Podiatry training covers dermatology in roughly 10% of its curriculum, despite skin and nail disorders representing 60% of patient encounters, according to a presentation delivered in Hollywood, Florida, at the Society of Dermatology Physician Associates 24th Annual Fall Dermatology Conference.
That training gap highlights a disconnect between podiatric education and everyday clinical reality. While podiatrists manage the vast majority of toenail disorders, systemic inflammatory conditions and complex biopsies frequently require specialized dermatological intervention.
Podiatry and Dermatology Manage Different Nail Conditions
Toenails sit at a clinical intersection for both specialties, yet their diagnostic orientation differs. William P. Scherer, DPM, MS, a podiatrist practicing in Delray Beach, Florida, told Medscape that conditions such as diabetic ulcers, heel pain, and bunions predominantly present in podiatry clinics. Conversely, systemic inflammatory diseases like psoriasis or dermatitis manifesting in the nail unit more commonly route through dermatology practices.
“Nail psoriasis is one of the conditions that I am very happy to refer. This is typically a whole-body problem, not just an issue for the lower extremity,” Scherer told Medscape.
Biopsy rates show this operational divide. Podiatrists perform an average of about three biopsies per year, whereas dermatologists average roughly 500 annually, according to Medicare data cited by Scherer. This variance stems from clinical orientation rather than a difference in care quality, creating an avenue for diagnostic collaboration.
Microtrauma Versus Mycotic Infection
Dermatology specialists frequently overlook biomechanical etiologies when evaluating nail damage. Trauma resulting in toenail dystrophy is relatively common but underreported in the literature, Scherer noted. A substantial proportion of these presentations stem from microtrauma caused by poorly fitted footwear.
Such mechanical stress compromises the nail plate, providing a direct mechanism for secondary fungal invasion. Isolating the mechanical trigger from the resulting infection remains vital for effective treatment.
“All onychomycosis is onychodystrophy, not all onychodystrophy is onychomycosis,” Scherer explained, advocating for the broader ICD code of onychodystrophy when exact etiology remains unconfirmed. While dermatology literature estimates that about 50% of onychodystrophy cases involve fungal pathogens, Scherer pointed to a large 2024 retrospective cohort podiatry study encompassing over 96,000 nail specimens, which he coauthored. Based on confirmatory laboratory testing, the study established an overall positive rate approaching 60%.
| Diagnostic Method / Treatment | Efficacy or Positive Rate | Clinical Consideration |
|---|---|---|
| KOH Preparation | Variable / Lower Sensitivity | Largely replaced by more reliable staining techniques |
| PAS and GMS Stains | High Reliability | Used in tandem to minimize false-negative results |
| Efinaconazole 10% Solution | 54% Mycologic Cure | Topical antifungal alternative |
| Tavaborole 5% Solution | 34% Mycologic Cure | Topical antifungal alternative |
| Terbinafine 250 mg Daily | 70% Mycologic Cure | Most common oral medication; resistance rising |
Laboratory Testing and Antifungal Protocols
Potassium hydroxide preparations lack adequate sensitivity for definitive diagnosis and have largely been superseded. Scherer recommended combining Periodic Acid-Schiff and Grocott-Gomori’s Methenamine Silver stains to reduce the risk of false-negative outcomes. Polymerase chain reaction assays are also employed to identify specific causative organisms.
For therapeutic management, topical agents show lower mycologic cure rates compared to oral regimens. Efinaconazole in a 10% solution achieves a 54% cure rate, while tavaborole in a 5% solution reaches 34%. Oral terbinafine at 250 mg daily delivers a 70% cure rate.
However, terbinafine resistance is on the rise. Scherer cautioned that preemptive resistance testing via PCR assay may be appropriate in select clinical settings.
Practitioners Find Referral Guidance Helpful
Marze Lush, PA-C with Brevard Surgery and Cancer in Rockledge, Florida, attended the presentation and noted the practical value of the guidance. “The idea of when to consider a referral is helpful,” Lush told Medscape.
Scherer reported a financial relationship with Bako Diagnostics. Lush reported no relevant financial relationships.
Hepatic Contraindications Require Liver Function Monitoring
Oral antifungal therapies such as terbinafine carry specific hepatic contraindications and require baseline liver function monitoring before initiation. Individuals with pre-existing liver disease or those taking medications with hepatotoxic potential must consult their prescribing physician prior to starting systemic treatments.
