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Dry Heel Fissures: Treatment and Prevention



Heel fissures associated with hyperkeratotic and anhidrotic skin are a common problem faced by many health professionals. Moreover, such lesions can act as a portal of entry for secondary infection and further complications. Challenges include creating optimal conditions for achieving wound healing in conjunction with reducing detrimental impact forces, removal of hyperkeratosis (callus) and ultimately; deterrence of further episodes. Thus, the successful treatment and prevention of dry heel fissures is dependent on addressing these multiple factors.
Belinda Longhurst, Carol Steele
Belinda Longhurst is a podiatrist with a special
interest in podiatric dermatology and Carol
Steele is a podiatrist, both at Winchester
Podiatry, Hampshire
Dermatological Nursing, 2016, Vol 15, No 3
Heel fissures are splits or cracks in
the epidermis, which can manifest as a
consequence of anhidrosis and may or
may not present with hyperkeratosis.
Epidermal fissures are superficial and not
considered to be a wound at this early
stage. However, with increased pressure
these splits become deeper, involving
the dermis so that they begin to bleed
and result in pain on weight-bearing
activities. These fissures are regarded as
partial-thickness skin wounds1 and are
at increased risk of developing infection.
Full-thickness ulcer formation can occur
if the fissure progresses further, resulting
in an open wound that has the potential
to lead to deeper infection and cellulitis,
especially in patients with diabetes and
peripheral vascular disease2.
Fissure formation often develops
at sites where the epidermis is under
direct physical stress, such as the heel
margin. The heel pad plays an important
role as a shock absorber by reducing
and transmitting impact forces. This
transmission of load was investigated
by Ahanchian et al3 who produced a
finite model that also demonstrated
propagation of tissue stress with
increased contact load. These areas of
high tissue stress are often associated
with fissures, despite the apparent lack
of direct pressure, particularly when
combined with anhidrosis. Furthermore,
the authors noted that impact forces
increase tensile deformation of soft
tissue and can create short-term vascular
changes in the heel pad. All of which can
result in tissue breakdown and fissuring.
Hashmi et al4 identified the
mechanical properties of both dermal
and epidermal cells on plantar skin and
how they react to physical stress by
generating inflammatory cytokines that
cause incomplete cell differentiation.
This leads to a clumping of corneocytes,
which manifests as hyperkeratosis and,
frequently, fissures.
Potential complications
In most cases dry fissures are simply a
nuisance and unsightly. However, when
the fissure extends to the dermis,
standing, walking or even lying in bed
can be painful, in addition to providing a
Dry heel fissures: treatment
and prevention
Heel fissures associated with hyperkeratotic and anhidrotic skin are a common problem faced by many
health professionals. Moreover, such lesions can act as a portal of entry for secondary infection and
further complications. Challenges include creating optimal conditions for achieving wound healing in
conjunction with reducing detrimental impact forces, removal of hyperkeratosis (callus) and ultimately
deterrence of further episodes by hydrating anhidrotic tissue. Thus the successful treatment and
prevention of dry heel fissures is dependent on addressing these multiple factors.
Citation: Longhurst B, Steele C. Dry heel fissures: treatment and prevention. Dermatological Nursing 2016, 15(3): 46-49
portal of entry for bacterial and fungal
Hyperkeratosis is a physiologic
process intended to form a protective
barrier against further soft tissue
damage4. However, these lesions become
pathologic when they split, become
painful or exhibit signs of secondary
infection. In cases of severe peripheral
neuropathy or vascular disease, such
as that seen in patients with diabetes,
hyperkeratotic fissures may be a
harbinger of ulceration because the
associated anhidrosis, abnormal load
distribution and stiffening of connective
tissue can lead to failure of skin
integrity2. For the person with diabetes,
having a foot ulcer can have a severely
detrimental effect on their quality of
life. Most amputations are preceded by
a foot ulcer and there is a likelihood
of psychological distress and anxiety6.
In addition to diabetes mellitus, other
systemic conditions can also render
patients more at risk of developing dry
heel fissures, such as hypothyroidism,
rheumatoid arthritis, systemic sclerosis
and scleroderma, due to the associated
anhidrosis and/or thickening of the soft
Manipulation of detrimental impact
forces, as described earlier, with orthoses
or heel cups, plays an important role in
both short- and long-term treatment,
Dermatological Nursing, 2016, Vol 15, No
in addition to prevention of dry heel
fissures by deflecting pressure3. However,
successful management also requires
removal of any localised cause of
hyperkeratosis, if possible. Topical, or
in some instances oral, treatment of
bacterial, fungal and viral infections, with
appropriate medication can eliminate or
reduce the underlying cause.
The skin integrity of superficial heel
fissures can be positively influenced
by regular reduction of hyperkeratosis
with a scalpel, abrasive file or keratolytic
agents, along with regular application
of a suitable emollient to hydrate the
tissues and restore the epidermal
barrier4, which is the goal of treatment
and continued management. Cells of
the stratum corneum maintain a high
water content with the assistance of
Natural Moisturising Factors, including
urea and extracellular lipids, which act
as a waterproof mortar between these
corneocytes7. It is here that the skin
barrier often fails with anhidrosis, which
occurs with ageing and other conditions,
such as eczema8.
Historically, moisturisers and creams
have been utilised as standard practice
to hydrate anhidrotic tissue. However,
many of these are petroleum- or
paraffin- based, which can be a fire
hazard if soaked into dressings, or contain
sodium lauryl sulphate, which has now
been documented as a sensitiser for
contact dermatitis and actually increases
trans-epidermal water loss8. Thus, the
requirement to adopt evidence-based
treatment with regards to the selection of
emollients is appropriate.
An emollient is a lipid-based
moisturising product that occludes the
epidermal surface, preventing trans-
epidermal water loss and takes the form
of ointments, sprays, creams, gels and
lotions. Ideally, these are used as both
a soap substitute in cleansing and then
applied as a leave-on moisturiser after
washing9. Emollients can make surfaces
slippery, so preferably should be applied
at night to reduce the risk of falls.
Efficacy is improved when applied under
occlusion, which can be in the form of
hydrocolloid dressings10, socks or heel
Humectants are the added
ingredients, such as urea, lactic acid,
glycerine, etc, which act as an adjunct
to the occlusive effect of emollients
and retain cell hydration by attracting
moisture from the dermis into the
epidermis. Trans-epidermal water loss
travels from the inner to the outer layers
of the epidermis and these humectants
retain this moisture and reduce water
loss. Urea is well documented for its
keratolytic effect on the epidermis in
concentrations of both 10% and 25%
by separating or loosening ‘clumped up’
layers of hyperkeratotic skin.
NICE Guidelines (2004)11
recommend regular use of emollients,
with the added humectant urea, as part
of the routine foot-care regime in people
with diabetes.
Pavicic and Korting2 concurred
that regular application of humectant-
based emollients improves elasticity,
hydration and desquamation rates of
the stratum corneum, thereby reducing
risk of ulceration, and that urea-based
moisturisers appear to be particularly
suitable for the removal and prevention
of callus and fissures.
The recently published Young
Townson Footskin Hydration Scale
for Diabetic Neuropathy12 classifies
the extent of anhidrosis and callus
into 4 levels. Level 1 is ‘well hydrated
heels, with little or no signs of drying’
with the recommended treatment
being a standard emollient after
washing, such as those containing 10%
urea, applied daily or nightly. Level
4 is ‘callused skin with open splits’,
and the recommendation here is to
assess for possible infection, advise
the patient not to wear open-backed
shoes without socks and prescribe a
25% urea emollient for daily use. They
suggest that once a level 4 patient
regains epidermal hydration they should
then switch to a lower percentage
urea content (ie 10%) as with level
Figures 1a and b
Pre- and post-treatment with emollient containing glycine and urea.
Figures 2a and b
Pre- and post-treatment with emollient.
a b
1, thereby promoting patient-specific
emollient therapy.
While emollients are regarded as safe
with limited side-effects, some individuals
do report stinging or discomfort on
application of those containing the
higher concentrations of urea7. This is
usually transient, however consideration
of patient-specific treatment in use of
emollients should be utilised, particularly
for those with sensitive skin, such as
eczema and psoriasis. These patients may
not exhibit hyperkeratosis, yet still suffer
with anhidrosis and recurring dry heel
It is well documented that the natural
moisturising factors, urea and glycerine,
can be severely depleted in patients
with eczema13, leading to anhidrosis
and fissuring of the heels (Figures
1-2) thus maintaining hydration is of
importance in this population. A recent
unpublished evaluation14 for a humectant
emollient, which contained 5% urea and
5% glycerine, suggested that a lower
concentration of urea together with
an additional sugar alcohol compound
humectant reduces the discomfort
associated with higher concentrations of
urea as the sole keratolytic.
Once a painful fissure develops,
preventative treatment such as callus
reduction and emollient use do little to
reduce the pain or the risk of bacterial
infection. Therefore, so long as no infection
is present, immediate measures should
Dermatological Nursing, 2016, Vol 15, No 3
be taken to reduce that risk and provide
instant and lasting pain relief by means of
closing the fissure.
When considering a wound closure
device, ideally it should be easy to use,
rapidly acting and painless in addition to
resulting in pleasing aesthetics, require
no device removal and be cost-effective.
Topical cyanoacrylate skin adhesives
offer many of the characteristics of this
ideal wound closure device15. Studies
have clearly demonstrated that a moist
environment is best for optimal wound
healing16 and cyanoacrylates (skin
adhesives) are reported to create an
occlusive wound healing environment and
a barrier to microbial penetration17.
The results of the 2009 Cochrane
database trials18 suggested that medical-
grade skin adhesives are an acceptable
wound closure option and demonstrated
no statistical difference between adhesives
and sutures for non-closure, infection
or appearance of non-infected surgical
wounds. It was also noted that adhesives
offered a decreased procedural time,
reduced cost and that immediate and long-
lasting pain was reduced, in comparison
with other wound closures. While these
trials were examining use of adhesives
for closure of surgical incisions, the
same benefits of wound closure can be
extrapolated for treatment of dry heel
In 2010, an evaluation of the
current effectiveness of a medical grade
glue in the management of dry heel
fissures was undertaken across four
podiatry practices19. An evaluation of 18
patients with dry fissuring of the heels
demonstrated patient satisfaction and
resolution of the heel fissure in 94%
of cases, with pain relief noted as a key
benefit of the modality.
While adhesives may be easy to use
and have some advantages it should be
noted that they are not suitable for all
fissures12, particularly where infection is
suspected or on areas of high tension,
and can only be used as an immediate
and short-term treatment20. Therefore,
skin adhesives can form a useful part of a
practitioner’s treatment plan (Figure 3).
Management and prevention of dry heel
fissures encompass both short- and long-
term treatment plans. The use of medical-
grade skin adhesive can be a useful
adjunct in short-term management to
promote healing of the wound, although
its use is limited to uninfected fissures.
Treatment of localised bacterial, fungal or
viral infections can eliminate or reduce the
underlying cause of fissuring, and removal
of pathological hyperkeratotic skin will help
restore epidermal function.
The risk of recurrence can be
significantly reduced long-term by
manipulating detrimental forces with
use of in-shoe devices such as heel cups.
Moreover, the importance of regular
application of patient-specific emollients to
maintain hydration of the epidermis and
thus preserve the integrity of the skin as a
barrier against infection should be stressed
by practitioners to ensure the patient
remains fissure-free.
1. Feldman DL. Which dressing for split-
thickness skin graft donor sites? Ann Plast Surg
1991, 27(3): 288-91
2. Pavicic T, Korting HC. Xerosis and callus
formation as a key to the diabetic foot syndrome:
dermatological view of the problem and its
management. J Dtsch Dermatol Ges 2006, 4(11):
3. Ahanchian N, Nester C, Howard D, Ren L.
3D modelling of the human heel pad. Salford
Postgraduate Annual Research Conference
2012, 31-36. Available at: usir.salford.
Figure 3
Tissue adhesive in the management of heel fissures.
4. Hashmi F, Nester C, Wright C, Newton V, Lam
S. Characterising the biophysical properties of
normal and hyperkeratotic foot skin. J Foot Ankle
Res 2015, 12(8): 35
5. Dockery GL. Mechanical Injuries. In:
Cutaneous Disorders of the Lower Extremity 1997.
WB Saunders, Pennsylvania, p242
6. Iversen MM, Midthjell K, Tell GS, et al.
The association between history of diabetic
foot ulcer, perceived health and psychological
distress: the Nord-Trøndelag Health Study.
BMC Endocr Disord 2009, 9:18. Available at:
7. Bristow I. Emollients in the care of the diabetic
foot. Diabetic Foot J 2013, 16(2): 63-6
8. Cork MJ, Danby S. Skin barrier breakdown: a
renaissance in emollient therapy. Br J Nurs 2009,
18(14): 872-7
9. Penzer R. Emollients: selection and application.
Podiatry Now 2005, 9: S1-S8
10. Springett K, Deane M, Dancaster P. Treatment
of corns, calluses and heel fissures with a
hydrocolloid dressing. J Br Podiatr Med 2001,
52(7): 102-4
11. National Institute of Health and Care
Excellence. Type-2 Diabetes: Prevention
and management of foot problems. Clinical
guideline 10, January 2004. NICE, London.
Available at:
12. Young M, Townson M, Hicks G. A
photographic scale to aid appropriate foot skin
care for people with diabetes. Diabetic Foot J 2014,
7(2): 70
13. Draelos ZD. Eczema Regimens. In: Draelos
ZD (Ed), Cosmetic Dermatology: Products and
Procedures, 2nd edn. John Wiley & Sons Ltd,
Oxford, 2015
14. Steel C, Longhurst B. An appraisal of
IMUderm [Unpublished data]
15. Beam JW. Tissue adhesives for simple
traumatic lacerations. J Athl Train 2008, 43(2):
16. Feldman DL. Which dressing for split-
thickness skin graft donor sites? Ann Plast Surg
1991, 27(3): 288-91
17. Mertz PM, Davis SC, Cazzaniga AL, Drosou A,
Eaglstein WH. Barrier and antibacterial properties
of 2-octyl cyanoacrylate-derived wound treatment
films. J Cutan Med Surg 2003, 7(1): 1-6
Coulthard P, Esposito M, Worthington HV,
van der Elst M, van Waes OJF, Darcey J. Tissue
adhesives for closure of surgical incisions.
Cochrane Database Syst Rev 2010, 12(5):
Longhurst B, Allan E, Bristow IR. The use
of cyanoacrylates in the management of dry
heel fissures: a preliminary study. Podiatry Now
2010, 13(9): 11-15
Vlahovic TC, Hinton EA, Chakravarthy D,
Fleck CA. A review of cyanoacrylate liquid skin
protectant and its efficacy on pedal fissures. J
Am Col Certif Wound Spec 2011, 2(4): 79-85
The BDNG would like to thank the following
companies for their continued support
Bio Diagnostics
Derma UK
LEO Pharma
Stiefel, a GSK Company
T&R Derma
BDNG Corporate Sponsors
Dermatological Nursing, 2016, Vol 15, No
... The feet were dried gently with a towel. Then, thermal images were again taken of the feet after the therapy [15][16][17]. ...
Full-text available
Plantar foot skin exhibits unique biophysical properties that are distinct from skin on other areas of the body. This paper characterises, using non-invasive methods, the biophysical properties of foot skin in healthy and pathological states including xerosis, heel fissures, calluses and corns. Ninety three people participated. Skin hydration, elasticity, collagen and elastin fibre organisation and surface texture was measured from plantar calluses, corns, fissured heel skin and xerotic heel skin. Previously published criteria were applied to classify the severity of each skin lesion and differences in the biophysical properties compared between each classification. Calluses, corns, xerotic heel skin and heel fissures had significantly lower levels of hydration; less elasticity and greater surface texture than unaffected skin sites (p < 0.01). Some evidence was found for a positive correlation between hydration and elasticity data (r ≤ 0.65) at hyperkeratotic sites. Significant differences in skin properties (with the exception of texture) were noted between different classifications of skin lesion. This study provides benchmark data for healthy and different severities of pathological foot skin. These data have applications ranging from monitoring the quality of foot skin, to measuring the efficacy of therapeutic interventions.
Full-text available
Topical tissue adhesives have been used widely in healthcare for the closure of wounds and lacerations (Beam 2008). A recent Cochrane review (Coulthard et al 2009) has indicated the benefit of this modality over other more traditional types of closure. However, little investigation has been undertaken into the potential applications of tissue adhesives in podiatry, such as closure of dry heel fissures which often cause pain and offer a challenge for podiatrists to manage effectively (Singh 1996). A case series is presented reporting the use of a glue in the management of dry heel fissures. A review of 18 patients treated with Octyl-Blend10™ tissue adhesive (MedLogic Global Ltd®, Plymouth, UK) was undertaken across four private practices in Hampshire. Each patient underwent administration of tissue adhesive by the podiatrist and was followed up for a minimum of three weeks. Outcomes were measured using a patient/practitioner evaluation and feedback form and digital photographs of the lesions before, during, immediately after and three weeks post treatment. Overall the response was positive from patients and practitioners alike with regard to ease of application, aesthetics and patient comfort. During the study period, 94% (17 patients) of lesions healed with no adverse events. Instant and lasting pain relief following application was reported by the majority of patients. Dehiscence of the fissure occurred in only 1 subject. This exploratory work suggests that cyanoacrylates, and the Octyl-Blend10™ tissue adhesive in particular, may have a place in the management of painful heel fissures.
Full-text available
While the adverse impact of a history of a foot ulcer on physical health among persons with diabetes is well known, little is known about the association between foot ulcer, perceived health and psychological distress. Results from various studies are difficult to compare as different study designs, samples and/or different questionnaires have been used. The aim of this study was to compare levels of anxiety and depression, psychological well-being and perceived health between persons with diabetes, with or without a history of foot ulcer, and persons without diabetes in a large study of community-dwelling individuals. This study included 65,126 persons, of whom 63,632 did not have diabetes, 1,339 had diabetes without a history of foot ulcer and 155 had diabetes and a history of foot ulcer. Levels of anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). Psychological well-being was measured on a four-item scale, and perceived health was measured with a one-item question. We investigated whether levels of anxiety, depression, psychological well-being and perceived health were different in the three study groups using multiple regression models controlling for demographic factors, body mass index, smoking and cardiovascular conditions. Separate multivariate analyses comparing the two diabetes samples were additionally adjusted for diabetes-specific variables. A history of foot ulcer was significantly associated with more depressive symptoms, poorer psychological well-being and poorer perceived health compared to participants without diabetes. In multivariate analyses, perceived health and psychological well-being were significantly poorer among those with a history of foot ulcer compared to those without diabetes. Among persons with diabetes, perceived health was significantly worse among those with a history of foot ulcer. After multivariate adjustment, levels of anxiety and depression and psychological well-being did not differ between the two diabetes groups. Perceived health and psychological well-being were significantly poorer among participants with diabetes and a history of foot ulcer compared to those without diabetes. Among people with diabetes, a history of foot ulcer had significant negative impact on perceived health but did not independently contribute to psychological distress.
Background Besides enhancing healing, an ideal dressing should prevent invasion of pathogens and control the number of bacteria already present in the wounds. Objective To evaluate the barrier and antimicrobial properties of a cyanoacrylate-based bandage (LAB) against Staphylococcus aureus or Pseudomonas aeruginosa on partial thickness wounds in swines. Methods: Barrier study Bacteria were inoculated over test materials (LAB, standard bandage, air-exposed) that were placed over wounds. The bacteria from wounds were quantitated at 24, 48, and 72 hours postinoculation. Antimicrobial study: Wounds inoculated with bacteria were covered with LAB, standard bandage, or hydrocolloid bandage or left air-exposed. The bacteria recovered from wounds were quantitated at 24 and 72 hours after treatment. Results: Barrier study No bacteria were recovered from LAB-treated wounds. Antimicrobial study: LAB reduced the number of inoculated bacteria in comparison to all other groups. Conclusion LAB is effective in protecting wounds from external bacterial invasion and reducing bacterial contamination.
Dry skin (anhidrosis, xerosis) commonly affects the feet of many patients. In a people with diabetes, dry skin has the potential to progress to cracking and fissuring creating a portal of entry for bacteria. The causes of the dry skin are varied and often multifactorial. Research evidence investigating the management of this condition using emollients is limited to a few small scale studies coupled with clinical experience. This paper will review how dry skin may develop, focussing on the diabetic foot, and suggest an approach to managing this common condition.
Background: Sutures (stitches), staples and adhesive tapes have been used for many years as methods of wound closure, but tissue adhesives have entered clinical practice more recently. Closure of wounds with sutures enables the closure to be meticulous, but the sutures may show tissue reactivity and can require removal. Tissue adhesives offer the advantages of an absence of risk of needlestick injury and no requirement to remove sutures later. Initially, tissue adhesives were used primarily in emergency room settings, but this review looks at the use of tissue adhesives in the operating room/theatre where surgeons are using them increasingly for the closure of surgical skin incisions. Objectives: To determine the effects of various tissue adhesives compared with conventional skin closure techniques for the closure of surgical wounds. Search methods: In March 2014 for this second update we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting. Selection criteria: Only randomised controlled trials were eligible for inclusion. Data collection and analysis: We conducted screening of eligible studies, data extraction and risk of bias assessment independently and in duplicate. We expressed results as random-effects models using mean difference for continuous outcomes and risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes. We investigated heterogeneity, including both clinical and methodological factors. Main results: This second update of the review identified 19 additional eligible trials resulting in a total of 33 studies (2793 participants) that met the inclusion criteria. There was low quality evidence that sutures were significantly better than tissue adhesives for reducing the risk of wound breakdown (dehiscence; RR 3.35; 95% CI 1.53 to 7.33; 10 trials, 736 participants that contributed data to the meta-analysis). The number needed to treat for an additional harmful outcome was calculated as 43. For all other outcomes - infection, patient and operator satisfaction and cost - there was no evidence of a difference for either sutures or tissue adhesives. No evidence of differences was found between tissue adhesives and tapes for minimising dehiscence, infection, patients' assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction. However there was evidence in favour of using tape for surgeons' assessment of cosmetic appearance (mean difference (VAS 0 to 100) 9.56 (95% CI 4.74 to 14.37; 2 trials, 139 participants). One trial compared tissue adhesives with a variety of methods of wound closure and found both patients and clinicians were significantly more satisfied with the alternative closure methods than the adhesives. There appeared to be little difference in outcome for different types of tissue adhesives. One study that compared high viscosity with low viscosity adhesives found that high viscosity adhesives were less time-consuming to use than low viscosity tissue adhesives, but the time difference was small. Authors' conclusions: Sutures are significantly better than tissue adhesives for minimising dehiscence. In some cases tissue adhesives may be quicker to apply than sutures. Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theatre, they need to be aware that sutures minimise dehiscence. There is a need for more well designed randomised controlled trials comparing tissue adhesives with alternative methods of closure. These trials should include people whose health may interfere with wound healing and surgical sites of high tension.
Introduction: Skin fissures are a common dermatologic condition caused by excessive dry skin, numerous systemic diseases, and backless shoe gear. They are defects in skin that fall into the category of damaged, partial-thickness skin wounds, as opposed to full-thickness wounds. Patients with heel fissures are at an increased risk for developing infection, which could cause more severe issues, especially in patients with diabetes and peripheral vascular disease. Methods: Five patients from Temple Foot and Ankle Institute, Philadelphia, PA, with a total of 8 heel fissures and 2 hallux fissures, were studied. Patients were dispensed 9 vials of a cyanoacrylate liquid skin protectant (Marathon(™), Medline Industries, Inc, Mundelein, IL) to be applied to the fissure every 3 days. Patients returned every 2 weeks for follow-up in clinic. Results: The hallux fissures and 4 of the heel fissures went to complete closure after 2 weeks. There was an average decrease of 1.16 cm in length of the heel fissure dimensions after 2 weeks and an average decrease of 1.1 cm in length of the hallux fissures. Conclusion: This novel skin protectant proved to be a comfortable, easy, and effective tool in aiding the resolution of pedal skin fissures.
Breakdown of the skin barrier is the first event in the development of atopic eczema (atopic dermatitis). Research over the past five years has indicated that this arises as a result of the interaction of environmental agents such as soap and other detergents with the products of changes in several genes. These genetic changes predispose to the breakdown of the skin barrier, which allows the penetration of allergens, triggering a flare of atopic eczema. This new understanding of how breakdown of the skin barrier is the first event in the development of atopic eczema provides a rationale for a renaissance in the use of a complete emollient therapy regimen in atopic eczema and related skin barrier breakdown diseases, such as asteatotic eczema and irritant contact dermatitis.
There is currently little agreement among surgeons regarding the dressing of choice for split-thickness skin graft donor sites, though many are available. In this article, I review the five major groups of dressings, open, semiopen, occlusive, semiocclusive, and biological. The different dressings in each group are described in terms of physiological basis for use, advantages, disadvantages, and practical application. Conclusions are reached regarding which donor site dressings might come closest to optimal for common clinical situations.