Dear Dr. Roach: I am an 81-year-old male in good health. Four months ago, I was diagnosed with meralgia paresthetica, a compression of the lateral femoral cutaneous nerve. I believe this occurred when I did a leg press on an exercise machine that had way too much weight for me. This resulted in a numb right thigh that initially had a great deal of sharp pains.
I have been receiving physical therapy treatments since then without a great deal of relief. The pain is less now, but the symptoms persist. According to what I have read, this condition should go away after six to seven months. Would acupuncture or a different modality help? Finally, if this continues, who should I see for further treatment?
B.A.
Meralgia paresthetica is an uncommon diagnosis, but by no means rare. I see one or two cases per year. You are exactly right that it is caused by the compression of a particular sensory nerve, but weightlifting is not a common cause. By far, the most common causes I see are people with recent weight gain (often with tight pants or belts) and a wallet always kept in the same pocket, which puts pressure on the nerve. Like nearly all neuropathies, it’s more common in people with diabetes.
When symptoms aren’t going away like they usually do, it’s important to redo an exam and make sure of the diagnosis. Although medications are sometimes used, my practice is to refer to a pain management specialist for consideration of a nerve block.
Dear Dr. Roach: I am 70 years old and have the dreaded toenail fungus that seems almost impossible to get rid of. Do you know of a drug or products that works effectively and quickly?
B.M.
No, there are no therapies that are both highly effective and fast-acting. In fact, there are no highly effective treatments at all. The best treatment is oral medication, such as terbinafine. The best estimate of a clinical cure occurs in about 62% of patients after 12 weeks of treatment.
Unfortunately, oral treatment has the potential for side effects. These are uncommon (about 5% of people had side effects compared to the placebo group), but there is a very rare risk of serious skin reactions and liver injuries, which can be fatal. I always discuss this possibility before prescribing it, even though it is rare. There are topical treatments that can be used, but they are much less effective (between 15% and 40%). They can also be extremely expensive, although there are manufacturer’s coupons to help.
Another big problem is that even if a person is cured, there is a high likelihood of the fungus coming back (20% to 50% in published trials). The risk can be reduced by careful foot and nail care, avoiding reexposure (especially in public places like gyms), and keeping your feet cool and dry by frequently changing your socks and shoes if they get damp from perspiration.
Between the less-than-perfect results from treatment and the possibility of serious side effects, many of my patients choose not to take oral medication for nail fungus if their major concern is a cosmetic one. In people with a history of skin infections due to nail fungus or symptoms like toe pain, then treatment is reasonable if the person understands the risks.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
