Foot Disorders and Warts Flashcards
Corn (clavus): traits, what differentiates it, causes
• Small, raised, sharply demarcated, hyperkeratotic lesion with central core
• Due to pressure from underlying bony prominences or joints
• Central core differentiates it from a wart
• Yellowish-gray and well circumscribed
- Diameter of ≤1 cm
- Base is on the skin surface
- Apex points inward and presses on nerve endings, causing pain
• Cause: inappropriate, tight-fitting shoes
Types of Corns
• Polished, shiny, dry hard corns (heloma durum)
- On bulb of big toe, 4th or 5th toe, or tips of middle toe
- Most prevalent
• Soft corns with whitish thickenings of skin (heloma molle)
- Extremely painful
- Grows between toes due to perspiration
Callus: traits, types, causes
- Broad base with even skin thickening
- On joints and weight-bearing areas on hands and feet (heel, ball of foot, toes, sides of foot)
- Indefinite borders (few mm-several cm diameter)
- Raised and yellow with normal ridges
• Types
- Discrete-nucleated: smaller, localized translucent center; painful with pressure
- Diffuse-shearing: covers larger surface area w/o central core; no pain associated
• Causes:
- Friction (loose-fitting shoes/tight-fighting hosiery)
- Walking barefoot
- Structural bio-mechanical problems
Exclusions for Self-care of Corns/Callus
- Diabetes
- Peripheral vascular disease (PVD)
- Lesions hemorrhaging or oozing purulent material
- Anatomic defect or fault in body weight distribution
- Extensive or painful, debilitating corns/calluses
- Proper but unsuccessful self-medication attempt
- Rheumatoid arthritis (RA) and complaint of painful metatarsal heads or deviation of great toe
Treatment of Corns & Calluses: Prevention/Goals
• Prevention - Eliminate pressure and friction - Select properly-fitted footwear • Goals of treatment - Provide symptomatic relief - Remove corns and calluses - Prevent recurrence by correcting underlying causes
Non-pharmacologic Treatment: C/C
• Daily soaking for 5 minutes in warm water
• Gentle debridement with callus file or pumice stone
• Use of barriers
- Circular foam or gel cushioning pads (gel preferred)
- Silicone toe sleeves filled with mineral oil for corns
- Foam spacer or lamb’s wool for soft corns
- Pad or lamb’s wool for painful callus
How to Select Properly-fitted Footwear
- Measure feet every 2 years
- Determine shoe length by longest toe of longest foot
- Distance between shoe tip and longest toe ~1/2” (1” in athletic shoes)
- For arch length, 1st metatarsal head should fit metatarsal shoe break
- For width, should be comfortable at 1st metatarsal joint (not cramped)
- Once size is determined, choose a shoe shaped to match foot shape
- If toe abnormalities (hammer toes) or use orthotics/padding, select toe box with adequate depth and width to prevent friction
- Ensure heel fits snugly and helps hold foot straight
- If physically active, ensure midsole provides cushioning and support
- Try on both shoes, wearing socks that will usually be worn
- If feet tend to swell, select shoes at the end of the day
Pharmacologic Therapy: Salicylic Acid (AE, CV, PV)
• MOA: decreases skin cell adhesion, increases water binding to soften skin
• AEs/Concerns:
- Redness / irritation
- May be hazardous in pregnancy
- Avoid in breastfeeding (Reye’s)
- In peds >2 y.o., limit to 1.8%-6% concentrations
• CV
- Liquid forms film to prevent moisture evaporation
- Extremely flammable and volatile; may be inhaled/abused
- Contain pyroxylin and various combos of volatile solvents or a plasticizer
- Some systemic absorption with prolonged use on large surface areas of children or renal/hepatic impairment
- Cap container tightly, store in amber/light-resistant container away from direct sunlight or heat
• PV
- Direct, prolonged contact → quicker resolution
- Solid or semisolid adhesive on backing material
- Trim to follow contours of lesion, apply plaster, cover with occlusive tape
- If using medicated disks with pads, apply disk and then cover disk with pad
Patient Counseling: Corns/Callus
- Remission can take several days to months
- Eliminate predisposing factors
- Apply only to corns and calluses
- Products with collodions are poisonous when ingested
- Max 14 days of self-care
Common and Plantar Warts (RF)
• Common, caused by HPVs • 7-10% of population has warts - 70% are common warts - Occurrences peak at 12-16 y.o. - Benign, often self-resolving
• Risk factors
- Previous or existing warts
- Immunocompromised health
- Chronic skin conditions
- Biting one’s fingernails
- Barefoot especially on wet surfaces
- Using swimming pools and public showers
- Working in a meat handling occupation
Clinical Presentation: C/P Warts
• Effect skin and mucous membranes anywhere on body
• Common warts
- Skin-colored or brown, hyperkeratotic, dome-shaped papule with rough cauliflower-like appearance
- Frequently occur on hands
- Painless
• Plantar warts
- Skin-colored callous-like lesions on feet
- May be painful, especially if in weight-bearing spot
• Can be confused with corns, calluses, or malignant growths
Exclusions to Self-Care of Warts
- Age <3 for salicylic acid products
- Age <4 for cryotherapy products
- Pregnancy or breastfeeding
- Diabetes, PVD, neuropathy (effects blood circulation to hands/feet)
- Immunocompromised patients
- Large or multiple warts located on one area of body
- Bleeding, painful, discolored warts
- Painful plantar warts
- On face, breasts, armpits, fingernails, toenails, anus, genitalia, or mucus membranes
- Warts not resolved after 12 weeks of self-treatment
• For salicylic acid products only:
- Immunosuppressive medications or medications that contradict salicylic acid
- Salicylate allergy
Cryotherapy for Warts (max duration)
• Destroys wart by freezing wart tissue
• Nitrous oxide (NO)
- Compound W NitroFreeze
• Dimethyl ether + propane
- Compound W Free Off Wart Removal System, others
- Place tip on wart x20-40 sec
- Blister forms under wart and falls off ~10 days
- Repeat after 10-14 days, up to 3x but change applicator
- Adverse effects: blistering, scarring, hypo- or hyper- pigmentation, and tendon or nerve damage with aggressive therapy
- Max duration = 12 weeks
Complementary Medicine for Warts
- Folklore
- Vitamin A
- Dietary zinc
- Garlic
- Duct tape
- Essential oils
Patient Counseling: Warts
- Warts are contagious and spread to other body parts or people
- Warts may progress to a more serious disorder
- See provider if not resolved after 12 wks of self-treatment
- Do not use medicines on moles, birthmarks, warts with hairs growing from them, irritated or inflamed skin, or infected skin
Treatment for Aching Feet
• Non-pharmacologic - Footwear with sufficient padding and cushioning (sport-specific shoes w. arch support, replace worn shoes/heel pads, shoe inserts, partial insoles, heel cups/cushions) - Use a night splint; strap or tape the arch - Decrease weight-bearing activity - Enter weight-loss program - Compression stockings (8-30 mmHg) - Apply ice and/or contrast bath soaks • Pharmacologic - Short-term OTC NSAIDs - Epsom salt baths
Exercise-induced Foot Injuries (ex; exclusions)
- Shin splints
- Blisters
- Ankle sprains
• Exclusions for self-care
- Stress fractures
- Achilles tendonitis
- Toenail loss
- Intermetatarsal neuritis
- Patients with inappropriate gait
- Patients with malformations of the foot
- Diabetes or PVD
Prevention & Treatment: Ex Foot Injuries
• Prevention
- Suitable footwear that fits properly
- Full or partial shoe inserts (also help lower back pain)
- Running on proper surfaces with correct posture
- Stretching before exercises
- Moisture-wicking socks (wool, acrylic)
• Treatment (PRICE, protect/rest/ice/compress/elevate)
- Stop activity, rest
- Alternative exercises
- Cryotherapy, ice bags alternating with heat
- Compression bandages
- Arch supports and heel cushions
- Systemic analgesics
COUNSELING: How to Properly Apply Ice
- Crushed ice in bag
- Squeeze out air (leaks)
- Wrap in thin towel
- Bind injury with wet elastic wrap, apply ice
- Ice for 10 minutes on, remove for 10 minutes
- Repeat 3-4x/day for 12-24 hours
(if ankle = keep in dorsiflexed)
- Fill ice bag with crushed or shaved ice 1/2-2/3 of capacity
- If needed, break ice into walnut-sized pieces w/o jagged edges but crushed/shaved ice is best
- Squeeze out the air, check for leaks
- Wrap ice bag in thin towel if not cloth-covered
- Bind injured part with wet elastic wrap, then apply ice bag
- If ankle is being wrapped, keep in dorsiflexed position
- Apply ice bag for 10 minutes, then remove for 10 minutes
- Repeat 3-4x/day until swelling decreases or 12-24 hours
COUNSELING: Properly Applying Compression Bandages
• Recommend elastic bandages according to area:
- 2” wide: foot, wrist, ankle
- 3” wide: elbow, knee, ankle
- 4” wide: knee, lower leg, shoulder
- 6” wide: shoulder, upper leg, chest
• Unwind and relax 12-18 inches of bandage at once
• If ice is being applied, soak bandage in water
• Overlap previous layer of bandage by 1/3-1/2 of its width
• Tightly wrap the point most distal from injury
• Decrease tightness of bandage as wrapping
• Cold or swollen toes and fingers indicate too tight
• Wash in lukewarm, soapy water and air-dry
Patient Counseling for Injured Feet
• Shin splints
- Rest and ice
- ASA or NSAID; do not take before workout to suppress pain or increase endurance
- See PCP if becomes a cramping, burning tightness repeatedly occurring at same distance or time
• Blisters
- Moisture-wicking socks (wool/acrylic); wear 2 pairs of socks with talcum inside
- Apply compound tincture of benzoin or flexible colloidion product (New Skin) to the blister before exercise to decrease pain and accelerate healing
- Apply antiperspirant (20% aluminum chloride) to feet to prevent
- If breaks, apply 1st aid antibiotic; cover with moleskin to protect
• Ankle sprain
- Max swelling occurs at 48 hrs but begin treatment ASAP
- Stay off foot, wrap compression bandage, apply ice, elevate
- See PCP if swelling >72 hrs
Ingrown Toenails
- Occurs when nail curves and embeds into flesh → pain
Causes
- Onychocryptosis
- Hyperhidrosis
- Trauma
- Obesity
- Excessive pressure on the toes
- Bedridden patients with too-tight bedcovers
Ingrown Toenail Treatment (Pharm, NonPharm, Exclusions, Refer)
• Non-pharmacologic
- Warm water soaks 10-20 minutes several times daily
- Insert cotton wisps or dental floss under nail edge
- Ensure shoes fit properly to eliminate toenail pressure
- Cut nails straight across
• Pharmacologic
- Sodium sulfide gel 1% (Dr. Scholl’s Ingrown Toenail Pain Reliever) BID for up to 7 days w/ retainer ring
- OTC NSAIDs
- Exclusions for self-treatment: if recurrent or oozes discharge, is significantly painful, or severely inflamed
- Evaluate in 3-4 weeks, refer if no relief
