Footcare-Module 148
Find out how to tackle and prevent three common foot conditions with our clinical guide
• common foot conditions, such as verrucas and athlete's foot
• the different products you can offer to treat these conditions
• tips for good foot hygiene
• when to refer patients with foot problems to the pharmacist
Download a pdf version of this module here
Download the Test Your Knowledge questions here
1. Verrucas
Verrucas are warts on the soles of the feet. They are caused by the human papilloma virus (HPV) and are usually harmless. They appear as areas of white skin, often with black dots in the middle (these are blood vessels). Unlike warts on other parts of the body, verrucas are not raised from the surface of the skin. In some patients they can be painful when pressure is applied.
They are very common – around 10 per cent of the population has a verruca at any one time, and most people will get them at some point in their life. Women are slightly more likely to be affected, and verrucas are more common in older children and teenagers than adults.
Verrucas are highly contagious and are spread by close contact with infected skin, or indirectly on objects such as towels or shoes. They are more likely to spread if the person's skin is wet or soft, which is why it's important to prevent transmission in places such as swimming pool changing rooms.
Treatment
You should refer a patient to the pharmacist if they have diabetes or a circulatory disorder, a large number of verrucas or if their skin is cracked and bleeding.
There are a range of possible treatments. Most of these include something that dissolves the skin (such as salicylic acid), dries out the verruca (such as glutaraldehyde) or freezes and kills the infection. Hard skin should be removed with a pumice stone prior to application, but people shouldn't use a scalpel to try and remove a verruca (or any other kind of wart).
It is important to tell patients that treatment of verrucas can take weeks or even months, and sometimes may not work at all, so it's important to reduce the risk of infecting other people.
Patients with verrucas should not share shoes or towels, and while they can still go swimming, they should wear either a waterproof plaster or a verruca sock both in the changing room and the pool.
Patients can be reassured that verrucas will eventually go away on their own.
Why refer patients with diabetes?
Patients with diabetes are prone to poor circulation in their extremities. This particularly affects the feet, and may mean infections can get out of control. Therefore any patient with diabetes who asks for advice about a foot condition should be referred to the pharmacist.
2. Athlete's foot
Athlete's foot is a very common fungal infection, usually starting between the fourth and fifth toes, which causes a rash. It can be itchy, flaky, cause red skin, and cause blisters, cracked skin and a burning sensation.
It's important that it's treated, as it is contagious and can spread to other parts of the feet and toenails. It can also cause cracked skin, so if left untreated it could result in a secondary bacterial infection.
Treatment
Athlete's foot is easy to treat. Products are available as creams, sprays and powders. Many products contain an imidazole antifungal (which all end in ‘azole', such as clotrimazole or miconazole). These kill fungi by interfering with cell membranes.
Other options include terbinafine, which remains on the skin for seven days and can provide up to three months' protection, and griseofulvin, which should only be used for four weeks at a time. Tolnaftate can also be used, which reduces the growth of the fungus. Always check the product is suitable for the patient, as some are restricted to certain age groups.
Treatment should be continued for two weeks after the condition clears to ensure it has been cured. It's important that patients maintain good hygiene during treatment – this includes drying feet carefully after washing (especially between toes) and changing socks daily. Natural fibres such as cotton will ventilate the feet and reduce the risk of reinfection. Antifungal powder can also be used to prevent recurrence.
If treatment doesn't work, or the infection is particularly bad (either spreading to the sole, toenails or upper skin of the foot, or there is sign of a secondary infection), the patient should be referred to the pharmacist. Patients with diabetes should also be referred.
3. Fungal nail infections
Fungal nail infections are common, affecting about 3 per cent of people. They can be caused by the spread of other conditions, such as athlete's foot, or because of unclean, sweaty trainers. Sometimes there is no obvious cause. The nails typically change colour (they can be black, yellow or even green) and may thicken. They can also become brittle, allowing pieces to be broken off easily.
Treatment
Nail infections should be referred to the pharmacist, who will assess the patient to make sure it is a fungal infection and not something else. If the patient needs treatment, they will be referred to their GP, who will take a clipping of the nail to identify the causative organism. Fungal infections are generally treated with prescription antifungals, or antifungal paint that is applied to the nail. However, this isn't a quick cure – it can take up to a year for antifungal treatment to cure the affected nail. Patients are usually able to see the new, healthy nail emerge and the old, infected nail will slowly grow out. While the nail is being treated, it's important that patients maintain good foot hygiene. This includes changing socks regularly, and trying to avoid wearing trainers as much as possible. Patients should also be advised to use a separate pair of clippers to cut their infected nail, as this will prevent the infection spreading to other, healthy toes.
Key points
• Patients with diabetes who have foot problems should always be referred to the pharmacist
• Patients need to take steps to prevent spread and reinfection with many foot conditions. These include using verruca socks or flip flops in communal areas, or using a different set of nail clippers for infected toenails
• Foot conditions tend not to resolve quickly – verrucas and nail infections can take months to heal and treatment for athlete's foot should be continued for
two weeks
Evaluation
• Are you familiar with the range of OTC treatments for feet? Find out which products are suitable for each age group, and their active ingredients.
• Your pharmacy probably stocks several types of nail clippers and scissors. Have a look at them, and work out their advantages and disadvantages. Which would you recommend?
• Some products create a
protective coating for verrucas, meaning the patient doesn't have to buy plasters or a verruca sock. Find out which products have
this effect.
• A lot of foot problems can be caused by ill-fitting shoes. Your pharmacy probably stocks a range of insoles and heel grips – make sure you know how these products are used.
