14.Scottish Intercollegiate GuidelinesNetwork (SIGN). Management of dia-betic foot disease. Guideline No 12.March 1997 (b).

15.Corner L, Curless R, Parker SG, et al.Developing guidelines for day hospi-tals for older people: adaptation ofnational guidelines for local use. JClin Effectiveness 1998; 3: 10–13.

16.Feder G, Eccles M, Grol R, et al.

Using clinical guidelines. BMJ 1999;318: 728–730.

17.Murphy MK, Black NA, Lamping DL,et al. Consensus development meth-ods, and their use in clinical guide-line development. Health TechnologyAssessment 1998; 2(3).

18.Duman M. Producing PatientInformation: How to research, developand produce effective information

resources. London: King’s Fund,2003.

19.NHS Executive. Information forHealth. An information strategy for themodern NHS 1998–2005. A nationalstrategy for local implementation.London: NHS Executive, 1998.

20. Department of Health. National ServiceFramework for Diabetes: Delivery Strategy.London: The Stationery Office, 2003.

328 Pract Diab Int November/December 2004 Vol. 21 No. 9 Copyright © 2004 John Wiley & Sons, Ltd.

ORIGINAL ARTICLE

Lessons from setting up the DREAM trial

Diabetes Vignette

A 74-year-old obese woman (BMI 36)developed type 2 diabetes threeyears ago and her diabetic controlhas been consistently poor (HbA1c

10–11%). Her other medical prob-lems were hypertension, hypercho-lesterolaemia, biventricular failure andhypothyroidism.

At a routine diabetic clinic visitshe complained of painful lumps thathad developed at the sites used forobtaining blood samples for glucosemonitoring. Examination showedlarge plaques of ungual warts at thelateral margins of the distal phalanxof the middle and ring fingers of theright hand (Figure 1), and the middlefinger and thumb of the left hand(Figure 2). She was advised to avoidtaking further blood glucose samplesfrom the affected fingers. Some ofthese warts were successfully treatedwith liquid nitrogen, but this therapywas too painful to be continued.Salactol paint (salicylate 16.7% +lactic acid 16.7 %) was applied topi-cally every day and proved effectivefor controlling these lesions.

Ungual warts are benign cuta-neous tumours caused by theHuman Papilloma Virus (HPV), espe-cially types 1, 2 and 4, and, due to

the poor response to available treat-ments, can persist stubbornly formonths or years.

Ungual warts can merge into largeplaques (as in this patient), encroachon the adjacent nail plate, and evencause bony erosions.1 Fissuring ofungual warts leads to pain and maypredispose to secondary bacterialinfections. Skin trauma such as punc-turing and biting inoculates the HPVDNA into other areas and may producenew lesions. In this patient, self-inocu-lation of the virus probably occurredduring blood sampling for glucosemonitoring – as reported in one other

instance in the diabetes literature.2

Ungual warts should be treatedaggressively in their early stages.

Misbah Khan, MBBSRayessa Rayessa, MBBS, MRCPChristopher Chan, MD, FRCPElderly Diabetic Clinic, Departmentof Medicine for the Elderly, BasildonUniversity Hospital, Basildon SS165NL, UK

References1. Baran R, Tosti A. Nails. In Fitzpatrick’s

Dermatology in General Medicine, 6th edn.Freedberg IM et al (eds). New York: McGraw-Hill, 2003; 667.

2. MacAdams MR. Hand warts associated withSMBG. Diabetes Care 1986; 8: 316–317.

Self-inoculation of ungual warts by blood glucose monitoringNo. 40 in a regular educational series of brief illustrated descriptions of interesting or unusual diabetes-related cases and conditions

Figure 1. Ungual warts at thelateral margins of the distalphalanx of the middle and ringfingers (right hand)

Figure 2. Ungual warts on thethumb (left hand)

Practical Diabetes International invites you to submit your favourite slide with clinical details for possible publication in this series.

CONFERENCE NOTICE

Obesity & HealthA multidisciplinary conference on the management of obesity in society7–8 February 2005, Manchester Conference Centre, Manchester, UK

For more information and to register for the conference please contact the Conference Secretariat,Index Communications Meeting Services. Tel: +44 (0)1794 511331/2; fax: +44 (0)1794 511455; e-mail: noch@indexcommunications.com; website: www.obesityandhealth.co.uk

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