Dr. Sneha Mariam Varghese
Venereology
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Patient's Query
Hello doctor,
I have a severe pricking sensation between my toenails. I also have an itching sensation radiating up to my leg. Almost I feel like something is crawling up. I have been on oral anti-fungal Terbinafine for two months and also applying a topical anti-fungal. I see no changes in my symptoms. It is very irritating, and I see a small burrowing in between my cuticle. The itch aggravates while exposed to water, and there are no relieving factors. I sometimes wake up with a severe itch. I have been to the podiatrists and dermatologists here, and they cannot identify the problem. I am a known diabetic patient for the past 10 years, and I am on Metformin and Glipizide. Please let me know if you need more information.
Hello,
Welcome to icliniq.com. I understand your concern, and from your history, it looks like you could be having, 1. Fungal infection, which is having delayed healing due to prolonged uncontrolled sugar levels. 2. Scabies, which are unlocked as inter-toes, are the only sites with other typical areas uninvolved. 3. Cutaneous larva migrans, a parasitic infection. 4. Diabetic neuropathy. I needed to know a few things. Have you taken any dose of deworming medication? Is anywhere else on the body affected? Is the itching more prominent at night? Any history of prolonged exposure to water recently before the episode started? What are your present fasting and 2-hour post food sugar levels? Please give the complete list of medications you are taking at present. Kindly revert so that I can guide you accurately.
Patient's Query
Thank you doctor,
I took Albandazole two weeks ago for a day. I usually feel the irritation while my legs are resting. It is not really keeping me up at night. However, I can sometimes feel it moving up and biting my back area or sometimes on the upper portion of my leg. The last time I got exposed to water was while taking a shower about two weeks ago. I try my best to isolate my foot from getting exposed to water. My recent fasting blood sugar was 94, PPS- 160-180, HbA1c -7.9 % (these levels were reached after I started the oral Terbinafine. Before that, I was constantly at 6.5). I am currently on Januvia 100 mg (started recently after the HbA1c hit 7.9), Metformin 500 mg, Glipizide 10 mg, Levothyroxine 88 mcg, Calcium, Vitamin D3, Probiotics, Topical Terbinafine, and oral Terbinafine 20 mg for two months.
Hello,
Welcome back to icliniq.com. Your glycemic levels are not high enough for neuropathic pain, so it is unlikely. We have to rule out cutaneous larva migrans or scabies burrowing. Kindly do the following investigation. 1. Skin scraping from the area for culture and sensitivity to find any organism. 2. LFT (liver function test) (to see any variation in liver enzymes after prolonged Terbinafine intake). Follow the medications after giving for culture and sensitivity. 1. Permethrin 5% lotion once for two weeks. It should be applied on the same day, both weeks. Eg. if applied on Monday this week, then to be applied on Monday itself in the following week. 2. Ketoconazole soap for bath. 3. Continue oral Terbinafine if LFT is normal. 4. Continue Terbinafine cream. 5. Tablet Cetirizine 10 mg once daily at night for one week. Provided there is no prior allergy to any of the medications. Keep the area always dry. Avoid tight footwear or socks. Wear open footwear. Iron your clothes before wearing them to kill the fungal molds. Wash the area with lukewarm water. Frequent changing of bed linens and towels are a must. Do not share your items. Maintain good hygiene. Kindly follow up after two weeks of Permethrin, together with the culture- sensitivity report and LFT report.
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Venereology
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