Medical Treatments

Calluses are areas of thickened skin usually creamy yellow in colour caused by excessive friction and pressure. The skin thickens to protect the area from friction and pressure, but once it becomes too thick it becomes painful. On the feet, calluses usually develop on the sole of the foot, commonly on the heel or at the ball of the foot under the metatarsal heads. This is because these are the areas where a majority of the pressure is taken. Calluses on the foot can develop into corns. Calluses may also form through wearing ill-fitting shoes.  Wearing suitable shoes with correct width and depth, soft soles and lower heels may help to prevent calluses. Whilst the build-up of hard skin on the foot is natural, bony deformities (such as bunions), and an incorrect walking action can all contribute to the formation of calluses.

Signs and symptoms
Calluses are are similar to corns, however with no central nucleus pressing down on the nerve end. They therefore tend to cause a wider spread burning sensation with a reddened appearance, rather than the sharp pain associated with corns.

Treatment involves painless removal and sometimes deflective or comfort padding may be applied afterwards.  Advice on how to maintain and help prevent the reoccurrence of the callus will be given by using a foot file at home.  The use of foot files and emollients on a regular basis will help minimise the build-up. Diabetic persons should consult a registered foot health practitioner for all foot abnormalities, including calluses. 

Corns are thickened areas of skin that form in response to excessive pressure and friction becoming sometimes very painful. They form to protect the skin and the structure beneath it from damage. Upon walking our body weight is distributed from the heel to the ball of the foot, on the tops of the toes and in between the toes. When the pressure is intense, growths appear corns. This pressure is not necessarily caused by walking, it can occur through ill-fitting footwear. Corns are usually hard and circular, with a translucent centre. They can become painful or ulcerated in response to the severity of pressure. There are 5 different types of corn, however the two most common are hard corns and soft corns.

Hard Corns 
These are usually about the size of a pea, and yellow in colour. They appear as a circular raised shiny patch of skin. They contain a nucleus which can push against the underlying nerve ending thus causing sharp intense pain.  In many people the toes curl downwards and do not lie flat. Fitting curled toes into ill- fitting shoes is the most common cause of hard corns, usually on the 5th (small) toe however they can occur on the tops, sides or tips of any of the toes. They can also appear under the ball of the foot, which is another pressure point.

Soft Corns 
These are whitish in colour and have a rubber-like texture. They usually develop between the toes and are caused by the rubbing together of the bones in the toes.

Seed Corns 
Tiny corns that tend to occur on the bottom of the foot.

Vascular Corns 
These usually start as a hard corn, however through inadequate self-treatment, nerve endings and blood vessels are pushed to the surface. These will bleed profusely upon paring.

Fibrous Corns 
These arise from corns that have been present for a long period of time and appear to be deeper rooted to the underlying tissue.

Treatment involves painless removal of the corn or various padding or silicone appliances can be made in order to prevent them from reoccurring. Home remedies are available, either as corn plasters or liquid, however these usually contain salicylic acid, which if you are diabetic should not be used. Excision using a scalpel is the preferred treatment by Registered Foot Health Practitioners, however this will not alleviate the causative factors, i.e. tight shoes.

It is a common persistent fungal infection of the foot characterized by itching, scaly and burning skin. It usually starts between the cleft of the fourth and fifth toes having a white, rubbery appearance, which can crack and become red and sore. It can easily spread between the other toes and to other parts of the foot and nails,. The soles of the feet can become scaly and raw and could have the presence of small pustules. The fungus thrives best in warm, moist enclosed conditions, namely in a shoe. It is for this reason that such importance is given to the drying of the feet especially between the toes, as this area provides an ideal breeding ground for the microscopic spores that cause athlete’s foot.
Athlete’s foot is highly contagious and can be easily picked up from wet floors, used towels, socks and shoes, (walking barefoot in changing rooms should be avoided). The fungus is very resilient and can lie dormant in shoes for weeks after the visible external symptoms have subsided.
The most common fungus or dermatophyte in fungal infections is Trichophytum Rubrum.

Signs and Symptoms

1. Intense itching between the toes known as inter-digital athlete’s foot.
2. The peeling of skin or cracking between the toes.
3. In ulcerative athlete’s foot the peeling of the skin worsens and cracks may develop, this can result in secondary bacterial infections.
4. Red and inflamed skin in which a series of raised bumps or ridges develop. Intense itching and a watery discharge may develop.
5. A red rash across the bottom of the foot, the skin becomes dense and scaly resembling a ‘moccasin’, which is why this type is known as ‘moccasin or plantar athlete’s foot’.

It is important to follow the advice on general foot and nail health in order to prevent athlete’s foot and its recurrence. If you have athlete’s foot it should be treated as soon as any signs or symptoms appear. Athlete’s foot infections may disappear of their own accord, however they can also persist for years. They are difficult to treat and may recur. Best results are normally obtained with early treatment before the fungus becomes established.

Occur due to an excessive build up of hard skin around the heel.It is often due to excessively dry skin, but cracks can also occur due to excessively moist skin. The cracks can often become open, referred to as a fissure, can bleed and become very painful.  Open heeled foot-wear in the summer is a major contributor to this problem.

Treatment involves painless removal of the hard skin and advice on how to minimise the return of the build-up.

Fungal nail infections are one of the most common conditions and among the most troublesome to treat. Fungal nail infections, called onychomykosis, can be a constant source of the skin infection on the feet.  When a fungal infection initially starts, you may see white spots on the surface of the nail plate, it is much easier to get rid of it at this stage, and then can spread to several toe nails. Some nails become abnormal, thickened and distorted due to fungal and yeast infections that could cause discoloration becoming yellowish brown, brittle and crumbly. The skin next to them may be inflamed, sore and scaly. Though toe nail infections take longer to clear totally in comparison to the skin ones as the nails receive very little blood supply. If left untreated, the infection may destroy the nail as well as the nailbed.

Treatment is painless by reducing the thickness of the nail plate using an electric drill, which exposes the fungus making it much more susceptible to the anti-fungal  medication.

Oral medications are available on prescription only, however these may have contra-indications and patients may be required to have a blood test during this course of treatment.

Other Nail Infections

Other nail infections can cause inflammation of the matrix (onychia) and inflammation of the tissue adjacent to the nail (paronychia). In people with lowered immunity, this may sometimes lead to serious complications, including more widespread infection extending up the leg (cellulitis). Trauma to the nails may lead to permanent nail deformity. This can be cared for by regular treatment, involving filing and possibly the use of a special drill.

Ram’s Horn Nails

This describes an uneven thickening of the nail plate which if left can develop into a gross deformity of the nail resembling a curved ‘ram’s horn’ shape. The nail will often also be a dark brown or yellow colour and have ridges along or across. The FHP will reduce your nail manually with a drill or file which provides immediate relief. This condition is most common in the great toe as it is this area which is most prone to injury. The most common cause is a single major trauma such as stubbing the toe. Trauma to one side of the nail bed can result in uneven production of cells which as the nail grows out causes it to curve. Patient education is important as it is essential to keep the nail plate as short and thin as possible. Footwear should be assessed to remove possible causative factors.

Ingrown nail known as ‘onychocryptosis’, this is a common, painful condition which occurs when the skin on the side of the toenail grows over the edge of the nail or when the nail grows into the skin. 
It is most common on the big toe, however it can develop on the other toes.
Usually the side of the nail penetrates deeply and it is difficult to see the edge. Some will just have a nail that appears deeply embedded down the side or sides of the nail. In some, the corner or a small spike of nail may penetrate the skin. It can be extremely painful, red and inflamed and in more severe cases can result in an infection, pus and bleeding. The toe may become red and inflamed.

Ingrown toenails can develop most commonly due to incorrect cutting of the nails. The nails should be cut straight across avoiding cutting too low at the edge or down the side; in an attempt to allievate the discomfort, but this usually leaves a spike of nail which when it grows forward, will stick into the skin again. The corner of the nail should be filed and be visible above the skin. Sometimes, if left too long, hypergranulation tissue may form which is a very red vascular piece of tissue that will bleed easily.

In some cases the nail is more curved than usual rather than being flat, this will cause the edge of the nail to grow in. The most severe example of this type of nail is one in which both sides of the nail are very curved, this is more commonly called a ‘pincer nail’ and the shape is usually inherited, but can be influenced by trauma or shoe pressure. Trauma, such as stubbing a toe or having one stepped on can cause a piece of nail to jam into the skin. Pressure from an adjacent toe, a bone deformity (e.g. bunion), tight-fitting footwear or hosiery can also be causative factors.

Signs and symptoms
Ingrown nails should be treated as soon as they develop. Unfortunately the first sign of an ingrown nail problem is pain. If the skin is red, painful or swollen on the sides of the nail, there may be an infection. The ingrown nail is in a warm, often moist, bacteria-rich environment, this provides a convenient entry for germs that cause infection.

Treatment
The offending spike of nail must be removed using sterile instruments, after this some antiseptic dressing is required for a few days, which in most cases will clear the infection. In some cases a course of antibiotics may be required. For nails that are excessively curved, a nail brace may be applied, which over time and as the nail grows will straighten the curvature. In recurrent cases it may be advisable to have a surgical procedure to remove the offending side of the nail. The cells responsible for making that section of nail are destroyed through the use of a chemical. People attempting to self-treat an infected toenail may worsen the problem.
Diabetic persons should consult a registered Chiropodist or their GP for all foot abnormalities.

Omega (involuted) Nail

If no discomfort is evident then it is sufficient to ensure that your nail is reduced in thickness and cut to conform with the shape of the toe.

If the condition is more severe then the podiatrist may deem minor nail surgery necessary to remove part of your nail and ensure that regrowth does not occur.

They are caused by an HPV virus (Human papilloma virus). The virus is very contagious and thrives in warm moist conditions such as the surrounding areas of swimming pools, changing rooms and bathrooms. The virus can also be passed on through towels.
They can range in size from a pin prick right up to covering large areas of the foot. They appear as small, innocuous circles on the skin. As they grow, they form a “cauliflower” like appearance and often are covered with tiny back dots, which are actually small blood vessels. Initially verrucae are painless, however they can also be painful and spread to other areas of the foot.

Signs and Symptoms

1. They can appear as slightly raised lesions. They may become rough and bumpy, distinguished by their cauliflower-like appearance. Most are grey or brown with dark pinpoints. These pinpoints are tiny capillaries that supply blood to the verruca.
2. The visible part of the verruca on the surface of the skin is a small part of the anomaly. Often the part of the verruca beneath the skin is much larger than the visible area.
3. Patients sometimes feel a ‘lump’ similar to having a stone in the shoe. This can cause discomfort especially if the verruca is in a weight-bearing or pressure area.
4. If left untreated, verrucas can grow up to 1 inch in diameter. They may become surrounded by smaller clusters, these are known as ‘mosaic verrucas’.

There are many options for treatment of verrucae:

1. Various chemical treatments on a weekly basis for up to 4-8 weeks or more.
2. Cryotherapy– This involves freezing warts with liquid nitrogen or nitrous oxide gas. This needs to be repeated every 2-3 weeks over a period of time, however this is difficult to determine because it is dependant upon the size of the verruca and the length of time it has been present.
   Over an undetermined period of time, and results in the disintegration of viral cells, allowing healthy cells to replace them.
3. Laser 

People with diabetes mellitus can develop a variety of foot complications. This can result in loss of sensation or a loss of ability to feel pain, heat and cold (Neuropathy) and reduced circulation (Ischeamia). Therefore, people with diabetes are prone to frequent and often severe foot problems and a relatively high risk of infection and ulcers. Patients with diabetes commonly develop onychomycosis because blood circulation is poor in the extremities, and the body’s ability to fight infections is compromised. However, with regular visits to a foot health practitioner, Neurological assessment and monitoring of the pulses of the feet along with patient education, appropriate footwear and daily foot inspections, one can prevent any serious complaints.

1. Wash feet daily with warm water and a mild soap.
2. Dry carefully especially between the toes. 
3. Change hosiery daily, ensure fitting is of the right size and try to wear hosiery made of natural fibres like cotton or wool. 
4. Apply a foot moisturiser daily to prevent the skin from cracking. 
   Do not apply between the toes.
5. If the skin is moist between the toes, wipe with surgical spirit. 
6. Examine your feet daily for cuts, breaks, grazes or blisters. Also check for areas of swelling, sudden colour changes and any discharge from cuts or beneath corns or nails.
   If you are unable to see well or have limited movement, ask a friend or family member to do this for you. 

Footwear is very important. Poorly fitting shoes are a common cause of foot problems in diabetic people.

1. Have your feet measured and check that the shoe fits well.
2. New shoes should be comfortable at the outset and should not need a ‘breaking-in’ period. 
3. Avoid wearing shoes with high heels, pointed toes or those that are tight around the toes. These can apply too much pressure on parts of the foot and can contribute to ulcers.
4. Check the inside of your shoes daily for sharp objects, cracks, stones etc which may irritate the skin.
5. Never use sharp instruments on your feet.
6. Never use corn plasters or lotions as they contain acids which can be dangerous.
7. Avoid direct heat or hot water bottles-loss of sensation and temperature sensitivity make these dangerous.
8. Do not cut your nails too short or down the side or edge of the nail.
9. Avoid walking barefoot.

Diabetes can affect the rate of healing and so breaks in the skin may take longer to heal.
Diabetic persons should consult a registered Foot Health Practitioner for any foot abnormalities and routine care.
Heel
Ideally the heel should have a broad base and the heel height should be no greater than 4 centimetres.
Heel Counter
This is the part of the shoe that holds the heel at the sides and the back, preventing movement when walking. It stabilises and maintains the position of the heel when the shoe makes contact with the ground. The heel counter should complement the shape of your heel.
Sole
The sole should be flat and smooth, with a slight curve upwards at the toes.
Upper
Ideally should be made of a natural material like leather and breathable. Not tight at the toes, which would constrict movement and may cause the toes to be squeezed together.
Lining
Should be smooth and without seams.
Fastenings
Shoes should have laces, straps with buckles or Velcro to keep the foot in place