Case Study 5

1. Case Study 5 68 year old man Self referral Reports unable to cut his toe nails because of thickness &shape

2. Further information • Medication: aspirin 75mgs, Cod Liver Oil, glucosamine • DP & PT palpable, no sensory impairment

3. Onychauxis – thickening of nail plate

4. Onychogryphosis– thickening of nail plate and lateral deviation of nail

5. Differential Diagnosis • Many possible causes – both systemic and local - of thickened and misshapen toenails.

6. Reactive Arthritis • Reactive arthritis: cod liver oil and glucosamine supplements indicate an arthritic condition. • Thickened toenails can be a symptom of reactive arthritis. • Reactive arthritis is a short-lived condition that is thought to be caused by a previous infection disrupting the normal workings of the immune system. Thickened toenails are a relatively rare symptom. More information from the patient concerning how long his arthritic symptoms have been present may indicate whether this is a likely cause.

7. Cardiovascular conditions • Cardiovascular conditions: 75mgs of aspirin daily is the dose used to treat or prevent heart attacks, strokes, angina and peripheral vascular disease. • Peripheral vascular disease (pvd) is narrowing due to atheroma of arteries other than those in the heart or brain. The arteries that take blood to the legs are the most commonly affected. • One symptom of the advanced stage of pvd is thickened toe nails. • This seems an unlikely cause of his thickened toenails as both dorsalispedis and posterior tibialis pulses are palpable. However, further information could be gained from the patient concerning whether he suffers from intermittent claudication.

8. Diabetic Neuropathy • Diabetic neuropathy: A diabetic's sweating mechanism is altered and as a result, dry, thickened toenails and cuticles can occur. • Thickened toenails can be a symptom of diabetic neuropathy. • This seems an unlikely cause as there is no indication of diabetes and furthermore there is no sensory impairment in the patient.

9. Onychomycosis • Fungal nail infection: • Onychomycosiscan cause a thickening of the nail plate • This cause cannot immediately be ruled out. Samples would need to be taken and sent to the lab for analysis. If found to be the cause, then an oral medication such as terbinafine or an anti-fungal nailpaint could be prescribed.

10. Psoriasis • Psoriasis: skin condition caused by rapid turnover of skin cells. In the toe nail, • psoriasis can cause thickening of the nail plate. • More information from the patient needs to be gathered concerning whether this condition is present in other areas of the body before this can be ruled out.

11. Pressure • Long-term pressure from shoes that are either too small or too narrow over the toes • can cause thickening of the toenails. • This is a likely cause. The patient’s shoes need to be examined for pressure marks both inside and outside of the shoe. It may be that a shoe with a deeper toe box needs to be worn in future.

12. Short term treatment plan • Thin down the nails using nail burr and file. • Examine footwear for signs of long term pressure and advise. • Offer advice for keeping nails short and thickness filed down. • Take clippings from nail to send for analysis to rule in/out onychomycosis. • Use information from patient to rule in/out likelihood of reactive arthritis and psoriasis. Possibly refer to his GP to check for peripheral vascular disease.

13. Long term treatment plan • Patient’s potential arthritis might mean that it is increasingly difficult to bend to cut his toe nails. For this reason, he may have to return every four to six week to have assistance in keeping his nails short and thinned down. • If results from clippings indicate onychomycosis, then patient will have to return to receive treatment and advice. • If the nails are so misshapen that thinning is not providing relief, then total nail avulsion may have to be considered.