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Flashcards in Common Foot Disorder Deck (58)

Describe the pathophysiology of corns and calluses

Normally, the rate of mitotic division in basal cell layer is the same as the rate of surface cellular desquamination (complete replacement is 1 month)
During corn or callus development, friction and pressure increase mitotic activity of the basal cell layer, leading to the migration of maturing cells through the prickle cell and granular skin layers. This results in hyperkeratosis


What factors contribute to corns and calluses?

Friction due to loos or tight fitting shoes
Structural biomechanical problems
Not wearing socks with shoes or wearing ill fitting socks
Walking barefoot
Weight gain
Secondary condition (plantar warts)


What is a corn?

Small raised, sharply demarcated, hyperkeratotic lesion
Central core/cone (radix) which is triangular shaped and points inward (hard corns)
Soft (heloma molle), hard (heloma durum) or plantar


What are the signs and symptoms of a hard corn?

Well defined
Yellowish-grey colour
Few mm to 1 cm or more in diameter
Shiny, dry and polished with a loss of normal skin pattern
Central core visible
Affects skin directly overlying bony prominence or may occur on soles of feet
Usually occurs on the surface of the fourth or fifth toes


What are the signs and symptoms of a soft corn?

Whitish thickening of skin
Soft in appearance
Usually found on webs between fourth and fifth toes
May be painful
Often confused with athlete's foot


What is a plantar corn?

A corn on the plantar surface of the foot that causes pain on ambulation
May be confused with a plantar wart


What is a callus?

Callosity or tyloma
Superficial patches of hornified epidermis
No central core


What are the signs and symptoms of a callus?

Normal skin patter, no central core
Borders are not well defined
Few mm to several cm in diameter
Slightly elevated
Found on areas where the upper layers of skin are naturally thick (i.e., soles of feet, especially on the heel or ball of the foot)


Describe the pathophysiology of a plantar wart

HPV enters the skin through small cut or abrasion
It infects the upper epidermis and causes squamous epithelial cells to proliferate
It can remain latent or cause subclinical infection (there's an infection but it can't be seen)


What is a plantar wart?

Common viral infection of the skin and mucous membrane
Benign tumour caused by HPV
Incubation period is between initial infection to warty lesion varies between 1 and 8 months
Warts are not permanent (they spontaneously clear between 6 months and 5 years)


If plantar warts spontaneously clear, why is it important to treat them?

They can spread
They are unsightly
They can be painful and restrict activities
They have the potential to transform into malignant lesions


What are the signs and symptoms of plantar warts?

They can occur on the sole of the foot, sole of the heel, great toe, head of metatarsal bone and ball
They are circular lesion with wart in the centre
The surface is rough, greyish-brown and friable surrounded by skin that is thick and heaped
Normal patter of skin is interrupted
Thrombosed capillaries appear as black dots in the centre of the lesion or as pin point bleeding sometimes described as seeds
Singly or in clusters
Usually painless unless direct pressure is applied


When completing differential diagnosis of common foot disorders, what other conditions should be considered?

Hard corn: callus, plantar wart
Soft corn: tinea pedis
Callus: corn, plantar wart
Wart: callus, corn, squamous cell carcinoma


What are the goals of therapy for corns and calluses?

To remove the corns and calluses
To avoid and prevent complications
To prevent recurrence


What are pharmacological treatment options for corns and calluses?

Salicylic acid is the first line treatment
For self treatment use: plaster vehicle (12-40%), collodion vehicle (12-17.6%)


Compare SA dosage forms used to treat corns and calluses

SA collodion: proxylin and various volatile solvents, such as ether, acetone and alcohol or a plasticizer (castor oil. Concentration: 17-17.6%
SA plasters/disk/pads: a uniform or semisolid adhesive mixture of SA in a suitable base which is spread on appropriate back material. Concentration: 40%


What are the advantages of SA collodion?

Forms film which prevents moisture loss
Usually easiest to apply for patent
Less apt to run onto other areas of skin


What are the disadvantages of SA collodion?

Takes longer to resolve
Flammable and volatile
Occlusive nature allows systemic absorption of drug
More irritating than other formulations


What are the advantages of SA plasters/disks/pads?

Provides direct and prolonged contact with skin
Plasters may be cut to fit size of lesion
Disks or pads are more convenient
Easy to apply


What are the disadvantages of SA plasters/disks/pads?

Patient may be sensitive to adhesive


When should collodions be used? What's the duration of treatment?

More useful in the treatment of soft corns rather than calluses
Hard corns and calluses: up to 14 days or earlier
Soft corns: 3-6 days


For what should plasters, disks and pads be used? For who long?

Hard corns and calluses are most easily treated with plasters
Maximum of 5 treatments over a 2 week period
1 treatment is a maximum of 48 hours at a time


How are collodions used?

Soak foot for 5 minutes, dry foot and apply once or twice daily
Apply 1 drop at a time until area is well covered
Allows drops to dry and harden
Do not let adjacent areas of skin come in contact with drug
Periodically soak foot in warm water and remove macerated skin


How are plasters, disk and pads used?

Soak foot for 5 minutes, dry and apply every 48 hours
If using plaster, trim plaster to follow controls of the lesion
Apply and cover with adhesive tape
If using disk/pad, apply appropriately sized on area and cover
Remove within 48 hours
Soak in warm water and remove macerated skin


What are non-pharmacological treatment options for corns and calluses?

Eliminate the cause of the condition
Soak affected area daily throughout treatment for 5-10 minutes in warm water and gently remove dead tissue (avoid use of sharp knives and razors, gently use a pumice stone or callus file)
To relieve pressure, a foam or cushioned pad with an opening can be used for up to 1 week or longer
Change cushion every day
Newer cushions consist of soft polymer that adheres to skin without leaving sticky residue
Custom pads can be constructed using moleskin or lamb's wool
Orthotic devices
Keep feet clean and dry
Avoid moisturizers between toes
Check feet daily


How can calluses and corns be prevented?

Maintain moisture balance (neutral unscented moiturizer, hydrating products (e.g., glacial base), anti-dehydration products (e.g., lubriderm))
Remove dead skin


Explain how to properly select footwear

Purchase shoes at the end of the day when feet are most swollen
Try both shoes on since one foot is larger than the other
Buy shoes in proper sizes and ask a trained professional to measure feet
Shoes should be fitted when individual is standing
First MTP joint should be in the widest part of toe box
Base of shoe length on longest toe of your longest foot
Make sure toes do not bump into front of shoe
Match shoe to activity
Heel should fit snuggly (avoid heels over 1.5 inches)
If patient plans to wear orthotics in shoe, orthotics should be worn during fitting
Once shoe size is determined, choose a shoe shaped to match shape of foot
If patient is physically active, make sure shoe's mid-sole provides adequate support and cushioning
Lace-up shoes are best
Shoes with a wide toe box and lower heel help to prevent toe crowding
Shoes with thicker soles provide cushioning


What are the monitoring parameters for corns and calluses?

Timeframe for improvement: visible improvement in a few days
Timeframe for resolution of the condition: 14 days for hard corn/callus, 3-6 days for soft corn


When should a patient see a physician?

Allergic reaction develops
Skin irritation develops that was not present before and/or is moderate to severe
Skin ulcers develop
Any skin irritation or stinging that is bothersome to the patient
Infection develops


What are the goals of therapy for plantar warts?

Alleviate or prevent pain due to wart
Eradicate lesions and prevent their proliferation
Prevent recurrence
Prevent transmission to other people


What are pharmacological treatment options for plantar warts?

Only plantar and common warts are self treatable
No single therapy is proven 100% effective
Topical SA is first line defence (12-40% in a plaster vehicle, 5-17% in a collondionlike vehicle, 15% in a chary gum-glycol plaster)


What are other (second line) pharmacological treatment options for plantar warts?

Dimethylether (DME) and propane
Duct tape
Cryotherapy with liquid nitrogen
Lactic acid
Formalin (37% formaldehyde)
Surgical intervention
Hyperthermic treatment
CO2 laser therapy


What is the ingredient, strength and MOA of duoplant ointment

Salicylic acid 25%, formalin 5% and lactic acid 10%
SA: keratolytic (removes skin cells infected with HPV and cause inflammation which reduces immune response)
Lactic acid: corrisive properties (enhances SA activity)
F: antiviral activity and anhydrite action


What is the ingredient, strength and MOA of duofilm liquid

Salicylic acid and lactic acid 16.7%
SA: keratolytic (removes skin cells infected with HPV and cause inflammation which reduces immune response)
Lactic acid: corrisive properties (enhances SA activity)


What is the ingredient, strength and MOA of duofilm patch and Scholl one step plantar wart remover pad?

Salicylic acid 40%
SA: keratolytic (removes skin cells infected with HPV and cause inflammation which reduces immune response)


What are the ingredient and strengths of Compound W liquid, Solver Plus liquid and Wart Remover gel?

Compound W liquid: SA 20%
Soluver Plus liquid: SA 27%
Wart Remover gel: SA 17%


What is the ingredient, strength and MOA of canthacure and cantharone

Canthardin 0.7% liquid
Vesicant which causes a blister to forma and wart become necrotic


What is the ingredient and MOA of Compound W Freeze Off and Wartner Plantar Warts

DME and propane
Freezes wart and causes a blister to form under it; wart fall of 10-14 days after treatment


What are the directions for SA 5-17% in collodion vehicle?

Apply 1 drop at a time until wart is covered. If SA touches healthy skin, wash off with soap and water
Use once daily to BID for max 12 weeks


What are the directions for SA 40% plaster and disk?

Tram plaster to fit wart; apply plaster and cover with tape
Disk: choose best size, apply and cover disk with pad
Use q48h for max 12 weeks


What are the directions for SA 15% in karaya gum glycol vehicle?

Apply hs for 8 hours; repeat procedure every 24 hours for a max of 12 weeks


What are the directions for Wartner and Freezeaway?

Apply to wart for 10-40 seconds; only 1 treatment is usually needed
May repeat after 14 days on same wart up to max 3 times for Warnter or 4 times for Freezeaway


What are the directions for cantharidin?

Applied by physician (keep lesion occluded for 3-7 days)


What are non-pharmacological/prevention treatments for plantar warts?

Avoid walking barefoot and keep feet covered in areas where transmission is more common
Change shoes and socks daily
Keep feet clean and ry
Do not share/touch any possibly infected objects or people
Use waterproof tape during treatment
Wash hands before and after cleaning feet and caring for wart
Do not bite, scratch, poke, probe or cut wart tissue
Do not use sharp knives or razors
Soak area throughout treatment for 5-10 minutes in warm water and gently remove dead tissue
Use good foot hygiene even when the wart is gone


How can duct tape be used for plantar warts?

May help with wart removal by causing irritation
Apply to wart for 6 days then remove and soak foot
Soak area throughout treatment for 5-10 minutes in warm water and gently remove dead tissue (treat for up to 2 months)


What are the monitoring parameters for plantar warts?

Timeframe for improvement: 1-2 weeks
Timeframe for resolution of the condition: Wart removal may take 4-12 weeks; maximum treatment is 12 weeks.
Warts may reappear months after initial treatment


When should a patient see a physician for plantar warts?

If the patient develops an allergic reaction after applying the product
If the skin becomes damaged and painful, inflamed or infected
If any wart persists after 12 weeks of treatment


What are side effects of SA for plantar warts?

Redness, burning or irritation


What are precautions and contraindications of SA for plantar warts?

Do not use on irritated, infected/broken skin, moles or birthmarks
Do not use on face, mouth, nose, anus, genitals or lips
Caution if patient takes salicylate, anticoagulants and LMW heparin
Apply petroleum jelly to surrounding skin if the patient has poor eyesight/difficulty using product
Highly flammable
Poisonous if swallowed and/or if inhaled


Describe the safety profile of SA in special populations

No human studies on use of topical SA during pregnancy
Excretion in breast milk and safety if consumed by nursing infant unknown
Caution if patient is under 3 or over 65


What are the side effects and precautions of DME/propane products for plantar warts?

Aching, itching, burning, stinging sensation; can cause burns and permanent scars if used on thin skin
Safety unknown during pregnancy or lactation
Caution if under 4
Caution if patient has DM, PVD or poor circulation
Do not use in inaccessible or hard to reach locations
Treat only 1 wart at a time on toe with a 2 week interval before treating another wart on same digit
Applicators are for single use


What are red flags? (18)

Corns or calluses that indicate an anatomic defect or fault in body with distribution
History of DM, PVD or malnourishment
Patient is immunocompromised or takes immunosuppressants
History of RA and complains of painful metatarsal heads or deviation of great toe
Patient has physical or mental impairments that make following product instructions difficult
Patient allergic to available options (i.e., SA, ASA, adhesives, etc)
Lesion is bleeding or oozing purulent material
Lesions extensive or are painful and debilitating
Proper self-medication has been tried without success
Patients under 3 or over 65 old
Skin is red, swollen, inflamed or infected
Growth that looks like a mole, birthmark
A wart with an unusual appliance
Hair growing from lesion
Extenstive warts at one site
Warts on mucous membranes, face, anus, genitalia or warts under nails
Warts are extremely painful and debilitating


What is a bunion?

Hallux valgus
Deformed big toe joint: joint is angled outward and big toe is angled inward towards other toes
5th toe may develop a bunion (bunionette)
Women are 10 times more likely to develop bunions than men


Describe the pathophysiology of bunions

Hypertrophy of bone and soft tissues around middle of great toe
Great toe becomes abducted and rotated which causes prolonged pressure over first MTP joint
May lead to painful inflammation and swelling of bursa over MTP joint, resulting in formation of a bunion


What are factors that contribute to formation of a bunion

Inherited foot type
Faulty foot mechanics
Constant abnormal joint motion
Shoes that fit improperly and high heels
Occupation that puts stress on feet
Friction from bone malformations
Vigorous exercise
Foot injuries


What are the signs and symptoms of a bunion

Usually bilateral
Bump on outside of edge of big toe
Thickening of skin at base of big toe
Usually asymptomatic but can become quite red, painful, swollen and tender
Restricted movement of big toe


What should be considered for differential diagnosis of bunion?

Gouty arthritis


What are the treatment options for bunions?

Must refer to a physician or podiatrist but in meantime:
Remove source of irritation
Select properly fitting footwear
Modify activity
Moleskin, foam or cushioned pads (bathe/thoroughly dry foot then cut into proper shape and apply)
Bunion guard (soft polymer gel with no adhesives that can be used up to 3 months)
Ice packs ant OTC pain relievers to decrease pain and swelling (acetaminophen and NSAIDs)
Splints and orthotic devices
If pain is severe: intra-articular corticosteroid injection available by physician
Surgery (last resort)