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I am researcher based in the UK and I am carrying out a research project at the moment investigating foot conditions, in particular the condition of cracked heels and fissures.
I am trying to establish a full and insightful picture of the condition and the way it makes people feel, emotionally and physically.
I want to explore the following areas:
The main symptoms,
The type of people that suffer from the condition and why
The way in which it is treated - by the sufferer or a qualified practitioner
How people feel when they have this condition
If anyone has any information or opinions or case studies that they feel would be useful as part of my research please let me know.
>The main symptoms,
Often asymptomatic and go unrecognised until a painful episode occurs. This would include infection and or bleeding
>The type of people that suffer from the condition and why
As a generalisation the condition is associated with the level of water content retained by keratin cells, where there is too little (anhydrosis e.g. diabetics) or local hyperhydration (hyperkeratosis and ichthyosis). When the integrity of skin is compromised and pliability reduced, the skin will tear (or fatigue) across (tensile) stress lines. Conditon is found in bith genders and those with nornmal and above normal body mass index.
>The way in which it is treated - by the sufferer or a qualified practitioner
Rehydration in the case of anhydrosis is usually through topical applications of barrier creams or chemical preparations. In the case of hyperkeratosis, regular physical reduction of the skin and first aid to infected areas by a myriad of ways. Acute episode usually respond well whereas chronic conditons have a poor prognosis.
>How people feel when they have this condition
Conditions apply and much depends on, co-morbidities I would think. A newly diagnosed diabetic may quite understandably prioritise their symptoms with their quality of life and consider (ill advisedly) feet a very low priority. Again as a generalisation, ugly (subjective term) skin with cracked heels may meet with self loathing and depression be regarded by defeatists as another cross to bare with no relief in sight. Often painful cracked heels are seasonal and hence considered as inevitabile, sometimes borne stoically. Others cope well with self care and or visit their podiatrist to manage the condition. The vast majority just ignore them.
Foot Note
Interesting to note, the clinical furniture in the vast majority of podiatric surgeries will facilitate easy examination of the foot with the exception of toise sites on the heel where fissuring (cracks) appear. Whilst many practitoners will alter their postion to reduce the heaped callus which often requires the client to kneel up on the examination couch (not always the most comfortable positon physically or socially for patient or client), no practitoner seems to have considered designing clinical furniture that would facilite this type of work, begging the question do practitoners really take the conditon that seriously?
I would certainly concur with all of these observations, particularly obesity. To this i would add that i have seen some really nasty fissures in patients with psoriasis and that i consider the second most common cause (after obesity) to be footwear. People who wear backless sandles or walk barefoot on carpet all day tend to suffer.
What an interesting project. I look forward to hearing what you come up with.
If I may add to what has already been said, I often hear people say of others with cracked heels, "Oh, I can't believe they have let their feet get that way" or "That's disgusting!". These people are often quite 'obsessive' over their personal hygiene... even to the point of complaining about the slightest hint of hyperkeratosis. When probing further into why they think this is so, invariably they will tell me that they used to have a problem with cracked heels.
Ever heard the excuses? "I know I should, but I can't be bothered moisturising" or "I'll slip all over the place and leave dirty footprints on my precious floors if I put cream on" They often accompany excuses such as "Oh I could never wear closed shoes, I need to look good at work" So, I guess you could say cracked heels are a psychosocial disorder.
Back at uni we used to apply Hydrocolloid dressings to particularly bad cases with some success. We would also encourage patients to apply a thick layer of moisturiser and cover with cling-wrap and a sock overnight. Ahhh, silky smooth heels in the morning.
>Foot Note
Interesting to note, the clinical furniture in the vast majority of podiatric surgeries will facilitate easy examination of the foot with the exception of toise sites on the heel where fissuring (cracks) appear. Whilst many practitoners will alter their postion to reduce the heaped callus which often requires the client to kneel up on the examination couch (not always the most comfortable positon physically or socially for patient or client), no practitoner seems to have considered designing clinical furniture that would facilite this type of work, begging the question do practitoners really take the conditon that seriously?
We have podiatry chairs that are adjustable to allow the patient to lie down. This is beneficial both for attending to heel callus, and casting in the prone position. It also allows for easier muscle testing and massage. If patients are unable to lie prone, the chairs reach a sufficient height to be able to safely treat heel callus.
"Fissures may be likened to ‘canyons’ – deep, perpendicular cliff walls leading down to a restricted narrow area at the bottom. Any movement of the stiff sides applies considerable stretch and torsional demands upon the narrow but flexible tissue area at the base.
'Safe Scalpel Technique' employs the tip of the blade to reduce the ‘canyon walls’ in order to produce instead a ‘shallow valley’ where the base area is broader and more uniformly flexible.
If the newly created flexible area is painted with Tincture of Benzoin Compound (a medical ‘varnish’), the area will be protected and immediately sealed by an antiseptic film which will not allow drying-out and so will retain flexibility. Application of an emollient preparation is best made 48 hours after reduction if the fissure has bled prior to, or during reduction."
This is an exerpt from 'Safe Scalpel Technique' - a copyright publication originating from the College of Foot Health Practitioners.
I wish you good progress with your research project.
It can be done and there are couches and additions to assist, however what I was suggesting is this is not standard to all podiatry surgeries and maybe practitoners per se devote less attention to the conditon than it might merit. I was proffering this may be something to do with practitioner's response to people with fissures and or the poor prognosis for the condition.
The reseach and technology is available to develop ergonomically appropriate clinical furniture but there is little interest from a profession to buy same. Instead they appear content to use the same furniture as they have done for the last 150 years with the full knowledge back ache is indemic to the profession. That last fact would speak volumes to a sociologist.
>If the newly created flexible area is painted with Tincture of Benzoin Compound (a medical ‘varnish’), the area will be protected and immediately sealed by an antiseptic film which will not allow drying-out and so will retain flexibility.
I understand the description but would be quite misleading to refer to a TBCo as a varnish. A paint, film or even second skin would be better. One complication cited with paints such as TBCo (alcohol and water base) is it is contraindicated in areas where there may be micro tears in the skin which are not visible to the naked eye. The barrier it forms theoretically could favour anerobic bacteria colonies which may cause infection of a wound. The alcohol base usually acts as an antiseptic and fast acting astringent (reduces the surface area). The action of T BCo is very short lived however and what has been described would be unlikely to arise, unless a plastic film was used.
>Application of an emollient preparation is best made 48 hours after reduction if the fissure has bled prior to, or during reduction."
The priority here is to ensure bleeding is stopped. 48 hours would have no actual physiological significance other than a rule of thumb. Cream based antiseptics (e.g. chlorhexidine gluconate) could be used at any time once the bleeding has been stemmed. In the case of small haemorrhages that could be immediately. Also today antispetic plastic sprays can be used immediately post haemorrhage after a clot has formed.
The hypertrophy of the epidermal cells is biochemically controlled and as the keratin is being removed the cells are contining to mass produce. Whilst the normal cycle is 28 days this maybe accelerated considerably and 48 hours after initial reduction you may have as much to cut away again (in some cases), So it is more favourable to increase the water content of the keratin cells as soon as possible after reduction (by whatever means). Skin cells uptake water very quickly but soon (numbered in days) reject the increased water content and no matter what is applied thereafter it makes little change to skin hydration.
That is why there is really nothing yet in a bottle or tube that yet can regulate chronic hypertrophy of the skin.
"I understand the description but would be quite misleading to refer to a TBCo as a varnish. A paint, film or even second skin would be better. One complication cited with paints such as TBCo (alcohol and water base) is it is contraindicated in areas where there may be micro tears in the skin which are not visible to the naked eye. The barrier it forms theoretically could favour anerobic bacteria colonies which may cause infection of a wound. The alcohol base usually acts as an antiseptic and fast acting astringent (reduces the surface area). The action of T BCo is very short lived however and what has been described would be unlikely to arise, unless a plastic film was used."
A varnish is a substance that, when painted on a surface, leaves a film or seal. Tinc Benz Co is indeed a medical varnish, akin to Whitehead's varnish used to retain oro-nasal packing. And it works, despite the quoted 'facts'. I can confirm that it works having used the technique for more than 20 years and closely observing the outcome. The same application is employed by athletes who rub the skin off the heel - painted with TBCo they can wear shoes and run the following day.
The best emollients have a high urea content - between 10 and 25%. Moisture is admitted and retained very effectively leading to early pain relief and rapid healing.
Good point, but I suppose having taught therapuetics and clinical pharmacology for just over 30 years now, I can say with some confindence I agree T BCo 10% will act through its alcohol base as a antiseptic and astringent. But this is only transient unlike a varnish. Modern pharmacy does offer many altertnatives which may arguably have better (longer lasting) benefits. This would not prevent prtactitoners form using T BCo., it is just rather dated, that's all.
>The best emollients have a high urea content - between 10 and 25%. Moisture is admitted and retained very effectively leading to early pain relief and rapid healing.
Technical defination here, 'emollient; usually refers to a bland cream (no chemical interaction) and Urea creams are not classifed as bland. Increasing urea will help retain water content in skin cells more so than a bland emollient and is usuallly used on ichthyotoc type lesions. Urea creams may in some skins cause urticaria (nettle rash) and hence is contraindicated, whereas a bland cream (emollient) would not.
I am not sure if urea creams could be classified as analgesic , nor capable of promoting healthy granualtion as you suggest "leading to early pain relief and rapid healing." But I assume you mean these benefits acrue from improved skin presentation. That would be my experience too.
In the case of heel fissures as a general application, I prefer to recommend urea creams (where there is no contraindications) more than barrier creams and emollients. Sometimes cost to the patients does necessitate however any kind of rub is better than no rub at all.
The reseach and technology is available to develop ergonomically appropriate clinical furniture but there is little interest from a profession to buy same. Instead they appear content to use the same furniture as they have done for the last 150 years with the full knowledge back ache is indemic to the profession. That last fact would speak volumes to a sociologist.
Hi Cameron,
Could you expand on what you mean by ergonomically appropriate clinical furniture?
I think there would be interest but some of the apathy is due to finance. And the profession may have healthier backs if the practitioners didn't partake in home visits (ever tried to access heels in a home visit!!).
> Could you expand on what you mean by ergonomically appropriate clinical furniture?
Office furninture which is desgined to facilitate foot examinations to be uyndertaken without disadvantage to operator or client. The Europeans are very aware of the benefits of ergonomically designed furniture and great acceptance of this approach has become more apparent with Health and Safety converns in the UK and US. When you compare furniture and room design for dentistry or gyenocology as examples over the last century you will see a marked difference which is not generally reflected in podiatry.
>I think there would be interest but some of the apathy is due to finance.
Without doubt. Podiatry has always been a service which carries relatively low overheads by comparison to others and general acceptance of what we trained on, would hold us in good sted, is a mind set.
>And the profession may have healthier backs if the practitioners didn't partake in home visits (ever tried to access heels in a home visit!!).
Like all pods I suffer from chronic back ache and have to do exercises everyday to stay supple. A colleague of mine undertook a survery several years back on the population of a hospital with matched samples taken of workers and clients and found the podiatrists reported more days off work due to back ache than anyone else including the patients.
So what I was trying to say was, if we were now engaged a environmental/ergonomist designer to plan for the work of a podiatrist from scratch, I would bet the first dollar I ever earned (still have it, well I am Scots :-)), the designer would come up with quite a different scenario to that which has prevailed (in the presence of obvious occupational hazards) for centuries.
Off shoppping now (according to She who must be obeyed)
Very interesting thread! My only reason to visit a pod, some 10 years ago, was cracked heels that did not heal. The cracks are less deep, but hey, I forget to cream and sock every night, and, as an Aussie, I walk bardfoot all the time. Carole
>And the profession may have healthier backs if the practitioners didn't partake in home visits (ever tried to access heels in a home visit!!).
Actually yes. Had a patient with major callus on scar tissue from a healed pressure sore posterior heel. Fortunatly she had a stairlift and we found the best way was to put the stairlift up half a dozen steps and then i sat on the lowest step. Not easy but easier! Best toy i ever bought for home visits was a head lamp. Looked a tit but nice to see what you're doing!
Possibly. I try to avoid asking patients to invite me to their bedrooms! Whilst i accept a certain amount of sexual harrassment from octogenarians as an occupational hazard theres no reason to give them oppertunities. :( Besides the rest of the house was so squalid i did'nt want to see the upstairs particularly!
... So it is more favourable to increase the water content of the keratin cells as soon as possible after reduction (by whatever means). Skin cells uptake water very quickly but soon (numbered in days) reject the increased water content and no matter what is applied thereafter it makes little change to skin hydration.
Is there any literature to suggest how many days it takes for the skin cells to reject the increased water content?
Surely if you apply enough cream (emollient or urea) it will eventually result in changes to skin hydration
Oh, and I was wondering, does anyone know if urea creams are contraindicated during pregnancy?
> Is there any literature to suggest how many days it takes for the skin cells to reject the increased water content?
Sure is a pile in pharmacy literature. I am aware of a couple of small studies where skin cells were measured before and after moisurisation. Bill Kerr in Edinburgh did a pilot a few years ago and his findings indicated the water uptake was almost immediate , but after a few days of application the water uptake dropped by 50%. Bill's email is <wkerr@qmuc.ac.uk > , I am sure he will be happy to give you more details.
Surely if you apply enough cream (emollient or urea) it will eventually result in changes to skin hydration
Apparently not albeit I am only aware of test with bland creams. Chemical creams such as calmurid may have a different outcome.
Oh, and I was wondering, does anyone know if urea creams are contraindicated during pregnancy?
The most common reaction to urea cream is a local urticaria. I am not aware of any contraindication in the case of pregnancy but you should be able to find this information out by referring to National Formulary of Martindale. I would ask your pharmacist or contact the company if you do not have access to reference text.
I am not aware of any contraindication in the case of pregnancy but you should be able to find this information out by referring to National Formulary of Martindale. I would ask your pharmacist or contact the company if you do not have access to reference text.
There have been reports related to coagulopathy during pregnancy after urea preparations application (from eMartindale):
1. Grundy MFB, Craven ER Consumption coagulopathy after intra-amniotic urea. BMJ 1976; 2: 677–8.
2. Burkman RT, et al. Coagulopathy with midtrimester induced abortion: association with hyperosmolar urea administration. Am J Obstet Gynecol 1977; 127: 533–6.
But, I have asked to my pharmacist (it is very easy for me, because I share my bed with her every night :) ): urea is quite safe except for the possible skin irritation and if you avoid to administer intravenously.
Regards,
Last edited by javier : 16th March 2007 at 11:25 AM.
Pare the callouses/fissures and then sand with Podospray umbrella bit and then I found these 2 emollients to work best ( tried them all to little avail until I stumbled across these 2) for my patients:
1. Believe it or not, "Bag Balm" they use on cow's utters!!! Similar to prolan with high urea content (looks like soft bee wax)
2. Glyocosmed (made by Blistex) aloe/vitamin E/glycerin/urea/silicone mix something like that
Toddle dee do
Have fun guys and girls it's only a chat room. United we stand and divided we fall....lighten up all and quit beating the drums.
Cracked heels
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