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Feet and legs are put through their paces each day but over time neglect, poor health and inappropriate footwear can all take their toll.

 

 

Foot care is an important pharmacy category, particularly over the summer months when people seek solutions to unsightly foot problems and subject their feet to increasing levels of activity. Maintaining the health and wellbeing of the feet and legs is also essential for avoiding complications in diabetes and helping elderly people to retain their independence.

In this article, we help pharmacists step up their support for customers by answering some common questions relating to the health and wellbeing of the lower limbs.

Are some people more prone to athlete’s foot than others?

As the name suggests, people who regularly take part in sport are more prone to athlete’s foot, says David Wain, director and podiatrist at Carnation Footcare, because the fungus responsible is typically picked up by walking barefoot on communal changing room or shower floors, while “enclosed shoes create the necessary moist, warm conditions for it to thrive”.

Treatment is necessary as the infection is not self-limiting, and can lead to cracked, sore feet or spread to other areas if left untreated. There are two types of over-the-counter antifungal treatments available: fungistatics and fungicidals. The former comprise imidazoles, including clotrimazole, tolnaftate and bifonazole, which work by inhibiting the growth of fungi. The latter, including terbinafine, work by killing the fungi. Products containing hydrocortisone 1% can also help to soothe the associated inflammation.

Poor adherence is a common issue with athlete’s foot treatments because the symptoms may disappear before the fungi have been destroyed completely. It is therefore essential that people continue to treat athlete’s foot for the specified time.

Various lifestyle measures can help guard against subsequent infections, including regularly changing footwear, wearing flip-flops in changing rooms and carefully drying between the toes after washing.

How long do fungal nail infections take to treat?

Fungal infections of the nail plate or bed (onychomycosis) develop slowly and cause the nail to become thickened, discoloured and distorted. According to David Wain, it is not always possible to identify the source of the infection, although damage to the nails or cross-infection from athlete’s foot are common factors. Wearing enclosed shoes increases the risk, while people with certain medical conditions, including diabetes and psoriasis, are also more vulnerable.

Treatment depends on the severity of the infection, and includes antifungal medicines such as terbinafine or itraconazole, topical antifungal products and, in severe cases, chemical removal or laser treatment. For cases affecting up to two nails, pharmacists can recommend an OTC nail lacquer containing amorolfine, which requires once weekly application. They may need to support patients to continue with treatment until the infected nail has grown out, which may take up to nine-to-12 months.

Alternatively, ointments containing urea are available which, when applied once daily and covered with a dressing, can improve the appearance of the nail in two to four weeks.

Poor adherence is a common issue with athlete’s foot treatments

 

What’s the best way to prevent and treat blisters?

Blisters are painful, fluid-filled lesions produced by friction and pressure. They usually occur due to walking for long periods in tight or poorly fitting shoes, but excessive moisture and toe deformities can be aggravating factors.

Customers should resist the temptation to pop blisters, but should instead apply a protective and cushioning blister plaster. Hydrocolloid blister dressings relieve pressure while promoting recovery. Open blisters should be washed with mild soap and water and treated with antiseptic and a soft gel dressing.

Keeping the feet dry and wearing correctly fitting shoes with socks can help keep blisters at bay, while products are available that reduce friction and help prevent blisters from forming.

Who is at risk of bunions?

Bunions are caused by a common toe deformity known as Hallux valgus, in which the big toe is angled excessively towards the second toe. A bunion is the bony prominence on the side of the big toe where a large sac of fluid (known as a bursa) can form, which can become inflamed and sore. The condition tends to progressively worsen and in severe cases can lead to walking difficulties, as well as increasing the risk of corns and calluses, says the Society of Chiropodists and Podiatrists (SCP).

Women are more at risk of bunions than men, which may be due to wearing restrictive footwear or because women have looser tendons. Bunions that develop in later adulthood may indicate underlying arthritis. Wearing deep, wide shoes with an adjustable strap or using orthotics can prevent the condition worsening while, in severe cases, surgery may be necessary.

What is the best way to treat corns and calluses?

Corns and calluses form as a result of pressure on certain places on the foot. The former appear over bony prominences such as joints, while the latter occur on larger areas of skin, such as the soles of the feet and the heels.

Patients should never attempt to cut corns themselves, says David Wain, who recommends applying corn caps containing salicylic acid, provided the user is otherwise healthy and does not suffer from diabetes or circulatory disorders. A trial involving 202 patients over three years at Sheffield Teaching Hospital NHS Foundation Trust found that medicated corn caps removed corns more quickly and gave greater relief than scalpel treatment, as well as reducing the likelihood of reoccurrence by 60 per cent, says Wain. Foam corn wraps are also available to cushion the area.

Calluses can be reduced with regular use of a pumice stone or foot file, followed by the application of a moisturising foot cream. Care should be taken to avoid the moist skin between the toes. Customers also have the option of using a product containing glycolic acid, which softens and exfoliates toughened skin.

What is the most effective way to tackle foot odour?

With 250,000 sweat glands, feet tend to sweat more than other parts of the body, but structural problems can also lead to excessive perspiration. Sweaty feet in adolescents may be due to over-active sweat glands triggered by changing hormonal levels in the body.

The SCP advises alternating footwear and wearing shoes made from breathable fabric (e.g. leather) along with cotton socks and medicated insoles to prevent any embarrassment and discomfort associated with sweaty feet. In addition, a careful foot hygiene routine involving antibacterial soap and a deodorising foot spray is recommended.

What is the difference between a verruca and a wart?

Both warts and verrucae are caused by the human papilloma virus (HPV), which breeds in warm, moist environments such as swimming pools and changing rooms. Children and teenagers are particularly susceptible to both.

Verrucae occur most frequently on the balls of the feet and appear as small puncture marks that later turn greyish and bumpy and may have a black spot in the centre.

By contrast, warts are small, skin-coloured, roughish excess growths of skin that can occur on their own or in clusters.

Unless the patient has diabetes or circulation problems, verrucae and warts can be safely and effectively treated with OTC products containing salicylic acid. However, if a verruca appears to be getting larger, the SCP advises consulting a podiatrist.

Keeping the feet clean and dry and covering up abrasions can help minimise the risk of infection, while verrucae should be covered with plasters to prevent transmission.

Can heel and arch pain be prevented?

According to consultant podiatrist, Dr Tariq Khan, around 10 per cent of the population suffer from plantar fasciitis – inflammation of the band of tissue that runs along the underside of the foot (the plantar fascia).

The problem is commoner in middle age, particularly if people are overweight or suddenly increase their activity levels. Wearing unsupportive footwear and standing for long periods can aggravate the condition. If untreated, plantar fasciitis can lead to mobility problems and loss of independence for elderly people.

Speaking at the launch of Carnation PediRoller, Dr Khan said: “Plantar fasciitis is the most common cause of heel and arch pain. It is caused by overloading the feet and repetitive movements, which lead to spasms and foot fatigue.”

He advises stretching the muscles in the feet after walking or wearing heels to “avoid spasms the next morning and prevent long-term problems”. Podiatrists recommend using a foot massage tool or a frozen water bottle to massage and stretch the foot, and relieve the pain of plantar fasciitis.

What are the risk factors for VTE?

Two-thirds of venous thromboembolism cases occur in hospital or or shortly after discharge. In fact, according to a House of Commons health committee report, an estimated 25,000 deaths occur as a result of hospital-acquired VTE in England every year – more than the combined total of deaths from breast cancer, AIDS and traffic accidents and 25-times the number who die from MRSA. Happily, the national VTE prevention programme has had some success in reducing the number of hospital-related blood clots.

NICE guidance requires hospital staff to carry out VTE risk assessments when patients are admitted to hospital and offer preventative treatment to those deemed to be at risk, including those undergoing major surgery or who will be confined to bed for long periods, people over 60 years and overweight individuals. Women who are pregnant or taking combined oral contraceptives or HRT are also at an increased risk.

Other risk factors include injury to the blood vessels, vasculitis and some forms of medication, such as chemotherapy. Despite media scares, long-haul travel is not thought to pose any greater risk of VTE than other long periods of inactivity. If people are concerned about developing VTE on a long journey, they can be advised to use fitted compression hosiery and do regular foot exercises.

Community pharmacists are well placed to flag up patients returning from a hospital stay who have not been risk assessed for VTE, and to undertake MURs or the NMS to ensure that patients understand how and why to take their prescribed prophylaxis.

What makes leg ulcers slow to heal?

An ulcer is a broken area of skin, in which the subcutaneous tissue (and in some cases the bone) has become exposed and has failed to heal due to an underlying problem, such as infection, poor circulation or diabetes.

The treatment of ulcers, which aims to protect the wound, prevent infection and speed up healing, can involve protective dressings, padding, hard skin removal, specialist supports, antibiotics and surgery, depending on the severity of the condition. However most ulcers are slow to heal and one-third fail to do so entirely.

According to the Lindsay Leg Club Foundation, there is a particularly strong correlation between low healing rates for leg ulcers and social isolation and poor adherence to treatment. In addition, the pain, odour and bandages associated with foot and leg ulcers can lead to poor self-esteem, depression and social stigma.

David Wain believes pharmacists could have a key role as part of a wider multi-disciplinary team in helping to prevent and treat foot and leg ulcers. For example, they should be able to identify and refer ‘at risk’ patients early, he says, as well as encouraging patients with diabetes to attend annual foot checks. They can also look out for problems such as cuts that do not heal, colour changes, swelling, movement difficulties, skin that feels hot to the touch and weeping skin.

What causes varicose veins?

Varicose veins are swollen, enlarged veins that are blue or purple in colour and may be lumpy, bulging or twisted in appearance. It is estimated that over 6 million people in the UK suffer from the problem – 5 million of which are women, according to Activa Healthcare.

Varicose veins occur due to ineffective valves in the veins of the legs, which allow blood to flow backwards and pool in the veins, causing them to become weakened, elongated and dilated. While the condition is not usually associated with long-term health problems, it can be painful and unsightly.

Varicose veins are thought to be hereditary, while other risk factors include pregnancy, old age, injury to the legs, constriction due to heart or lung disease, being overweight and long periods of inactivity.

The first sign of varicose veins is usually a feeling of heaviness or aching in the legs, followed by swollen feet and ankles and muscle cramps. Using graduated support tights at this stage may prevent the condition from worsening, while advanced cases may benefit from sclerotherapy injections, compression therapy or surgery. Regular exercise and avoiding long periods of inactivity may also help.

Who is most at risk of oedema?

Oedema (fluid retention) can occur anywhere in the body but is most common in the feet and ankles, where it is known as peripheral oedema.

As well as swelling or puffiness of the skin, oedema can cause skin discolouration, aching limbs, stiff joints, weight gain or loss, and raised blood pressure and pulse rate. Most cases of oedema occur in older people who have been standing or sitting for long periods on a hot day, while in some cases the problem is due to an underlying heart or kidney condition or a side-effect of medication. In severe cases, oedema can also collect in the lungs and cause shortness of breath (pulmonary oedema).

Fluid retention may be reduced by regular exercise, losing weight and elevating the legs several times a day, while diuretics may be prescribed to reduce fluid build-up.

Oedema is described as chronic if it has been present for longer than three months. In chronic oedema the fluid in the tissues can cause skin alterations, such as ‘pitting’, tissue thickening and fibrosis. Supervised treatment with inelastic compression bandages and hosiery is required to reduce the swelling.