Priority 22 from the Foot Health PSP

UNCERTAINTY: How are common nail and skin foot infections caused, diagnosed and treated? How can they be prevented?  (JLA PSP Priority 22)
Overall ranking 22
JLA question ID 0092/22
Explanatory note Many people that provided raw uncertainties that underpinned this researchable question were concerned about common foot infections most notably fungal nails. Whilst there is some high quality evidence to support the use of terbinafine in the management of fungal nail /skin infections and some moderate evidence to support the use of salicylic acid preparations in the management of verrucae, for many people they have tried these interventions and have perceived little to no success in the long term. Longer term research is required of a higher quality to establish why the current evidence based treatments are not effective for many patients, what the alternative treatments should be and to understand the education that people need to help self-manage / prevent such infections.                                            

CD001781 – Kwok et al (2012). Topical treatments for cutaneous warts. Modest therapeutic outcome for the use of Salicylic acid over the use of cryotherapy, no advantage of duct tape over placebo. V little evidence for the effectiveness of lesser used agents and poor quality of studies.    CD003584 – Bell Syer et al (2012). Oral treatments for fungal infections of the skin of the foot. Evidence suggest terbinafine more effective than griseofulvin and terbinafine/itraconazole more effective than no treatment. But more reliable data is required over follow up period greater than 6 months                                 
CD010031 – Kreijkamp-Kaspers et al (2017). Oral antifungal medication for toenail onychomycosis. High quality evidence for the use of terbinafine/azoles compared with placebo, terbinafine has a greater effect than azoles.Low quality evidence suggests terbinafine may reduce recurrence rates. 

Health Research Classification System category Generic health relevance 
Extra information provided by this PSP
Original uncertainty examples How are some foot problems diagnosed without any swabs or tests e.g verruca? ~ I have a hard patch on the underside of my foot and has been treated as if a verruca but GP not confident that this was the case. Treatment has not worked. ~ Why is it so difficult to treat fungal nails and why does it take so long to resolve? I tried everything and even used oral treatment and it did nothing? ~ Why after so many treatments and many years is there no significant improvement in my fungal toenails? ~ Fungal diseases/infections of the feet - what long term problems can they cause? ~ My main question is around the prevalence of fungal infections especially in those with chronic disease and compromised immune systems. There aren't any efficient and rapid treatments especially for nail fungus and unless the current treatments are used daily for months/years there is little improvement. This is an area for research as I do think it contributes to cross infection especially in those with high risk feet such as in those presenting with diabetic ulceration, PAD ulceration and skin inflammatory conditions such as cellultitis, psoriatic arthritis and in those with lymphoedema.
Submitted by Healthcare Professional x 7, Patient x 20
PSP information
PSP unique ID 0092
PSP name Foot Health
Total number of uncertainties identified by this PSP. 30  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 26 September 2019