Subungual ulceration of the 1st toenail successfully treated with Activon Tube
Introduction
A female patient aged 62 presented at the podiatry clinic with an infected lysing 1st toenail which was extremely painful. It had been exudating for two months and was slightly malodourous. The patient had seen the GP who had prescribed a seven day course of flucloxycillin . There was one day remaining of the antibiotic, which at this point, had not resolved the infection. The patient could not recall any trauma so it was assumed that the cause was footwear related. She was particularly anxious about the toenail because she was booked to go on a beach holiday with her granddaughter in a few days and thought she may not be able to go.
The patient had a history of venous ulcers, presenting at the initial assessment with a healing ulcer on the right medial leg. The reason for these had not yet been established because the leg was too painful when the GP tried to perform an APBI. A doppler test revealed extremely rapid but biphasic pedal pulses on both feet and sensations were intact. The patient was prescribed amitriptyline for back pain and trazadone for depression. She was otherwise in reasonably good health.
Treatment
The toenail was removed to approximately 5mm still attached at the base which exposed a subungual lesion with pyogenic granulomas and thick sloughy tissue. It was too painful to debride the slough so a decision was taken apply Activon Tube with a dry sterile dressing on top and to refer the patient back to the GP surgery for a swab as the flucloxycillin had not resolved the infection. The patient was advised to keep pressure off the toe and keep the dressing dry and intact until her appointment.
Result
The Practice Nurse saw the patient at 9.30am and called me afterwards to report that the wound was almost dry, there was no infection and no slough present and she could barely obtain any exudate for the culture. The pyogenic granulation had subsided. It may well be that the antibiotics had kicked in but this would probably not have removed the slough or reduced the pyogenic granulation so quickly. It was concluded that the Activon Tube had contributed to what was undoubtedly a remarkable recovery.
Outcome
The patient was discharged with some advice about footwear and prevention and was delighted as she was assured that she would most certainly be able to swim in the sea with her granddaughter.
Discussion
The cause of the venous ulcers remains to be investigated. No advice was given with regards to treatment as the GP surgery was dealing with this issue.