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Greenbrae, CA 94904


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Tune in to hear from our doctors, Dr. Anthony Fedrigo and Dr. Oendrila Kamal about the latest and most up-to-date information about all things related to foot and ankle and sometimes life in general.  


By Foot and Ankle Specialists of Marin, Feb 19 2016 08:52PM

The third condition we see in the winter is something I like to classify as cold induced tissue trauma. This can be from extreme frostbite, which is uncommon in Marin County, to chilblains (pernio), to Raynauds Syndrome. Frostbite and Chilblains is from overexposure to cold for a prolonged period of time and can lead to very serious tissue loss.

Raynaud's Syndrome is a cold induced vasospasm of the small arteries that go to our fingers and toes. Several patients a year come to our office with the complaint of color changes or wounds on the tips of their toes. Unlike overexposure to cold, Raynaud’s happens when the temperatures drop, but the patient is wearing shoes, socks and warm clothing. Patients often notice color changes first in their fingers. The fingertips around the nail, or up to the first or second knuckle will turn white. This can last for several minutes. Then the fingers turn bright red followed by a bluish/purple color. The physiology behind this is what is called a vasospasm. As the blood leaves our core, it cools as it moves into our arms and legs. The cold blood and cold temperatures can cause the arteries to spasm in some people. As this happens the blood vessels clamp down, and less blood flows to the skin and the skin blanches and turns white. As metabolites build up in your tissues, mainly nitric oxide, the blood vessels dilate. Sometimes they dilate so much that you get a rush of blood back into the body part and the skin turns bright red. As the blood rushes in, the venous system gets overloaded and venous congestion develops causing the tissues to turn blue. The problems arise during the blanching phase of Raynaud's. As the tissues are “starved of blood,” inside of that harsh shoe and sock environment, tissue damage begins to occur from rubbing and friction. The longer the vasospasm, the higher the risk of worsening tissue damage. Patients often come in with wounds on the plantar fat pads of their toes with no known cause of trauma. The surrounding skin will have a mottled red, purple appearance. With a careful history, the patient will describe color changes they have noticed in their fingers, which goes unnoticed in their feet in closed shoes.

Treatment for Raynaud’s Syndrome is tailored first to prevention. Keeping your extremities warm is the key. Not only hands and feet, but arms and legs. I tell my patients you need to wear long underwear, long Johns or leggings to keep the blood warm as it moves from your trunk to your feet. The same goes for the upper extremity. You need to insulate those arms and legs and protect from the cold. Patients with severe Raynaud’s often have vasospasms even in warm weather. Patients that have severe Raynaud’s are often treated with oral nifedipine, a vasodilator used to treat high blood pressure. The effect of nifedipine, helps prevent the arteries from spasming. It is very important to treat any wounds that form from the tissue trauma. This can be as simple as covering the wound with a topical antibiotic and a large sterile dressing, to more advanced wound care techniques which we perform at Foot and Ankle Specialist of Marin.

So to recap. Keep your feet clean and warm, but dry, all Winter long, and remember… Spring is coming.

Dr. Anthony Fedrigo

By Foot and Ankle Specialists of Marin, Feb 17 2016 08:45PM

The second condition we see in winter is Onychomycosis, aka: Toe nail Fungus. While treating skin is relatively easy, treating toenails is much more difficult. When the skin is wet, fungal infections spread from the skin to the nails. Do you see a theme here? Fungal infections are moisture driven. The main reason we develop toenail fungus is trauma. Inside a shoe and sock all day is a very harsh environment. The trauma to our skin and toenails makes us susceptible to fungal infections. The toenails are particularly prone to fungal infections because of this. Shoe trauma to the nails causes the toenail plate to move and shift on top of the nail bed. What I mean by trauma, is just daily shoe wearing. Not acute trauma like dropping a frozen Thanksgiving turkey on your toe. As the trauma occurs the toenails lifts off the nail bed, and those pesky dermatophytes find their way under your toenail. At first you may just notice some thin white or yellow streaks at the tips of your toenails. Sometimes the streaks will be along the nail groove where the skin meets the side of the toenail. As it progresses, you start to see yellowing, thickening, and sub-ungual build up under the toenail. As you build up more dissolved skin, nail and fungal elements under the nail plate, the nail can start to change shape and the nail may take on a more curved appearance. I often have patients ask if they should try and clean this out from under their toenails. The answer is no. As you use an instrument to clean under your toenails, you not only lift the nail plate more, helping the fungus get further underneath, you also push these microscopic organisms further and further under the toenail plate. This is a common problem with patients that get regular pedicures. Watch for our summer time blog on how to avoid these common problems from pedicures.

The difficulty in treating toenails, unlike skin, is the slow growing nature of toenails. A toenails takes 9-12 months to grow from start to finish. Typically the fungus grows faster. So even though you produce perfectly sterile healthy toenails, as they grow out, the fungus in the toenail continues to reinfect the healthy toenail. As a result, there are very few topical treatments to clear your toenails of a fungal infection. All of the products over the counter may help, especially if treatment begins very early in the course of the infection, but for the most part, I tell my patients we are hoping for controlling the spread, not curing the condition when using an over the counter topical treatment. And I have heard of just about every topical home remedy from Clorox to Vics Vapor rub, to oregano oil, to grapefruit seed extract oil, and white vinegar to listerine to being applied on the nails. You name it, someone has tried it. That goes to show you how common onychomycosis is in the population.

Now this takes us to medical treatments. In my opinion there are only two options for cure. The first is a prescriptions topical that is relatively new on the market called Jublia (efinaconazole). The other is a prescription oral antifungal called Lamisil (terbinafine). Jublia is applied daily for 11 months. Remember how slow toenails grow. When applied daily, Jublia acts as an external barrier to prevent further fungal infections of the nail plate. Once a week I recommend patients cut and file away any loosely attached nail. The goal of Jublia is to apply it to the remaining healthy nail by removing the infected damaged toenail.

Lamisil is an oral antifungal medication available only by prescription. Lamisil is taken once daily for 90 days. Before you start the medication you need to get a blood test to check your liver enzymes. Even though the risk of liver involvement is very low, a baseline liver function test (LFT) is recommended. At the end of your 90 day course of Lamisil your toenails will not look any better =( . It takes another 6 to 9 months for your nails to clear up. Again the reason, slow growing toenails. On the other hand, fingernails grow almost twice as fast as toenails. So if you want to have great looking toenails by summer, Winter is the time to start treating your toenails

Dr. Fedrigo

By Foot and Ankle Specialists of Marin, Feb 16 2016 07:20PM

Part One:

Winter is well under way in most parts of the country, although in California right now we have a high of 72 degrees! But in the rest of the country, winter can be especially hard on your feet. At Foot and Ankle Specialists of Marin, we don’t see as many of the common summertime injuries such as puncture wounds, plantar fasciitis and other barefoot trauma, but we do see increased fungal infections and cold induced tissue trauma during winter.

With cold weather many people wear thicker socks and warm boots. This leads to increased moisture in the shoe and sock which translates to moist skin. The human foot has more sweat glands per square inch of skin than any other part of your body. Your feet are designed to perspire. Whether you notice it or not, feet perspire. When there is more moisture against your skin, there is more fungal and bacterial growth. These microorganisms are responsible for a whole host of problems, as well as most of the odor from our feet and other parts of our bodies. Unfortunately you can never cleanse your body entirely of these organisms. Dermatophytes (Derm=Skin, Phyte=”Plant” or fungus) are a group of 4-6 different fungal species that live on ALL human skin. You can never avoid these organisms. They are always present in low numbers on our skin. We never really know they are there until we get some type of skin or nail change that alerts us to their presents.

One of the easiest way to avoid fungal infections of the foot is to keep your feet clean and dry. Athletes Foot, or Tinea Pedis, develops when the feet are in a moist environment for a prolonged period of time. During the winter we often see more athletes foot than in summer. The reason is not only the warm socks and boots, but also from wearing socks to bed at night. Many people have very cold feet and it is difficult to sleep when your feet are cold. The simple solution is to sleep with socks on. As a side note, having cold feet does not necessarily mean poor circulation. As long as you have strong pulses in your feet, the coldness is not likely from circulatory compromise. Your Podiatrist can further assess this and we will discuss more cold feet conditions below. Sometimes cold feet are just cold feet. Unfortunately sleeping with socks on leads to more perspiration during the night, and more fungal growth on the skin. You may not notice it the first few night, but after a couple of night of wearing socks, you may start to notice redness and itching between your toes or on the soles of your feet. Patients will often wear the same pair of socks for several nights in a row. People believe that since you are not wearing the socks in your shoes, the socks don’t get that dirty. True they may not get dirty, but you keep increasing the fungal load in the sock every night. Then when you put your foot into the sock with a high fungal load, you get a massive exposure to a large amount of fungus. Often people will wake up at night with extreme itching and redness on their feet.

So, the obvious solution? Don’t sleep with socks on. If you need to warm your feet before you go to bed, put a clean pair of socks on before you get in bed so your feet have time to warm up. Then before you go to bed, remove the socks and put them in the dirty cloths hamper. If you develop some redness, itching or peeling skin on your feet and toes, start using an antifungal cream right away. Fungal skin infections, when treated early, clear easily since we make skin rapidly. In about a months the skin you are looking at will be replaced. That is why most over-the-counter antifungals recommend treating your skin for about 6 weeks. Patients always ask if they need to treat their athletes feet since it doesn’t really bother them, and often times it doesn’t even itch. Well the reason I recommend treating athlete's feet is because the breakdown of the skin from the fungal infection can lead to a secondary bacterial infection. Bacterial infections are much more invasive and aggressive, often leading to deep space infections and wound formation. If this occurs you need to get medical treatment immediately and start an antibiotic to prevent a worsening infection.

Dr. Fedrigo

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