August 2017 - Volume 30 - Issue 8

  • Richard "Sal" Salcido, MD
  • 1527-7941
  • 1538-8654
  • 12 issues per year
  • 1.088

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Original Investigations

Clinical Management Extra

Welcome to Wound Clinical Solutions Investigation (CSI). See if you can make the diagnosis.

Q.  A 52-year-old male patient with a history of diabetes presented to the clinic with friable hypergranulation tissue and bleeding from the side of his big toe. What's the diagnosis?

 CSI photo 6-30-17.jpg

A. This is an ingrown toenail, or onychocryptosis, which usually involves the great toenail. This condition is characterized by the corner or side of the nail plate growing into the periungal skin.  Eventually, puncturing of the soft flesh can result in pain, redness, swelling, bleeding, and infection. 

What causes an ingrown toenail?  There are several factors that are thought to be the cause of onychocrytosis, including:

  • Genetic predisposition: Ingrown toenails tend to run in families.  Some people are born with congenital misalignment of the big toenail rendering the nail discolored, thickened, triangular, and oyster-shell like. 
  • Inappropriate nail care:  Cutting the toenail too short and tapering or rounding the corners of the nail to make it follow the curvature of the toe tend to promote the shrinkage of the distal nail bed. This limits the space for the regrowing wide nail and encourages the nail to grow into the skin.
  • Excess moisture: Individuals with hyperhidrosis and those who sweat when exercising may have excess moisture in the toe area.
  • Inappropriate footwear: Wearing shoes or socks that are too tight puts pressure on the nail and forces it to grow into the skin.
  • Repetitive trauma: Activity that injures the nail, such as kicking a soccer ball or hitting the pedals during driving, may contribute to an ingrown nail.

The severity of ingrown toenails is categorized into 3 stages: Stage 1 is characterized by erythema, slight edema, and pain. Stage 2 involves more severe symptoms and formation of granulation tissue.  In Stage 3 (shown above), abscess formation, chronic induration of the lateral nail fold, and nail fold hypertrophy, are evident along with other coexisting symptoms.

How should an ingrown toenail be treated?

The scientific evidence for the treatment of ingrown toenails remains scarce and somewhat controversial.  All in all, partial nail avulsion followed by either phenolization or direct surgical excision of the nail matrix seems to be the most effective treatment. Phenol is a chemical cauterant that also has antiseptic and local anesthetic activity.  Other nonsurgical options are used widely but their effectiveness is inconclusive:

  • Packing using wisps of cotton or dental floss to place under the ingrown lateral nail and lift the nail off the skin.
  • Taping using tapes to pull the lateral nail fold away from the lateral nail edge.
  • Nail braces are designed to flatten the nail.
  • Foot hygiene: Keep the feet clean and dry.
  • Footwear adjustment to prevent pressure to the nail.
  • Nail care: Trim the nails no shorter than the edge of the toe and gently file any sharp edges with a nail file.







Modulator for Macrophages Identified

Diabetic foot ulcers are very difficult to heal due to poor blood circulation, neuropathy, and other risk factors. Macrophages are essential for tissue repair and they play a key role in the normal wound healing process maintaining a balance between inflammatory and anti-inflammatory reactions (pro-reparation). Canadian researchers affiliated with the University of Montreal Hospital Research Centre discovered a way to modify macrophage behavior to promote anti-inflammatory and pro-reparatory reaction by means of a special protein called Milk Fat Globule Epidermal Growth Factor-8, or MFG-E8.  The researchers developed a treatment by adoptive cell transfer using a patient's own cells, which are harvested, treated, and re-injected to exert their action on an organ. This immunotherapeutic has been shown to also be useful in reprogramming cells to facilitate healing of the skin.


Parasite Tested for Wound Healing

Scientists from the Australian Institute of Tropical Health and Medicine (AITHM) are testing a molecule, granulin, produced by a Thai liver parasite, Opisthorchis viverrini, for the treatment of chronic wounds.  The researchers worked to establish which parts of the molecule were critical to wound healing, and to find a way to reproduce the active parts of granulin molecules (peptides).


Histone Deacetylase Proteins Inhibitors for Healthier Skin

Psoriasis is one of the most common skin disorders, characterized by red, flaky patches on the body. Histone deacetylase (HDACs) proteins inhibitors, already widely used to treat cancer, may be an effective therapy for psoriasis. The HDACs are a class of enzymes that remove acetyl groups (O=C-CH3) from an ε-N-acetyl lysine amino acid on a histone, allowing histones to wrap DNA more tightly. They have shown that HDAC3 inhibitors help increase expression of aquaporin-3, or AQP3, a channel that transports glycerin, a natural alcohol and water attractor that aids healthy production and maturation of high-turnover skin cells by producing phosphatidylglycerol.  Since the immune system is believed to play a key role in psoriasis, many current treatments generally suppress the immune response, which increases the risk of infections, even cancer. In the future, scientists hope they can directly enhance the presence of AQP3 and commensurate increase in glycerin.


MicroRNA Inhibitors Investigated as Local Therapeutic Agents

MicroRNAs are interesting target structures for new therapeutic agents. They can be blocked through synthetic antimiRs. However, to date it was not possible to use these only locally. Researchers at Goethe University Frankfurt have successfully used light-inducible antimiRs for the treatment of wound healing. MicroRNAs are small gene fragments that bond onto target structures in cells and prevent certain proteins from forming. As they play a key role in the occurrence and manifestation of various diseases, researchers have developed what are known as antimiRs, which block microRNA function. The disadvantage of this approach is, however, that the blockade can lead to adverse effects throughout the entire body since microRNAs can perform different functions in various organs. Researchers at Goethe University Frankfurt have developed antimiRs that can be activated very effectively over a limited local area by using light of a specific wavelength. To this purpose, the antimiRs were locked in a cage of light-sensitive molecules that disintegrate as soon as they are irradiated with light of a specific wavelength.  The researchers injected the antimiRs in the light-sensitive cage into the skin of mice and then released the therapeutic agent into the tissue with the help of light. They were able to prove that pinpointed activation of an antimiR against microRNA-92a helps wounds to heal.


Bacteria-fighting Ingredient Found in Crustaceans

A research team at Lodz University of Technology in Poland has developed a hydrogel dressing that can speed up aspects of wound healing by incorporating antibacterial and biodegradable substance called chitosan, extracted from the shells of crustaceans, within the dressing itself.  The extraction process involves isolating a substance called chitin that is found in the shells.  The resulting chitosan is useful to stop bleeding and has been known for its antimicrobial properties for decades.


Thrombin Used for Wound Healing

The researchers from Lund University in collaboration with researchers in Copenhagen and Singapore have discovered that fragments of thrombin, a common blood protein found in wounds, can aggregate both bacteria and their toxins. The aggregation of bacteria and endotoxins takes place quickly in the wound and removed by the body's inflammatory cells to minimize the spread of infection.


Selective Nonoperative Management of Abdominal Gunshot Wounds

Selective nonoperative management (SNOM) of abdominal gunshot wounds is safe and avoids unnecessary laparotomies that may minimize postoperative complications. This is an alternative for less severe injuries that do not involve any major organ damage or significant blood loss.  Analysis of data from the Research Consortium of New England Centers for Trauma (ReCoNECT) indicated SNOM patients had significantly lower rates of complications (8.5% vs 34.7% for patients who underwent an operation) and death (0.5% vs 5.2%), and shorter stays in the intensive care unit (median of 0 days vs 1) and hospital overall (median of 2 days vs 8).