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Dry Heel Fissures: Treatment and Prevention

Authors:

Abstract

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
46
Belinda Longhurst is a podiatrist with a special
interest in podiatric dermatology and Carol
Steele is a podiatrist, both at Winchester
Podiatry, Hampshire
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Dermatological Nursing, 2016, Vol 15, No 3 www.bdng.org.uk
Introduction
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
infection5.
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
tissues.
Management
Manipulation of detrimental impact
forces, as described earlier, with orthoses
or heel cups, plays an important role in
both short- and long-term treatment,
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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
sleeves.
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
fissures.
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
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Dermatological Nursing, 2016, Vol 15, No 3 www.bdng.org.uk
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
fissures.
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).
Conclusion
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.
References
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):
935-41
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.
ac.uk/29427/1/2012_proceedings_v2.pdf
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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
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5. Dockery GL. Mechanical Injuries. In:
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... The feet were dried gently with a towel. Then, thermal images were again taken of the feet after the therapy [15][16][17]. ...
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