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Hello.

Just seeing if anyone could help me. I am treating a patient at the moment who is an underwater diver. When he is out at sea working he spends around 8 hours per day under water. He has some fissuring on the plantar forefoot area under the 3/4/5 met heads. The fissures open after he has been diving for about 8 days. Then heal up after being on land for 1-2 days. I need a dressing that will stay on and keep the area waterproofed for the time he spends under water. The dressing is ideally meant as a protective and preventative mechanism for the area so the fissure doesn't open up

Does anyone have any ideas as to what the best type of water proof dressing would be? Any ideas on how to keep this on for several days at a time?

Water proof dressing are obviosly quite expenisve. Do not want him spending $20 a day on a dressings!

Any help would be greatly appreciated.

Kind regards,
Dean

__________________
Regards,
Dean

Dean:

I would think it would be much easier for your patient to put a good moisturizing cream/ointment onto his feet as soon as he gets dried from his shift in the water and then use it again under occlusion at night, rather than trying to keep his foot dry during diving. 16 hours of moisturizing versus 8 hours of diving.....the time out of the water should win out. Have you tried that yet? Petroleum jelly and "bag balm" are two low cost items that can work quite well for his type of problem. I would also try to keep the skin as thin as possible in the area by self debridement.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

there are also these sorts of things

Dri Cast

or Dry Pro

__________________
Stephen Tucker
Eastern Health
Podiatry Manager

My location

Hi
I agree with Kevin - very difficult to keep the area completely dry when he's in water.
I usually recommend `Heel Balm` made by Flexitol for patients with painful fissures and I have found it very effective (providing the patient uses it regularily).
Apply b.d or t.d.s then cover the affected area with a cheap,non sterile dressing or even an old pair of socks.Plastic bags work well but can be slippery!
Regards
Deborah

Hi all,

I too was thinking along the same lines as Stephen.

Could present problems though as 'Dri cast' website states:

Quote:

PER SESSION - Recommend approximately 20 minutes at a time. Any longer and condensation from use/sweat will build up and cause dampness and negate the use of the cover.

O/P:

Quote:

When he is out at sea working he spends around 8 hours per day under water.

Regards,

Mandy.

__________________
:)
twirly

Mandy Brooks
Brooks Podiatry
S64 0DE

Suffering a fondness for odd things.

Thanks for the reply Kevin. I should have given a little more information. He is diving for eight hours, for the rest of the day he is on the boat barefoot, his feet are always wet. Only time when they have a chance to dry out is when he is sleeping for 6or so hours - even then he says his feet are never dry!

I have debrided the hyperkeratosis around the area significantly and he is already using a urea base emollient cream regularly when he is on land for the 1-2weeks. It actually looks OK at the moment as he has been on land for 5 days.

He is a 35 year old male and he would not wear a dry-cast etc - to much hassle and inconvenience for him.

I was initially thinking more along the lines of an opsite island dressing, something he may only have to change once every day or two - however I wasn't sure how this would stand up to being submerged for the majority of the day? I believe the skin integrity is being compromised with being submerged for so long, and then walking on the decks of the boat for a further 6-8 hours is causing the fissure to open up. (I haven't seen it when he has just come off the boat - I am only assuming).

Dean

__________________
Regards,
Dean

So take this with a grain of salt (no pun intended) because its in no way evidence based medicine, just some small things I was told from an esthetician when I was having problems with my face drying out when I started diving. I was only diving for a few hours and its a little easier to treat the face then the foot when standing on a wet boat for the rest of the day. I'm sure you may have already addressed most of these but figured I'd pass it on anyways:

- increase water intake after dive
- bring spray bottle with fresh water and a mild soap to wash salt off immediately before it dries and then keep as protected as possible
- using a long acting waterproof sunscreen as a barrier while diving
- she also recommended Mario Badescu - Protective Cream for Swimming - I never did try that one but perhaps you could look for any product with similar active ingredients and base
- Also, its common for divers to develop an atopic dermatitis of Xerotic eczema so perhaps trying something like Nerisalic that combines a keratolytic with a topical corticosteroid overnight might step it up a notch but this is contraindicated in deeper fissures so it would depend what its current depth is - not a long term solution but perhaps can get things to the point where their manageable with typical emoliants

Where is this guy that his working conditions are so primitive? What temp is the water? and being a regular diver myself, who owns a dry suit I'd have to say that getting your feet wet is entirely optional. Maybe he does all this hard work and still makes no money? but if has not got a dry suit he is not that serious about looking after himself or he is very tight fisted?
regards Phill Carter

The patient is working off the central/northern queensland coast. Iam guessing, but I think water temp this time of the year would be around 20degrees?

I know very little about diving. Are you able to get diving socks/boots, which could be kept on whilst underwater and on the boat that would keep the feet dry?

__________________
Regards,
Dean

Higher temps in air and water are more difficult because people are less willing to wear a dry suit, but there are tropical dry suits that would slove his immersion problems for use when in the water. On the boat it's more straight forward, get some water proof footwear and good wicking sock fibre technology and it should help a lot. This sounds to me like the person getting sun burned from lying on the beach: you're supposed to fix them but they won't stop lying on the beach in the sun.
regards Phill

You can't get just socks that will keep his feet dry under water, but some one clever enough could make them, just a dry suit in reverse for the feet only.
regards Phill

Have him try a XeroSox vacuum sealed protector over a polypropylene or wool sock. He can apply zinc oxide in a stiff ointment base (Desitin in the USA, used for diaper rash) on the lesions.

Vacuum seal the XeroSox, pull on the wetsuit/drysuit over it. Probably a size
HL15 would be best.

see: XeroSox.com or XeroSox.co.nz

Cheers

Frederick

Hi Stephen,

How do these go for people with mobility problems, who you would be hesitant to use placcy bags on?
Do you know how easy they are to operate and if they are non-slip?

I'm trying to find a solution for a stubborn elderly man who likes his showers, but we are unable to use waterproof dressings on him, as his skin is too dry and they continually fall off, and I am concerned a plastic bag on his foot would be more of a risk to his health than the ulcer!

thanks for your help and for any other suggestions!

Bianca

Have you considered Cavillon in cream or liquid? It is a sillicone product that was formulated for incontinent patients to prevent urine burning and maceration of the skin. Working as a registered nurse I have used it around wet wounds to prevent maceration to healthy skin. It also comes in a spray or lollipop applicator in a liquid form that when applied to healthy skin around a wound will help the dressing adhere much better. Useful on foot dressings!!!

Hi Bianca!!!!
You could always try Kerraboot (ArkTherapeutics).......it's a wound dressing but as the name suggests is like a boot with a velcro strap around the top to keep water out but it has grippy things on the bottom to reduce slippage............
There is SealTight as well but I don't think it has the grippy things!!
Emma

I have heard of of keen weekend sailors who get fissures on hands and fingers from al ot of rope work using superglue in fissures to keep out saltwater, relieve pain and start the healing process. It could be possible that the surgical glue, I think its called HISTOCRYL or similar, (used instead of sutures) may be worth a try for forefoot fissures on someone spending most of the day diving. Follow up with the creams and balms etc after days diving.

I think it's just as much the time spent on deck as it is the time in the wet suit. You'd need something to wick away the sweat as well as protect from the wetness while on deck, as well, waterproof dressings even if they stayed on would trap the sweat underneath creating equal problems.
Water proof footwear or just waterproof (gore-tex) socks in regular deck shoes combined with highly effective moisture wicking socks layered next to the skin might help for deck conditions. Gore-tex lining/socks allows sweat to escape and prevents water going in. This combined with a good barrier cream for use during the dives might be helpful, but whether your client will tolerate this is debatable.
My feet have completely peeled with some nice deep cracks when I've had them stewing all day in a damp shoe on some rainy hiking and canoe trips, and I've known a few deck hands who just can't avoid this problem standing barefoot on the wet deck all day.

http://www.sealskinz.com/