A questionnaire survey study on nail disease prevalence in patients under podologic foot care

Nail disorders (ND) are frequent among the geriatric population but our knowledge about underlying diseases causing specific ND is low [1, 2, 3, 4, 5]. We therefore analyzed ND in patients presenting for podologic treatment in an outpatient setting in Germany. The setting of podologic care in Germany is unique, given that a specialist nurse, the so-called podologist, who has passed a three-year training curriculum in foot care, especially with patients suffering from diabetes mellitus (DM), are providing this care in private outpatient settings. In contrast to podiatrists, podologists are not allowed to use a scalpel or other instruments for perform active debridements that goes along with bleeding.

The questionnaire asked for 16 specific NDs and some additional patient characteristics, including gender, age, height and weight. To ease uniform definition of underlying ND and to standardize the repertoire of possible answers a priori list of specific NDs was included with definitions for each disorder aside (Electronic supplementary material [ESM 1]). Because of missing data final data set included 1619 cases.

Of all reported “cases” onychomykoses were diagnosed in 30.7%, ungius convolutes in 41.8%, onychauxis in 29.4%, onycholyses in 13.4% and ungius incarnatus in 22.5%. DM as a comorbidity was present in 60.3%, peripheral polyneuropathy (PNP) in 48.9%, peripheral arterial disease (PAD) in 29.9%, congestive heart disease with signs of heart failure (HI) in 29.7%, obesity in 29.7% and lymphedema (LE) in 21.9% of reports. With advanced age onychomycosis and onychausis was more likely, but not the others (ESM 2). Male gender was more likely to be associated with onychomycosis, whereas in females unguis convolutus, onycholysis and unguis incarnatus were reported more frequently. Diagnosis of DM was more likely with onychomycosis and unguis convolutus, however not unguis incarnatus. High body mass index >30 (obesity) was associated with diagnosis of unguis convolutus and onychauxis.

A final regression analyses shows that specific ND was mostly associated with gender: male patients presented more frequently with onychomycosis, but less frequently with onycholysis, unguis convolutus and incarnatus (ESM 3). An age >75 years was associated with a higher prevalence of onychomycosis whereas obesity was associated with unguis convolutus. The comorbidities DM, PNP, PAD and LE were not associated with the considered ND. In contrast, heart insufficiency is associated with onychomycosis, onycholysis, onychauxis and unguis convolutus.

The main findings of the questionnaire survey reveal that gender has a higher impact on type of ND than advanced age. With advanced age a predisposition for onychomycosis exist, whereas in females onycholysis and unguis convolutus and incarnatus are more prevalent. Unexpectedly, the impact of comorbidities such as DM, PAD, PNP and LE for specific ND is low, only with heart failure and congestive heart disease the prevalence of onychomycosis, onychausis, onycholyis and unguis convolutus increases.

A limitation of the survey that it specifically addresses the professional environment and patient cohort cared for by podologists in Germany and all data regarding comorbidities are based on personal information and not on medical reporting. Confirmation of comorbidities was not performed, also the severity was not assessed. Furthermore, diagnosis of ND relied on the expertise of the podologists only. Although these are well trained in diagnosing ND, the accuracy of the diagnoses only relied on their judgement and knowledge.

Prevention of ND requires knowledge of the kind and timing of diseases. Our survey questionnaire study reveals that gender has a strong impact on the type of ND, to a lesser degree advanced age and obesity changes the type of ND. Furthermore, the comorbidity of congestive heart disease and heart failure may require additional attention regarding the occurrence of ND, which may likely results from chronic limb ischemia and edema formation in the legs.

Electronic supplementary material