungal medication, and laser will not work.  The nail may have to be removed.   I have also seen patients with psoriatic nails.  Psoriasis can cause abnormal looking toenails, and while they will often have "pits" or little holes in the nail, sometimes the nails just look thick and discolored with debris under the nails.  Some patients don't even know they have psoriasis, and again the use of medications for fungus will not help them.  Laser treatment may have some benefit in these patients, but they certainly will not respond the same way that fungus nails respond to laser. 

    Once again, biopsy of the skin on the foot can be used to confirm or rule out the presence of a malignant condition.  It must be understood however, that there are many other reasons that a biopsy of that thickened, discolored, dry, or wet skin or nail may be needed.  While most dermatologists, and many podiatrists do perform skin biopsy on the foot, this is one diagnostic tool that is NOT done often enough!   When the diagnosis of a skin or nail problem is questionable, or the problem just is not responding the way it should be responding, ask your doctor to do a biopsy.  

      

   

  Peripheral neuropathy, as we have spoken about before, is a gradual degenertaion or deterioration of the nerves, especially the small nerves of the feet.  It is most commonly seen in people with diabetes, but there are many other causes as well.  This can include idiopathic (where there is an unknown underlying cause, but many things have been ruled out), as a result of chemotherapy for cancer, vitamin deficiency (especially B12, although Thiamine and other vitamin deficiencies can also be to blame), heavy metal toxicity (mercury, lead, and even arsenic), and several others.  No matter what the cause of the neuropathy, the result is often the same.  There is usually numbness, tingling, pins and needles sensations, paresthesias (crawling sensations or other feelings of things that are not there), burning pain, sharp shooting electrical shocks, muscle abnormalities (causing hammertoes, change in muscle tone, muscle wasting, etc.), and autonomic changes (decrease in sweating, dry skin, discoloration, cold or hot feeling, etc.).  A person may have NONE or ALL of these findings.  Much of this will depend on how long the problem has been present (Diabetics, for example, may show no changes or have no symptoms at first, but the longer they are diabetic, the more of these problems may present themselves).  

   Once the diagnosis of peripheral neuropathy is confirmed, there are a number of treatment options.  Many drugs can be used to treat the symptoms of peripheral neuropathy.  The problem with drugs is that they just treat SYMPTOMS.  For the most part, these reduce the pain and burning, but really do little or nothing for the numbness or lask of sensation, which can be worse for the patient in the long run.  Narcotic medication is often the worst, because in addition to just masking the pain, the patient can suffer from sedation and constipation, and can, and often does, become addicted to the narcotic.  

     There are a number of vitamins that can help, and often help quite a bit, not only with the pain and burning of neuropathy, but also with the numbness and tingling that occurs.  These vitamins, in some cases, can actually result in the growth of new small nerve fibers within the skin.  One of these that has shown great promise is alpha lipoic acid.  Taking up to 600mg of this vitamin, up to three times per day, has often been shown to be beneficial in treating neuropathy in the diabetic patient, and the non-diabetic as well.  A lower dose is often advised to start with, and many pharmacies sell the vitamin in as low as 100mg.  B vitamins, such as B6, B9, and B12 have also shown beneficial effects in treating neuropathy.  A prescription medical food, known as Metanx, can also be prescribed if the over the counter vitamin therapies are not working.  One must understand, that none of these vitamin therapies will show results quickly.  A month is often the minimum amount of time needed to see any change at all, and in many cases it may take 2-3 months to see a significant improvement.  The advantage to using these vitamin therapies is that there are typically NO side effects, little or no drug interactions, and often the cost is significantly less.  In many cases, the beneficial effects of these can be measured OBJECTIVELY using an ENFD - or epidermal nerve fiber density test.  This is a skin biopsy, usually done just above the ankle, to measure how many nerve fibers are present within the epidermis (the outer layer of the skin) BEFORE the vitamins are prescribed, and can be repeated  AFTER (usually six months) treatment has been started.  This can often show a significant increase in the number or density of nerve fibers.

     In an upcoming blog, we will be talking about the use of LASER for peripheral neuropathy, another NON-INVASIVE treatment that is showing great results for a number of people with peripheral neuropathy.

 

Richard S. Eby, DPM

7348 East Brainerd Road

Chattanooga, TN.  37421

(423) 760-3115

www.rebyfootcare.com

By contactus@rebyfootcare.com
September 04, 2015
Category: Heel Treatments

  YES!  It is true.  There is a very good chance that if you have plantar fasciitis - the very bad pain on the bottom of the heel that starts hurting in the morning and acts up whenever you sit down and get back up on it - your pain will probably get better if you lose a little weight!  Now - by no means am I saying that ALL people with heel pain are overweight.  There are people who are very thin that have heel pain.  But the vast majority of people with pain on the bottom of the heel will see at least some pain relief, and many will see a LOT of relief, by losing a little weight.

   Plantar fasciitis is caused by a tightening of the ligament on the bottom of the foot that runs from the heel to the base of the toes.  When it becomes painful, it is due to a chronic inflammation, and sometimes small tears within that ligament or fascia.  Anything that causes more pressure on the foot - sports activities, long periods of walking or standing, flat feet, very high arch feet with weight concentrated on the heel, and excess weight - can make it worse.  While people of normal weight DO get heel pain, a large number of people where this condition is long-standing and very difficult to treat are...well...LARGE.  I once saw a woman get a single steroid injection into her heel, lose just 10 pounds (and the woman was just very slightly overweight to start) go for 14 YEARS without pain.  The really odd thing is that when she came back to me for a second injection, she said she had recently gained that weight back.  I've seen people have gastric bypass surgery after having uncontrolled diabetes, cardiovascular disease, AND heel pain - where after several unsuccessful to slightly successful treatments for heel pain LOST 80 to 100 pounds (and these were BIG people to start)...see their heel pain resolve COMPLETELY, the need for diabetic medication go WAY down or even eliminated.  Of course their blood pressure many times stabilizes as well.

A few years ago I bought an old house and decided I would "rehab" it.  That's basically fixing it up, and in my case spending more money on the supplies and labor than I did on the house!  To keep expenses from getting totally out of hand, I agreed to pick up some of the materials needed at Lowe's and Home Depot, and have them ready for the contractor to put in.  I have knee arthritis, so going up and down the 20 or so stairs at the front of the house was no fun anyway.  But just carrying cans of paint up those steps caused my knee pain to become excruciating.  If that wasn't bad enough, carrying kitchen cabinets up was even worse.  A few extra pounds made a hug difference in my knee pain, and it does the same to the heel.   

   Not every one will see heel pain resolve completely as a result of losing weight, but if you or someone you love has had heel pain for a year or more, it has not responded well to treatment, and you may just be carrying around a few extra pounds, give it a try!   Losing a little weight may just make a BIG difference in your level of pain.

 

Richard S. Eby, DPM

EbyFootCare

7348 East Brainerd Road

Chattanooga, TN.  37421

(423)760-3115

www.rebyfootcare.com

PODIATRIC MEDICINE is not often considered an "Alternative" healthcare field.  Recent advances in the treatment of foot and ankle conditions, especially those that have arisen out of technological advancements, have given birth to a whole new host of treatment options that can not be considered surgical, and certainly don't fit the usual definition of "medicine."  These include such modalities as SHOCKWAVE TREATMENT,  COLD LASER TECHNOLOGY, CLASS FOUR LASER TREATMENT, OZONE THERAPY,    NUTRITIONAL THERAPY,  NAIL LASER TREATMENT, PRP (Platelet Rich Plasma), and the list goes on!  

I am very happy to announce the premier of LASER FOCUSED FOOTCARE!  This is a Podcast I have developed to inform patients, prospective patients, and other interested parties about the many available treatment alternatives for foot and ankle pathology.  About once a week, I will discuss traditional, as well as "alternative", treatments for foot and ankle conditions.  I call it Laser Focused Footcare since  I have a profound interest in LASER therapy for pain and inflammation, as well as nail and skin conditions affecting the lower extremities.  I am developing and refining protocols for treatment of peripheral neuropathy using a combination of Cold Laser Therapy, Class Four Laser Therapy, and Vitamin/nutritional support.  This is a very innovative approach, and is DRUG FREE.    I still feel there is a place for TRADITIONAL therapies - and often write prescriptions for Gabapentin for neuropathy, NSAIDS for arthritis, give STEROID INJECTIONS for heel pain, and do BUNION SURGERY - when indicated.  I believe the public needs to be AWARE of all treatment options, educated on those options, and then make an informed decision.  Please join me by becoming a subscriber - SIGN UP IS FREE, but you need an iTunes account.   Once again - find my Podcast under Alternative Health - LASER FOCUSED FOOTCARE by Dr. Richard Eby.   Thanks for taking a step in the right direction!

Richard S. Eby, DPM

7348 E. Brainerd Road

Chattanooga, TN.  37421

(423) 760-3115

www.rebyfootcare.com

www.laserfocusedfootcare.com

By contactus@rebyfootcare.com
June 15, 2015
Category: Uncategorized

     A TAILOR'S BUNION is a bump on the outside of the foot (just behind the little toe).  It is an enlargement (either a truly enlarged bone or a relative enlargment) of the head of the fifth metatarsal bone.  There are five metatarsal bones, one behind each toe.  The heads, or ends of these bones make up the "ball" of the foot.  A bunion is an enlargrment of the first metatarsal head, often accompanied by a turning or shifting of the big toe towards the smaller toes.  A TAILOR'S BUNION Is basically the reverse.  The fifth metatarsal head is enlarged, and the little toe often moves in toward the other toes.

     Tailor's Bunion deformity is also sometimes called a "bunionette" and may be an actual enlargement of the bone (where the head is larger on the outside) or a "relative enlargmenet."  This means the fifth metatarsal may not actually be bigger, it may just look bigger because the entire fifth metatarsal is deviated OR there may be a bend or splaying of the fifth metatarsal.  In other words, the bone may be normal at the base, near the center of the foot, but there may be a bend in the bone causing it to bow outwardly.  The name "Tailor's Bunion" is one case where the deformity is NOT named after a doctor, as many deformities or surgical procedures are named.  Instead, it is called a TAILOR'S Bunion, because years ago, people who tailored clothing sat barefoot in a crossed leg position.  This put pressure on the side of the little toe, causing it to push in, and causing back pressure on the fifth metatatarsal pushing it out.  

    Treatment for a tailor's bunion is usually surgical.  While no treatment may be needed if there is no pain, ulceration, or other associated deformity, in many cases there is pain over the "bump."  In mild cases, an ostectomy or removal of just the "bump" can be performed.  This is in those rare cases where the bone is actually enlarged and there is little or no deviation or bend in the bone.  In most cases, an osteotomy is needed.  Defined sometimes as a "surgical fracture", an osteotomy is when a cut is made in the bone, the head (containing the "bunion") is moved in (closer to the fourth metatarsal) and held in place with a pin, screw, or other form of fixation.  In very severe cases, where the entire fifth metatarsal is out of position, it may be necessary to make the bone cut at the base of the bone.  In older individuals, patients with diabetes and ulcerations that may not be candidate for an osteotomy, the entire fifth metatarsal head can be removed.  This is not advisable for young, healthy individuals, as the cosmetic result is often not as good, and it is possible to regrow the bone. 

      Conservative treatments for this condition are not often effective long-term, but can include padding, wider shoes, injections of steroid solutions into the soft tissue (bursa) which may be inflamed and painful, the use of oral anti-inflammatory medications, and orthotic devices (especially if pain is plantar or on the bottom of the foot rather than just the side).  

      Tailor's bunion deformity is a common condition.  The condition may or may not be painful, and treatment is usually dependent on the severity of the deformity and symptoms.

 

 

Richard S. Eby, DPM
EbyFootCare and Laser Center

7348 East Brainerd Road'

Chattanooga, TN.  37421

(423)-760-3115

www.rebyfootcare.com





This website includes materials that are protected by copyright, or other proprietary rights. Transmission or reproduction of protected items beyond that allowed by fair use, as defined in the copyright laws, requires the written permission of the copyright owners.