The Bay Area Reporter - April 17, 1998
Jeff Getty, ACT UP/Golden Gate Writers Pool

Although feet have always been susceptible to toxicity and nerve damage, many primary care physicians fail to look at patient's feet on a regular basis. Many patients also find it easy to ignore early foot problems, but some foot afflictions can become dangerous and can lead to serious and harmful conditions even among healthy populations - and can be magnified and overwhelming for HIV-positive patients and their doctors.

Dr. Jon Tinkle is an HIV specialist podiatrist who recently edited Clinics and Podiatric Surgery - HIV and the Lower Extremities, a text by W.B. Saunders about HIV-positive foot complications and their remedies. He currently has a practice at Davies Hospital in San Francisco. Practicing in the heart of the AIDS epidemic, Tinkle has been in a unique position to see thousands of HIV-positive foot problems walk into his office over the years. A pleasant and unassuming individual, Tinkle says that he doesn't like to step on other people's toes, but many times primary care HIV doctors ignore their patient's foot problems until the situation becomes far too serious. Often, HIV and AIDS patients never even remove their socks for physicals and routine follow-ups.

HIV-related foot problems are best treated when caught early, and are widespread. Although Tinkle has never heard of any study done to measure this, he suspects that between 70 percent and 80 percent of both HIV and AIDS patients have foot problems that need attention. And as HIV disease progresses, foot ailments worsen as well.

Neuropathy: the nerve!

Few podiatrists specialize in HIV, let alone know how to treat the complications aggressively. Tinkle feels that education is the key to better foot health. To that end, he travels around the country lecturing other doctors in the field. One of the more important topics he addresses, and one of the more common foot problems he encounters, is neuropathy.

The nerve pain of neuropathy can be caused by drugs, by secondary infections such as CMV, or by the HIV virus itself. Tinkle says that people with the condition should first try to determine the cause of the pain, to see if a change in medications is in order. The next step is to begin physical therapy, including massage and acupuncture. He is particularly fond of micro current and its newer version, called the "H-wave." Studies in New York have shown favorable results with H-wave treatment, which is something like electrical acupuncture, requiring an about an hour a day.

When treating the symptoms of neuropathy, Tinkle prefers not to add more drugs to treat nerve pain - after all, it's drug toxicity that most likely caused the problems in the first place. He does recommend vitamin B, but said he has not seen many results from nerve growth factor as of yet.

Lowering viral load does not seem to take neuropathy away in the feet. Higher stress levels, however, do seem to increase it .

No fun in fungus

Another common foot problem is fungus. This tends to get worse as immunity is diminished. It is first seen in discoloration of the nail plate as well as nail thickening. Doctors treat this by first cutting down the nail and then adding a topical antifungal. Tinkle prefers Nixoral shampoo on fungus nails because it seems to penetrate deeper. If fungus problems have grown serious, he also treats with Lamasil and Sporanox oral medications.

Warts on the feet, caused by strains of Human Papaloma virus (HPV), are called Planters warts. These little devils can become very resistant and hard to treat. They also indicate that the patient is HPV-positive. Although different from the other HPV strains, which cause genital and other skin area warts, all other infectable parts of the body should be inspected for warts as well. The current treatments include cutting them off, burning them with acids, and freezing them. (It seems only the Spanish Inquisition knew how to treat warts.)

According to Tinkle, there are two types of Planters warts: single warts or small size, and the dreaded mosaic: they can get very large and are hard to get rid off. Recently Tinkle and other have begun using bleomycin - a chemotherapy drug - injected directly into the wart. But even with the best treatments, they can come back.

Tinkle warns that a very common place to catch these warts are public showers at gyms. HPV can live in wet areas and are very contagious. "I owe a lot of my business to that gym's shower over on Market Street," he remarked. He recommends wearing sandals or flip-flops to avoid catching the wart virus on the feet.

Measuring trouble by the foot

KS is often first detected around the feet, and can look like a bruise or bug bite. Anything that looks new and unusual should be shown to your doctor. When skin lesions appear there could also be internal lesions. Regular foot inspections could lead to early KS detection.

Bone tumors and fractures can cause pain and changes in foot appearance and structure, even leading to tumors. Mostly these tumors are benign; sometimes they need surgery. These are fairly rare problems, but more are seen in HIV-positive populations.

As T-cells drop, the soles of the feet get increasingly dry, a problem that can also result from drugs. Because that dryness can lead to cracking and infections in the feet, Tinkle says it is important to use moisturizer on the bottom of the feet.

Heel pain can be more chronic in people with HIV, especially during seroconversion. Muscle bands around the heel will tighten up, caused by body aches. "We use a special support if it is not just a transient problem," Tinkle remarked.

Last, but not least, ingrown nails are the number one problem for HIV-positive patients. No one is quite sure whether they are caused by drugs or HIV. The best treatment is to first cut the nail away from the infected skin. Tinkle notes that topical creams don't work well at all. Ingrown nails may not become serious and can clear up on their own, but if they persist beyond three days to a weeks, see a doctor.

No kidding: infected nails, if let go too long, can lead to a bone infection. The treatment for this complication is IV drug therapy - and possibly amputation.
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