Surgical removal of nails and some peculiarities of complex treatment of destructive polyonychomycosis complicated by secondary nail ingrowth in patients with type 2 diabetes mellitus

Abstract

Dermatophytes infecting matrix provoke dystrophic changes in nails and form subungual hyperkeratosis and dermatophytome which compress a toenail. It is a key pathogenetic link of secondary ingrowth that influences therapeutic tactics, particularly, necessity of surgical removal, choice of enzymatic therapy with serratiopeptidase in complex treatment. This type of therapy is characterized by high fibrinolytic, anti-inflammatory and anti-edematous activity in comparison with other proteases. Type 2 diabetes mellitus commonly involves background insulin resistance, hyperglycemia, endothelic dysfunction, disturbance of coagulative blood properties that indicate chain relationship of cause and effect. The aim of the work: to elaborate optimal succession of complex treatment, surgical removal of nails, local and systemic therapy after removing damaged nails in destructive onychomycosis complicated by secondary nail ingrowth in patients with type 2 diabetes mellitus with mycotic damage of nails. The study involved treatment of 62 patients (48 males and 14 females aged 42-65) with type2 diabetes mellitus throughout 10 years (2005-2015). Systemic therapy with itraconazole was applied before and after surgical treatment (debridement of main onychial damages). The complex treatment involved administration of serratiopeptidase to 25 patients with subungual hyperkeratosis associated with nail ingrowth. The patients with type 2 diabetes mellitus (main group and comparison group) with polyonychomycosis and trichophytic subungual hyperkeratosis and secondary nail ingrowth experienced considerably decreased NOMA-index of b-cells function and increased NOMA-index of insulin resistance. Onychectomy and marginal matrixectomy were performed by mechanical cutting and diathermocoagulation and further curettage with Folkman spoon. Simultaneously, dermatophytome and hyperkeratoid layers on nail bed were removed. Sanation of other nails was performed with ciclopirox-containing lacquer for prevention of mycotic re-infection. Systemic enzymatic proteolytic therapy with serratiopeptidase significantly improved primary results of subungual hyperkeratosis complex treatment. It decreased perifocal swelling and inflammation; stimulated necrolytic and reparative processes in the operated wound that was clinically manifested by increased granulation and epithelization; increased healing of the wound surface; decreased duration of temporary disability. The applied complex treatment may be indicated for severe resistant cases of dermatophytic polyonychomycosis with subungual hyperkeratosis and secondary nail ingrowth, particularly in patients with type 2 diabetes mellitus.