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ask an expert: Podiatrist

Annette is the branch chairperson for the SA Podiatry Association (SAPA) in KZN, as well as being the chair of the footwear committee for SAPA. Her special interests are paediatric podiatry, diabetes and footwear related foot problems.
The importance of the correct footwear for our children (and ourselves) cannot be underestimated. If you have any queries, Annette is very happy to help Moms with her expert advice.

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Q  After having a fungal infection i now have 3 brittle thickened toenails. i am even embarrased to wer sandals. any home remedy that you can suggest. thank you
- VilmA

A;. The reason why so many people experience failure in getting rid of fungal infections in the feet is that they have not been made aware of something called the “circle of infection”.

In skin fungal infections, it works something like this:  Fungal spores land on skin -> from the skin, spores get into shoes -> warmth, internal dampness and darkness of shoes plus dead skin cells provide perfect environment for spores to germinate- > shoes (usually closed shoes) are packed away -> person has treatment which resolves skin infection -> person puts on shoes next season -> fungal spores land on skin -> circle begins again.

In toenail fungal infections (often transported from the skin into nail crevasses and under the front of the nail plate): Fungal spores get under the nail plate and germinate -> fungus grows under the nail, creating more spores -> spores drop into shoes -> toenails are cut and spores land on nail clippers (maybe shared by other persons in the family, so fungal spores are spread) -> spores drop into showers, on carpets, prayer mats, gym floors, socks… -> person undertakes proper medical treatment for toenail fungal infection -> is re-infected via shoes, or socks, or shower environment or shared nail clippers, etc. -> fungal spores get under the nail plate ->circle begins again.

Breaking the circle takes a mental commitment to do whatever it takes to prevent re-infection. Fungi and their cousins yeast infections and mould are not destroyed by anti-bacterials such as Dettol or Savlon. Fungus is not destroyed by household laundry (even at 90 degrees) or detergents.  Two inexpensive “weapons” if you like, are effective – UV radiation (good old sunshine) and household bleach (to be used on things only, not on your feet!!!). 

Try also to starve the infections of the humidity they need to thrive - if feet are sweaty, this is a risk factor and appropriate foot anti-perspirants must be used (see your pharmacist or podiatrist). Feet must be dried properly after washing (use a separate towel, to be rinsed with bleach periodically and dried in the sun). Use drying anti-fungal powders on the skin and between toes. Add bleach to final rinses on socks. Use a 50/50 bleach/water solution on a squeezed out cloth (which you keep for this purpose) to thoroughly swab out the inside of shoes/slippers/sandals.

Take care not to splash bleach on shoe uppers or you may damage them. Removable  insoles from sports shoes can be soaked in bleach solution overnight. Dip your nail clippers in bleach overnight, then rinse and pack away. Discard contaminated nail files or bleach them and dry in the sun. Use flip flops in the shower so that you don’t pick up someone else’s spores. 

Socks need to be treated every wash, shoes need regular bleach + UV (sun) treatment at least once a week. Tilt shoes and expose their insides to the sun’s rays (pull down the tongue to open up a lace-up shoe) so that the rays can get into the depths of the toe box.

Consult a podiatrist (www.podiatrist.co.za) to get your fungal infection properly diagnosed (other conditions such as psoriasis, for example, can mimic a fungal nail infection). He or she will take nail samples for laboratory analysis so that the most appropriate medication is indicated for the species of fungus/yeast.

There is no home remedy that can safely be used on skin or toenails to effectively clear a resistant infection. Herbal remedies have varying results and need to be applied more than once a day – some of them, three times a day, so we find that most people don’t keep up that level of effort for long enough.

Lastly, be patient and consistent in your vigilance. Once under medical treatment, it can take up to 2 months to clear a skin infection and it takes between 9 to 10 months to completely clear a fungal nail infection.  You need to ensure you are always taking steps to break the circle of infection, particularly in KZN due to our climate. Skin, shoe and sock anti-fungal hygiene plays an enormous part in determining how successful you will be in enjoying infection-free skin and toenails.

Yours in foot health, Anette Thompson, M Tech Podiatry (UJ) B Tech Podiatry (SA)


Q. A reader enquired, “Since having my daughter, I developed very hard skin and painful big fissures in my feet which sometimes crack and bleed. Is there anything I can do at home to try to alleviate the pain. I am embarrassed by my feet and can’t go barefoot in public such as to the beach; also because it hurts so much to walk on.”

Dear Reader, in your instance, the most likely cause of your cracked heels is directly related to the increased load carried in pregnancy, changes to your hormones then and now, as well as increased load in picking up your child in daily mothering activities. For the benefit of other readers, I’d like to list a few other causes of cracked heels, as your question does not have a quick and simple answer...

Excessive dryness and wetness
The most frequent cause of heel fissures or cracks is dry skin (xerosis).  This is often complicated if the skin around the heel has overlying thickened callus.  Callus is always mechanically caused by peak pressure or friction. Thickened or built-up callus cannot bend easily together with underlying layers of skin, so the mechanical impact of your heel strike in walking can often trigger cracking.  Ground reaction forces on callused heel cracks will displace the cracks deeper, often resulting in painful bleeding. Be aware that habitually walking barefoot actually contributes to a drying out effect on the skin.

Dry skin is not the only culprit.  Both extremes of dryness and wetness can affect the skin’s intrinsic tensile strength.  Excessive sweating can result in soggy skin, which will slide, setting up friction that can trigger callus formation.  Perpetually damp callused heels have poor tensile strength and can just as easily crack as dry heels.

Fungal infection
Secondary to very dry or excessively damp skin, fungal infection can further weaken the skin, causing fissures or cracks.

Mechanical factors
Standing for long periods of time on hard surfaces can predispose heels to crack.  High impact sport such as running will increase the ballistic effect on your heels.  Increased pressure on your heels from carrying weight in excess of your normal body weight, whether through being overweight e.g. in pregnancy or in early motherhood carrying infants, or constant excessive load carrying in any form may lead you to develop cracked heels.  Biomechanical reasons include heel spurs (bony outgrowths of the heel bone), mal-alignment of the metatarsal bones, flat or high arched feet and abnormalities of gait (the way in which you walk).

Metabolic reasons
Some medical conditions can lead to skin becoming very dry, for example, psoriasis and eczema. Dry skin due to reduced sweating can occur from damage to fine nerves (neuropathy) of the autonomic nervous system in such illnesses as diabetes mellitus.  An under-active thyroid will decrease metabolic rate, leading to a decrease in sweating and result in dryness of the skin. Spinal, pelvic, thigh, leg or ankle surgery or trauma can affect the nerves controlling sweat gland function in the feet. Metabolism post pregnancy and breast feeding may take a while to stabilize and you need to ensure that you consume a balanced diet rich in omega 3, 6 and 9 oils as well as your daily requirements of vitamin C for optimum skin health.

What can I do about cracked heels?
Keep skin supple. Any generalised and gradual buildup of hard skin (such as that caused by walking barefoot outdoors) can be removed by means of daily light abrasion (using a pumice stone or fine grit foot file) together with regular night-time use of a heel balm containing at least 15% urea (check the label).  Always moisturize at night before bedtime:  applying heel balm in the morning could cause your feet to perspire excessively inside your shoes.  Consult a podiatrist (if deeper cracks are present)  for painless removal of cracks and medical dermabrasion to restore the layers, after which all you have to do is daily maintenance.

The urea in your heel balm is the important ingredient that weakens the keratin bond, allowing moisturizers to penetrate below the keratin level, keeping skin supple. (N.B. Urea is formulated in a laboratory so it is both halaal and kosher).  Foot creams that do not contain a keratolytic ingredient such as urea will never penetrate the outer heel skin (stratum corneum layer) satisfactorily.

If your feet are always moist or damp, you may need to use a daily anti-perspirant in the morning on the soles of your feet to dry them sufficiently so that dry abrasion (hand held foot file) will work.  Never use anti-perspirants if cracks are already present.  Severe perspiration levels respond well to medical strength anti-perspirants available on consultation with your podiatrist.

Foot care products containing tea tree can prevent fungal infection since recent studies have shown that tea tree has anti-fungal, anti-viral and antiseptic properties.

Never pick or peel skin on thickened heel callus. This will tear across layers, leaving uneven patches that act as a haven for bacteria, and may cause further cracking.  Never attempt bathroom surgery on cracked heels or heel callus. If cracks bleed, you may use adhesive dressings or gauze to relieve pressure on the heels until such time as you can consult a podiatrist.

Never use any form of chemical pads or metal objects (including skin “graters” or scissors) or blades to remove callus.  Your best efforts will result in an uneven surface – that alone will stimulate more callus formation by creating microscopic overload areas. You may risk self-injury and infection.  All cracked heels are best treated by a podiatrist.

Avoid footwear in which your foot will slide around, so as to avoid the friction that stimulates callus formation.  Buy shoes and sandals with shock-absorption in the outersoles or innersoles or both.  Heels can dehydrate to greater or lesser degrees in open-backed footwear in the hot South African climate, so maintain adequate hydration by means of heel balm preparations.

Avoid the use of excessively hot water in bathing or showering – it may cause your feet to perspire while doing so, resulting in loss of valuable moisture from underlying skin layers.

When should I consult a podiatrist about cracked heels?
When dry heels and/or callused cracked heels fail to respond to light abrasion, combined with daily use of a heel balm containing urea, that’s the time to see your podiatrist. A podiatrist will painlessly and smoothly remove the cracks.  He or she may apply various temporary pads to relieve the pressure.  Permanent solutions may include special heel pads or heel cups to stop sideways heel expansion, recommendation of appropriate shoes, or special accommodative innersoles to relieve pressure, or orthotics to correct or accommodate functional problems of your foot structure or gait.

If callus only seems to appear on one side of your heels, or more so on one side of your heels than another, you may have an anatomical or gait imbalance.  These are common problems in biomechanics, which podiatrists are trained to treat.  Your podiatrist is qualified in dermatology of the foot, so consult a podiatrist should you have psoriasis or eczema on your heels.

Ask your podiatrist to simply assess your shoes and your heels if you’re uncertain.
What should I know about footwear to prevent cracked heels?
Look for a good fit at the heel area. Remember that pressure or friction is the cause of callus in the heels.  In the case of open-backed styles, poor fit may result in part of your heel constantly stepping on the edge of the shoe or sandal. 

Styles that improve fit are those that grip around the heel (either closed heel or strap) plus a fastening or closure across the instep of the foot.

Shoes that are too wide will cause shearing stress under the foot as it slides around in the shoe, causing callus to build up under the foot.  Look for a style with suitable fastening across the instep of a shoe to prevent the slide.

Shoes that are too narrow in the heel will pinch the edges of the heel, causing hard ridges of callus.

Shoes made from leather and breathable materials are best since they neither contribute to dehydration nor excessive sweatiness of the feet.

Thin soled shoes or shoes without innersole cushioning will transfer all the ground reaction forces of hard impact with man-made surfaces directly into the bones of your feet, causing the stimulus for callus formation.   

Complications of cracked heels

Untreated cracked heels can result in health complications.  The most common is development of other callused areas under the foot as you change your posture and/or gait to avoid further pressure on your cracked heels.  You may even develop knee, hip or back pain.  Cracks may deepen to the dermal layer, resulting in bleeding.  Open cracks can become infected with viral, fungal and/or bacterial infection.  In diabetics and persons suffering from poor circulation, healing is slower so cracked heels should be avoided.  Always seek professional help. 

Call the South African Podiatry Association on 0861 100 249 or log on to www.podiatrist.co.za for the details of your nearest podiatrist.  Remember that podiatrists are registered with the Health Professions Council, and you may, therefore, claim their fees from your medical scheme.


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