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Category Archives: Insights

A Guide To Dry Skin Disorders In The Lower Extremity

At this wintry time of year, more patients may be presenting with cracked heels and itchy feet due to dry skin. Accordingly, this author discusses the diagnosis and treatment of different forms of dry skin, including dry skin concomitant with common diseases. 

How many times a day do you see any of these conditions: stasis eczema, eczema, atopic dermatitis, contact dermatitis, xerosis, psoriasis or stucco keratosis? The skin might seem like a structure you have to get past in order to get to the muscles, bones and other organs. However, the skin problems are what bring patients into a podiatrist office with symptoms like tightness, tingling, itchiness, burning, scaling, flaking and lichenification. When you cannot concentrate on your work because you are scratching.  When your sleep is interrupted because of burning sensations or when you have noticeable dry skin patches on your legs, then dry skin is in the fast lane.

The skin can be a “mirror” of what is going on in the body and therefore needs to be taken into concern and consideration. The lower legs and heel are notoriously problematic with dry skin symptoms. However, when visiting your podiatrist for these problem, the hands and forearms will also be examined. This will help in  evaluating the problem so as to get a big picture of what is going on. The feet do not exist in a vacuum.    The skin acts as a barrier and protects underlying tissues from infection, desiccation, chemicals and mechanical stress. Disruption of these functions results in increased transepidermal water loss and deceases in the stratum corneum’s water content, and is associated with conditions like atopic dermatitis, eczema, xerosis, contact dermatitis and other chronic skin diseases.

Moisturizers can improve these conditions through restoration of the integrity of the stratum corneum, acting as a barrier to water loss and replacement of skin lipids and other compounds.1 Despite the knowledge of well recognized aggravating factors, the etiology of dry skin conditions is an enigma and the management of the condition is often suboptimal.2    In the foot and ankle region, we have three types of skin: plantar skin, which has no oil glands and the largest number of sweat glands anywhere; dorsal skin, which is normal skin; and the skin overlying the shin, which is the thinnest and more prone to injury.    Dry skin occurs when the stratum corneum is depleted of water. The skin’s outer layer consists of dead, flattened cells that gradually move toward the skin’s surface and slough off. The cells of the stratum corneum have lost their nucleus, are rich in keratin and are known as “corneocytes.”3 Intercellular lipids bind the corneocytes together. When this layer is well moistened, it minimizes water loss through the skin and helps keep out irritants, allergens and germs.

However, when the stratum corneum dries out, it loses its protective function. This allows greater water loss, leaving your skin vulnerable to environmental factors.    Under normal conditions, skin requires a water content of 10 to 15 percent to remain supple and intact.4 This water gives the skin its soft, smooth and flexible texture. The water comes from the atmosphere, the underlying layers of skin and sweat. Oil produced by skin glands and fatty substances produced by skin cells act as natural moisturizers, allowing the stratum corneum to seal in water.

The skin contains natural moisturizers: ceramides, glycerol, urea and lactic acid. These help rehydrate skin to prevent water loss, which is the reason that many of the products out on the market contain urea, lactic acid, salicylic acid and glycol. They are trying to “mirror” the skin. The essential ingredient of an emollient is lipid (fats, waxes and oils).5    Ceramides are the natural moisturizing factors and are the major lipid constituents of the intercellular spaces of the stratum corneum. These lipids theoretically provide the barrier property of the epidermis.2 The link between skin disorders and changes in barrier lipid composition, especially in ceramides, is difficult to prove because of the many variables involved. However, most skin disorders that have a diminished barrier function present a decrease in total ceramide content with some differences in the ceramide pattern.

Patients with skin diseases such as atopic dermatitis, psoriasis, contact dermatitis and some genetic disorders have diminished skin barrier function.6    We continuously lose water from the skin’s surface by evaporation. Under normal conditions, the rate of loss is slow and the water is adequately replaced. Characteristic signs and symptoms of dry skin occur when the water loss exceeds the water replacement, and the stratum corneum’s water content falls below 10 percent.7    Any factor that damages the stratum corneum can interfere with its barrier function and lead to dry skin. By and large, the feet are not subject to the typical factors that affect skin elsewhere including long, hot showers and cold, dry air, detergents and solvents. The feet are more subject to chafing and rubbing due to walking as well as the interplay between socks and shoes.

 

What You Should Know About Skin Structure And Ethnicity

A recent study has demonstrated that skin properties at the level of the stratum corneum vary considerably among ethnic groups.8 East Asian and Caucasian skin are characterized by low maturation and a relatively weak skin barrier. African-American skin is characterized by low ceramide levels and high protein cohesion in the uppermost layers of the stratum corneum.    There is more transepidermal water loss in African-American skin than in Caucasian skin, predisposing patients to more xerosis. Ceramides are the major lipid constituent of lamellar sheets present in the intercellular spaces of the stratum corneum. These lamellar sheets provide the barrier property of the epidermis.2    Ceramide levels in African-American skin are the lowest while Caucasians, Hispanics and Asians have the highest levels.9 So one can infer that black skin is more prone to xerosis and the pathology can be due to xerosis.

 

African-American communities use the term “ashy” to describe dry skin. The skin is dry, cracked and powdery, and one can see the skin flakes more easily on dark skin. In our society, the ashy color is considered unacceptable and many African-Americans use oils or petrolatum to address this.10    We generally regard moisturized skin as healthy and healthy looking. There may be corresponding changes in the optical properties when skin is moisturized.11 In healthy skin, there is less light scattering at the skin surface and more light penetration into the deeper skin layers when the skin is moisturized. As a result, the skin appears darker, more pinkish and more translucent.    One popular moisturizer is shea butter. Shea butter is a yellow “fat” or “oil” extracted from the nut of the African shea tree. Complications of the use of occlusive emollients such as Vaseline and shea butter used on the dorsal foot and lower leg can result in “oil folliculitis” if the leg is hairy.

Pertinent Insights On The Relationship Between Footwear And Dry Skin

Unlike any other anatomical area, the feet are subject to much chafing, rubbing and sweating, which can affect the skin surface. Wearing shoes without socks can dry out the feet depending on the material the shoes are made from. Due to body heat and moisture, there is almost always higher heat and humidity inside your shoes. If the shoe material is breathable as in leather, the heat and humidity being pushed out can escape from the shoes and such ventilation keeps your foot dry and comfortable. Non-breathable material such as vinyl blocks the heat and humidity inside. Some people have sweatier feet than others and this will interact with the shoe as well. Sweaty feet actually dry out the skin quicker. Shoes that do not fit as well (flip flops, open backed sandals) produce more friction to dry out the skin.    However, when dry skin occurs on the feet, the symptoms of discomfort are magnified due to shoe wear, the stretching of the skin on the feet each time we step down and by certain synthetic materials in the socks and shoes that dry the skin out even more. Due to the confining nature of the shoes we wear and the lack of fresh air that hits the skin of the feet due to our socks and shoes, dry feet need specialized care in order to prevent pain. In many cases, shoes we wear can also protect our feet from dry skin and fissures if they fit properly and are made of breathable material.

 

Abnormal foot mechanics and deformities cause abnormalities in the way we walk. This subsequently causes certain areas of the feet to bear abnormal amounts of weight, which may result in dry patches, calluses, corns and fissures. Orthotics and wearing correct shoes help to spread out abnormal weight and reduce friction. One must remember that the skin of the feet has no oil glands and must rely on the sweat glands to moisturize the skin. Sweat glands operate by secreting a substance comprised mostly of water, sodium chloride and electrolytes. Accordingly, sweat is more “drying” than moisturizing. Each of our feet is densely covered with approximately 250,000 eccrine sweat glands, making feet one of the sweatiest places on the body.

 

The lack of oil glands makes preventing dry skin difficult but if we had oil glands on our feet, we would slip and slide with each step we took. Socks absorb sweat and are supposed to prevent blisters. It is known that certain synthetic socks can decrease the temperature of the foot as much as 3º and that is enough to prevent blister formation by limiting sweating. Dry feet are not the same as dry skin of the feet.  One study looked at fabric softeners and surmised that fabric softeners provide benefits to individuals with dry skin because of the decreased friction of the garments against the skin.12 Since friction results in heat, the heat will dry your feet out faster. It is known that nylon and rayon socks cause dryness to the skin.    In one study, the prevalence of Type IV hypersensitivity to rubber allergens was evident in patients with stasis eczema and/or venous leg ulcers over an 18-month period.13 Accordingly, vascular hose in some patients may result in a dry, itchy skin response and when not wearing the hose at night, patients must moisturize.

Treatment Tips For Specific Skin Conditions

Stucco keratosis. This is a keratotic papule that is usually present on the distal lower acral extremities of males. Stucco keratosis seems to appear with a higher frequency in males but it is not genetic. The lesion is asymptomatic and patients usually do not complain of having the lesions. The name stucco keratosis derives from the “stuck on” appearance of the lesions. The lesions are usually found in elderly patients. The differential diagnoses are seborrheic keratosis and melanoma.

Xerosis. Xerosis results in generalized or localized pruritus and dry, itchy skin. Rubbing and scratching causes increased irritation, leading to more pruritus and inflammation.14

Lichen simplex chronicus (neurodermatitis). Prolonged itching and scratching can lead to skin that is thick, scaly and leathery. The patches can be raw, red or darker than the rest of your skin.

Stasis dermatitis (venous eczema, varicose eczema). Stasis dermatitis is not “true” dermatitis but instead is due to venous hypertension in the lower leg. This is caused by insufficiency of the superficial veins as well as the long saphenous vein. One study found that when patients received classical flush ligation and a saphenectomy, lower leg dermatitis healed in all 10 patients within eight to 12 weeks, and there was no recurrence.15

Eczema craquelé (winter itch, asteatotic eczema, xerotic eczema, desiccation dermatitis). Eczema craquelé occurs mostly in elderly individuals with tight, red, dry skin that progresses to superficially fissured dermatitis. The irregular network of fissures resembles a dry riverbed and is visible on the shins of legs. This is essentially “advanced” xerosis.9

Atopic dermatitis. In this form of eczema, one has more sensitive and drier skin due to an autoimmune condition.

Psoriasis. Psoriasis involves the rapid buildup of rough, dry, dead skin cells that form thick scales. These scales bleed when patients pick them off. It occurs mostly on the plantar skin in the foot.

Which Came First, Dry Skin Or The Itch?

Dry, “flaky” skin is an irritant and causes cutaneous inflammation, which in turn results in pruritus. Once the itch-scratch-itch cycle starts, the skin gets worse. The inflammation irritates the nerve endings.16 Treatment of dry skin is one of the most important measures against pruritus.17 Prevention is very important.

Researchers have rarely found correlations between itch and objective measures of barrier function and skin dryness such as skin hydration and transepidermal water loss. Recent experimental evidence indicates that damage to the stratum corneum with acetone/ether and water elicits a scratching response in mice and rats.18

Skin diseases associated with itch include eczema, atopic dermatitis, dry skin, contact dermatitis, psoriasis, lichen planus and bacterial infection.

Topical treatments for itch/dry skin: Polidocanol (Asclera, Merz Aesthetics) Capsaicin Menthol Phototherapy Lotions and creams Steroids Systemic treatments for itch/dry skin: Antihistamines Antidepressants Gabapentin (Neurontin, Pfizer) Opiate antagonist

Keys To Diagnosing Dry Skin

For the most part, dry skin is a purely clinical diagnosis. A thorough history, review of systems and physical examination are critical to determining its cause. Examination of the skin may be misleading. There are frequently only secondary lesions, eczematous changes, lichenification and excoriation, and the inciting cause may not be present. If primary lesions are present, a skin biopsy can lead one to a diagnosis. One must consider systemic causes of dry skin/itch, such as cholestasis, uremia, hyperthyroidism, medications or lymphoma.

However, if the normal topical treatments are not resolving the condition, have the lab test for thyroid function, renal function, liver function, HIV, zinc level, cancer, or Sjögren’s syndrome.

Treating Dry Skin

The first step to treat dry skin is to add water to the skin and apply a hydrophobic substance to keep it there. The substances include water-in-oil creams and lotions or 100% oil ointments to lock in the water. No matter what the cause of dry skin is, occlusive moisturizers, humectant emollients and keratolytics are three commonly used topical treatments. For the most part, emollients work by retaining water in the skin where it is needed and enabling the repair of damaged cells on the skin’s surface. Emollients also act as a barrier to the environment, preventing irritants from penetrating the outer layer of the skin (epidermis) by creating a protective lipid film.3 

Occlusive emollients such as petrolatum prevent water loss only by acting as a layer of oil on the surface of the skin to trap water and prevent evaporation. Humectant emollients such as Eucerin (Beiersdorf) penetrate the stratum corneum and draw water from the dermis to retain it in the epidermis.

Keratolytics such as lactic acid, salicylic acid and glycolic acid help remove scales. Many times all three are together in one product.    

 

While topical steroids do not treat dry skin, they do decrease the inflammation of the skin and the “itch” factor. Maximum hydration can occur with 60% propylene glycol in water applied under occlusion.19 When using topical steroids, choose a mid-potency steroid for dorsal skin and a high potency to super high potency steroid on plantar skin. All topical steroids have increased absorption through the incomplete skin barrier.    

When discussing the choice of emollients, a continuum exists between oily ointments and water-based creams and lotions. Ointments are best for the driest of skin conditions and for use at home when patients are not wearing tight clothes or working with others. The application of ointments can cause folliculitis in hairy areas, an unusual issue in the foot and ankle. The frequent use of emollients reduces the need for steroids.20

To avoid or treat xerosis, patients should moisturize their feet right after a bath or shower. They should avoid soaking their feet in hot water for long time periods, using drying soaps on the feet or scrubbing feet dry.    Anecdotal and limited data suggest that gabapentin, cutaneous field stimulation, serotonin antagonists and ultraviolet B phototherapy may reduce itch in some of these patients.

Combating The Effects Of The Sun

The sun adds to the drying out of the skin just like the cool air of winter and the dry air of a desert. If the skin barrier is compromised, patients can have increased dryness. Snow, sand and water increase the need for sunscreens because they reflect the sun’s rays. A sunscreen product acts like a very thin bulletproof vest, stopping the ultraviolet photons before they can reach the skin and inflict damage. It contains organic sunscreen molecules that absorb UV and inorganic pigments that absorb, scatter and reflect UV. There are sunscreens now that help prevent dry skin by moisturizing as well.21   

The sun’s heat dries out areas of unprotected skin and depletes the skin’s supply of natural lubricating oils. In addition, the sun’s UV radiation can cause burning and long-term changes in the skin’s structure. The sun causes dry skin, sunburn and actinic keratosis. Skin appears as dry, flaky and wrinkled.

Other Considerations With Dry Skin Conditions

Cracked heels. Podiatrists frequently see cracked heels due to poor foot mechanics, prolonged standing, being overweight, poor shoe gear, open backed shoes and the usual cause, flip flops. It is the perfect storm of friction, lack of oil producing glands and inadequate shoegear. In these conditions, the fat pad under the heel expands sideways and increases the pressure on the side. If there is any lack of moisture in the heel, it will crack.    Accordingly, if you have an overweight patient with diabetes who wears house slippers much of the day, expect her to have cracks in the heels. Cracked heels are more common during the winter months although if you spend extended amounts of time in the sun, it can also dry out your skin to cause cracked heels. Medical conditions including diabetes, obesity, thyroid disease and psoriasis may also cause dry, cracked heels.    

Aged/elderly skin. In elderly skin, the epidermis thins and the corneocytes do not adhere to each other as well and the skin loses its water-binding capacity. Dry skin is itchy skin and itchy skin is dry skin. It is difficult to split them up. Itching in the elderly presents a diagnostic and therapeutic challenge. A thorough history, review of systems and physical examination are critical to determining the cause of itching.    Examination of the skin may be misleading.

There are frequently only secondary lesions, eczematous changes, lichenification and excoriation, which we may misdiagnose as a primary dermatitis. Xerosis may be the cause but it is sometimes merely coincidental. If primary lesions are present, a skin biopsy can aid in diagnosis. Consider systemic causes of itching such as cholestasis, uremia, hyperthyroidism, medications or lymphoma. 

If the cause remains elusive, consider idiopathic itching of the elderly or so-called “senile pruritus.” The pathophysiology of this form of pruritus is poorly understood but it is likely that age-related changes of the skin, cutaneous nerves and other parts of the nervous system play a role.22

Treating Dry Skin That Is Concomitant With Common Diseases

Certain disease states can cause xerosis so in the workup, one should make note of congenital and acquired ichthyoses, atopic dermatitis, hypothyroidism, Down syndrome, renal failure, malnutrition, malabsorption, HIV, lymphoma, liver disease, Sjögren’s syndrome and certain drugs.

End-stage renal disease (ESRD). This is a progressive and irreversible kidney dysfunction lasting three months or more. Nearly all patients with ESRD have at least one dermatological disorder, and these skin and nail changes can occur before or even after initiation of dialysis or transplantation.23 Some authors have suggested that ESRD–associated xerosis may be a result of decreased water content in the epidermis. Clinical and histologic evaluations have shown an overall decrease in sweat volume in patients with uremia as well as the atrophy of sebaceous glands.24

Xerosis occurs in 50 to 75 percent of dialysis patients.24 It manifests as poor skin turgor with scaling, dryness and fissuring of the skin, particularly affecting extensor surfaces of extremities.    

Of those with chronic renal failure, 15 to 49 percent experience pruritus. Of those patients undergoing dialysis, the prevalence is up to 50 to 90 percent but as dialysis has improved, it has become less common.24 In acute renal failure, pruritus is very uncommon. The pruritus of ESRD is most often generalized and light, but can be severe and unremitting.23

Hypothyroidism. Hypothyroidism is more common in women and people over the age of 50. The thyroid produces too few thyroid hormones and this reduces the activity of the sweat and oil glands, leading to rough, dry skin. Symptoms with a high specificity for hypothyroidism include constipation, cold intolerance, proximal muscle weakness, hair thinning and dry skin. Dry skin can be a symptom of hypothyroidism in infants and children as well. A blood test can determine the level of thyroid stimulating hormone as well as thyroid hormones T3 and T4.

 

Diabetes. People with diabetes have a high incidence of xerosis of the feet, especially on the heels. While assessing for predictors of foot lesions in patients with diabetes, one study found that 82.1 percent of their patients had skin with dryness, cracks or fissures.25 An unpublished survey of 105 consecutive patients with diabetes conducted by one of the authors revealed that 75 percent had clinical manifestation of dry skin. Dry skin often leads to cracks and fissures, which can serve as a portal of entry for bacteria.    

Despite possible “dry skin” definition discrepancies across the studies, it is clear that the skin dryness is one of the earliest and most common manifestations of type 1 diabetes. The clinical observations are supported by objective findings of a reduced hydration state of the stratum corneum and decreased sebaceous gland activity in patients with diabetes without any impairment of the stratum corneum barrier function.26

Liver disease. The liver neutralizes toxins and filters bile salts. If the liver’s function is impaired, these materials can accumulate in the body and deposition in the skin causes irritation and itching. In cholestatic liver disorders such as primary sclerosing cholangitis and obstructive gallstone disease, pruritus tends to be generalized but is worse on the feet and hands.27

In Conclusion

Dry skin can be persistent and recurring due to the long list of possible causes. Clinicians often treat dry skin with hydrophilic and/or lipophilic moisturizers.

Hydrophilic moisturizers must penetrate the stratum corneum deeply to function properly whereas lipophilic moisturizers should remain in the upper stratum corneum layers.28

Traditionally, clinicians used humectant and occlusive technologies to treat dry skin. Originally, non-lamellar forming ingredients such as petrolatum were in use but recent research has shown an advantage of using lamellar-forming factors such as ceramides, pseudoceramides and phospholipids.29

As with all topical treatments, adherence is the great challenge one faces in the management of skin diseases. Strong odor from ingredients and greasy compositions may be disagreeable to the patients. Furthermore, low pH and sensory reactions, from lactic acid and urea for example, may reduce patient acceptance.30

The number of studies on skin barrier function and hydration is endless. There is a long list of products available and some may work better depending on certain skin characteristics of the person. Many podiatry friendly companies have products that include CeraVe (Valeant), Eucerin, AmLactin (Upsher Smith), Cetaphil (Galderma), Borage Therapy (ShiKai), Uramaxin (Medimetriks), Carmol 40, Lubriderm (Johnson and Johnson), and Aveeno (Johnson and Johnson).

Dr. Morse is the President of the American Society of Podiatric Dermatology. He is a Fellow of the American College of Foot and Ankle Surgeons, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Morse is board certified in foot surgery. He is on the Podiatric Residency Educational Committee at the MedStar Washington Hospital Center in Washington, D.C. 

References

1. Nolan K, Marmur E. Moisturizers: Reality and the skin benefits. Dermatologic Therapy. 2012; 25(3):229-233.

2. Coderch L, López O, de la Maza A, Parra JL. Ceramides and skin function. Am J Clin Dermatol. 2003; 4(2):107-29.

3. Watkins P. Using emollients to restore and maintain skin integrity. Nursing Standard. 2008; 22(41):51-57.

4. Pons-Guiraud A. Dry skin in dermatology: a complex physiopathology. J Eur Acad Dermatol Venereol. 2007; 21(Supp 2):1-4.

5. Vorgeli D. The vital role of emollients in the treatment of eczema. Br J Nursing. 2011; 20(2):74-80.

6. Choi MJ, Maibach HI. Role of ceramides in barrier function of healthy and diseased skin. Am J Clin Dermatol. 2005; 6(4):215-23.

7. Johnsen G, Haugsnes A. A new approach for an estimation of the equilibrium stratum corneum water content. Skin Research Technology. 2010; 16(2):142-145.

8. McKinley-Grant L. VisualDx: Essential Dermatology in Pigmented Skin. Lippincott, Philadelphia, 2011, pp. 322.

9. Aziz N. Xerosis and eczema craquele. In McKinley-Grant L (ed): VisualDx: Essential Dermatology in Pigmented Skin. Lippincott, Philadelphia, 2011, pp. 316.

10. Johnson B, Moy R, White G. Ethnic Skin – Medical and Surgical. Mosby, St Louis, 1998, p. 4.

11. Jiang ZX. DeLaCruz J. Appearance benefits of skin moisturization. Skin Research & Technology. 2011; 17(1):51-5.

12. Fujimura T, Takagi Y. Real-life use of underwear treated with fabric softeners improves skin dryness by decreasing the friction of fabrics against the skin. Int J Cosmet Sci. 2011;33(6):566-571.

13. Gooptu C, Powell SM. The problems of rubber hypersensitivity (Types I and IV) in chronic leg ulcer and stasis eczema patients. Contact Dermatitis. 1999; 41(2):89-93.

14. Arndt K, Hsu J. Manual of Dermatologic Therapeutics, seventh edition. Wolters Kluwer, Philadelphia, pp. 72-74.

15. Sippel K, Mayer D, Ballmer B, Dragieva G, Lauchli S, French LE, Hafner J. Evidence that venous hypertension causes stasis dermatitis. Phlebology. 2011; 26(8):361-5.

16. Hazin R. Recognizing and treating cutaneous signs of liver disease. Cleve Clin J Med. 2009; 76(10):599-606.

17. Bigliardi PL. Pruritus–causes, diagnostics and treatment. Revue Medicale Suisse. 2006; 2(63):1115-8.

18. Yosipovitch, G. Dry skin and impairment of barrier function associated with itch – new insights. J Cosmet Sci. 2004; 26(1):1-7.

19. Scott S. Atopic dermatitis and dry skin. In: Krinsky D. Berardi R, Ferreri S, et al (eds). Handbook of Nonprescription Drugs, 17th edition. American Pharmacists Association, Washington, DC, 2012, pp. 615-630.

20. Domino F. 5-Minute Clinical Consult 2014, 22nd edition. Lippincott Williams and Wilkins, Philadelphia, 2013.

21. Available at http://www.scientificamerican.com/article.cfm?id=how-does-sunscreen-protec . Published May 7, 2007. Accessed Dec. 6, 2013.

22. Ward JR, Bernhard JD. Willan’s itch and other causes of pruritus in the elderly. Int J Dermatol. 2005; 44(4):267-273.

23. Lynde C, Kraft J. Skin manifestations of kidney disease: Conditions range from benign to life-threatening. Parkhurst Exchange. 2007; Vol.15, No.02

24. Nunley JR, Elston DM. Dermatologic manifestations of renal disease. Available at http://emedicine.medscape.com/article/1094846-overview . Published April 11, 2012. Accessed Dec. 9, 2013.

25. Litzelman DK, Marriott DJ, Vinicor F. Independent physiological predictors of foot lesions in subjects with NIDDM. Diabetes Care. 1997; 20(8):1273-1278.

26. Pavlović MD. The prevalence of cutaneous manifestations in young patients with type 1 diabetes. Diabetes Care. 2007; 30(8):1964-1967.

27. Ballmer-Weber BK, Dummer R. Pruritus in frequent skin diseases and therapeutic options. Praxis. 2007; 96(4):107-11.

28. Caussin J, Rozema E, Gooris GS, Wiechers JW, Pavel S, Bouwstra JA. Hydrophilic and lipophilic moisturizers have similar penetration profiles but different effects on SC water distribution in vivo. Experimental Dermatol. 2009; 18(11):954-61.

29. Pennick G, Chavan B, Summers B, Rawlings AV. The effect of an amphiphilic self-assembled lipid lamellar phase on the relief of dry skin. Int J Cosmet Sci. 2012; 34(6):567-74.

30. Loden M. Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders. Am J Clin Dermatol. 2003; 4(11):771-88.

Editor’s note: For related articles see “Keys To Differentiating Eczematous Eruptions In The Pedal Skin” in the April 2009 issue of Podiatry Today, “What You Should Know About Atopic Dermatitis” in the September 2005 issue, “A Guide To Skin Conditions Of The Diabetic Foot” in the September 2004 issue or “Treating Psoriasis In The Lower Extremity” in the February 2011 issue.    

To access the archives, visit www.podiatrytoday.com. For an enhanced online experience, check out Podiatry Today on your iPad or Android tablet.

Improved Exudate Control Utilizing Advanced Moisture Management Dressings for Diabetic Foot Limb Salvage, Surgical and Post Operative Wounds

Improved Exudate Control Utilizing Advanced Moisture Management Dressings for Diabetic Foot Limb Salvage, Surgical and Post-Operative Wounds

Babajide A. Ogunlana DPM, FACFAS, PCWC -Chief of Podiatric Surgery at Memorial Hermann Southwest Hospital in Houston, Texas

BACKGROUND

Surgical wounds closed with sutures  or staples1 heal by primary intention.  Wounds generated from limb salvage  surgery often cannot be closed  simply by sutures and follow a  healing path like that of a chronic  wound. These surgical wounds can produce large amounts of drainage  which can lead to higher chance for  maceration, breakdown to the  surrounding skin, and even  dehiscence. The wound dressings  utilized need to not only manage the exudate but provide protection to  the surrounding skin while the wound  progresses through the healing  cascade.

 

METHOD

A case series study was conducted  consisting of a 15-patient sampling  that underwent potential lower limb-saving surgery, such as flaps, wound  closure, and digit/partial foot  amputation requiring drainage  control.

An advanced moisture management  dressing* was utilized as the primary  dressing for exudate control and  protection to the peri wound. The  technologywithin the dressing wicks  away excess exudate while  maintaining a moist wound  environment2.

Following sharp surgical debridement and wound bed preparation, the moisture management dressings  were applied to the wound and multi-layer compression** was used  when clinically necessary.

Dressing change frequency varied based on drainage levels from once a week (low) to upwards of three times per week (high). The wounds  were examined for exudate amount, quality of the wound bed/peri-wound, overall patient comfort, and  ease of use.

 

CONCLUSION

The advanced moisture management dressings were able to handle the varying drainage levels while still  maintaining an optimal environment at the wound and peri-wound skin.

Patients were adherent and overall  wound outcomes improved with this  course of treatment.

Exudate levels managed with this  moisture management dressing  coupled with standard and advanced  wound care treatment protocols,  including serial sharp wound  debridement and edema control,  showed promising results in advancing wound healing in these very complex limb salvage cases.

 

RESULTS -CASE EXAMPLE#1

  • 56 years old AAF with raging gas forming infection in a chronic non-healing diabetic foot ulcer. Was Initially recommended for Right BKA.
  • Emergently taken to OR for Right great toe amputation, partial first ray amputation with wide excisional debridement –Copious amounts of drainage.
  • Xenograft application on 07/27/2020 with non-adherent dressing and moisture management dressing* usage for exudate control.
  • Wound fully healed on 12/31/2021.

 

 

 

 

 

 

RESULTS -CASE EXAMPLE#2

  • 56 year old AAM with wet gangrene in both feet for >3 months. Underwent Right foot open TMA, Left foot open TMA of the “gangrene slippers”.
  • Right: Packed with packing strips, non-adherent gauze and moisture management dressing*. Left: non-adherent primary dressing and two (2) moisture management dressings*. 
  • Xenograft application on 02/19/2021 with non-adherent dressing and moisture management dressing* usage for exudate control.
  • Right: Wound progressed towards fully healed.  Left: Wound continues to contract and progress towards healing with continued moisture control from the dressings.

 

 

 

 

 

 

 

FOOTNOTES

Milliken Healthcare Products, LLC, Spartanburg, SC:

Active Fluid Management Technology

*TRITEC Silver, ULTRA Silver, ULTRA,  ULTRA Border,AGILE

**CoFlex TLC two-layer compression

 

REFERENCES

  1. Dumville JC, Gray TA, Walter CJ, etal. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev.2016;12(12):CD003091. Published 2016 Dec 20.doi:10.1002/14651858. CD003091.pub4
  2.  Okan et al. The role of moisture balance in wound healing. Adv. in Skin and Wound Care 2007, 20:39-53
Why A Visit To The Podiatrist Is Just As Important As A Trip To The Dentist's.

Why A Visit To The Podiatrist Is Just As Important As A Trip To The Dentist’s.

Who Is A Podiatric Surgeon?

A podiatrist is a doctor, but not just any doctor but a doctor who specializes in the treatment and care of the lower limbs (with particular attention to the feet and ankles)! 

Doctors of Podiatric Medicine (DPM) are physicians or surgeons who treat the foot, ankle, and related bones and joints of the leg. The title ‘chiropodist’ is an old, outdated way of referring to a podiatrist—which you may have heard before. A podiatrist has the title DPM in front of their name, just like how a regular doctor has the title DR in front of theirs.

The podiatrist who is a specialist in foot surgery is known as a podiatric surgeon. They are certified by the board to handle both diagnosis of general foot health and surgery for disorders of the foot and ankle.

For a podiatrist to work in any state, they have to be licensed. This license has to be renewed every few years or they won’t be able to work. It is also necessary for them to keep themselves informed about the current news and developments in their field in order to give the best care available to their patients. They may do this by attending training seminars or reading journals.

TRAINING:

The education of a podiatrists begins with four years of undergraduate study followed by a four year course in an accredited podiatric medical school, which is then marked as complete by three to four years of residency at a hospital where they put their knowledge to practice and gain more experience in the field.

To be deemed qualified by the American Board of Podiatric Medicine, a podiatrist needs to pass all the required exams set by the board. Some podiatrists can also choose to take on more specialized roles that focus on specific areas of treatment, such as foot & ankle reconstruction or plastic surgery—to name a few.

This stringent process ensures that every podiatrist has the necessary knowledge to properly care for your feet.

 

Care of The Feet

Podiatrists care for patients of all ages, shapes and sizes (not only old folks have problems with their feet!). Because of this it is expected that they would be able to provide treatment for a variety of different foot conditions in the same way you would get treated by your family doctor.

Some areas that a podiatrist can be specialized in are listed as follows:
  • Sports Medicine
  • Reconstructive Surgery
  • Podiatric Diabetology (treating the foot conditions that occur with diabetes)
  • Podopediatrics (foot problems in children)
  • High-risk Wound Care [and more…]

If you have a persistent pain in your feet it might be necessary to see a podiatrist but even if your foot doesn’t hurt, it’s a good idea to have your feet checked once in a while. A podiatrist can safely remove the calluses on your feet and clip your toenails correctly (to avoid getting ingrown nails). A podiatrist will also be able to tell you what kind of shoe is best for the shape of your feet (in order to avoid unnecessary discomfort).

Common conditions of the feet include

Calluses Infections Of The Foot (Athletes’ Foot) Fractures or Broken Bones
Ingrown Toenails Arthritis Correcting Walking Patterns
SmellyFeet Foot Injuries Bunion Removal
Flat Feet Sprain Skin/Nail Diseases
Blisters & Warts Hammer Toes Tumors
Corns & Bunions Cast Ulcers
Ligament/Muscle Pain Prosthetics Wound Care
Orthotics to support/strengthen the foot (braces and insoles) Casts Amputation

Risk Factors

Certain health conditions may cause or make you prone to foot problems, These include:

  • Heart Disease or Stroke
  • Arthritis
  • Obesity
  • High Cholesterol Levels
  • Diabetes
  • Poor Circulation

Diabetic patients are more susceptible to having foot problems. Carefully observing any change in how your feet feel or keeping a record of the symptoms regarding your feet can help with future diagnosis. Treating the underlying condition itself can also help alleviate foot pain.

 

It would be best to let your podiatrist know if you have any symptoms of foot complications caused by diabetes:
  • Sharp/Burning Pain
  • Sores & Ulcers
  • Cracking Skin
  • Dry & Cracking Toenails
  • Tenderness
  • Calf (back of the lower leg) pain during walks

It might be necessary to see both a podiatrist and your usual doctor (or family doctor) if you start having pains or get an injury in any part of the foot. You are also likely to pay visits to other specialists for further treatment if physiotherapy can help relieve your symptoms. Your feet need to be examined by your doctor (podiatrist or otherwise) to discover the reason for your pain.

 

Tests and scans for foot pain include:

  • A Blood Test
  • X-ray
  • CT scan
  • Nail Swab
  • MRI scan
  • Ultrasound

 

Reasons To See A Podiatrist

  1. Flat feet: It might be necessary to wear orthotics (orthopedic support) like arch supports or foot braces to reduce pain (in the case of flat feet) and to give support to weak/injured foot ligaments. Molds of your feet are taken to ensure that your orthotics fit just right!
  2. Nail Infection: If the pain in your foot is a result of a health condition, your usual doctor might be able to give treatment. For example, a fungal nail infection can be treated with antifungal medication.
  3. Gout or Arthritis: These two conditions can cause you to feel pain (in your feet and toes). Treatment of gout and arthritis will alleviate this pain.
  4. Diabetes can damage the nerves in your feet. This often leads to pain, numbness, and sores on your feet and legs. If your foot issues are because of diabetes, you’ll need to see both a podiatrist and other doctors who specialize in treatment of the nerves and blood vessels.
  5. Joint pain/problems: It might be necessary to see a podiatrist (and other doctors specializing in the treatment of bones) to treat an ankle or knee problem. Long-term physical therapy may also be required to strengthen the muscles and joints in your legs.

 

When To See A Podiatrist

The foot is a small but complex part of the body, comprising 26 bones—and a number of joints, ligaments, tendons and muscles.

All of these make your feet the perfect limb to help you be active and mobile, while also supporting the weight of your entire body.

Foot pain limits your movement. It can make you walk with a limp and your unbalanced gait can eventually affect your hips, back and spine. Other health conditions damage your feet if they aren’t treated on time.

See a podiatrist if your foot hurts persistently or you get a painful injury. Urgent medical care may be required if you have any of these symptoms persist for more than a few days:

Notify your podiatrist or family doctor immediately if you are able to walk or put weight on your foot.

Podiatrists are specialists of the foot who spent years studying and training just to help keep your feet healthy. Getting your feet examined by your podiatrist (even when you have healthy feet) helps prevent future foot problems… And if your feet do have a problem, they will diagnose it and craft the best treatment plan tailored to you.

Book a  time with Dr. Babajide Ogunlana 

Spotting Diabetes (Mellitus) Early: Signs and Symptoms

Spotting Diabetes (Mellitus) Early: Signs and Symptoms

Diabetes (Mellitus) Early: Signs and Symptoms

There are signs that let you know if you have diabetes mellitus and give you a chance to start treatment early before things get too detrimental. These signs depend on what kind of diabetes mellitus you might have. Diabetes means “excessive urination” and mellitus means “honey”, these two words together means “sweetness in urine” or in other words “sugar/glucose appearing in urine”. There are many forms of diabetes mellitus that are due to different causes.

Diabetes may be primarily—caused by another disease, or secondary—caused by damage of the pancreas by another disease. Approximately 98% of diabetes patients have primary diabetes mellitus, the idea behind this article is to help learn about the two kinds of primary diabetes: Type 1 and Type 2 diabetes.

Insight and self-consciousness, makes it mainstream to ponder the wholeness of our health. There is an abundance of social media influencers advertising “eating plan” and “exercise regimen”. Lifestyle apps that keep you healthy by reminding you to drink water, recommending what best to eat and at what time and ensuring you have enough breaks during the day.

Considering all these general mindfulness being the “in thing” in our society, it is alarming to see that so many people don’t understand the inner workings of their own bodies. So many people go through everyday life,  experiencing the symptoms of diabetes but take it as a normal occurrence because a large number of the symptoms do not present as dangerous on their own, and that in itself is its danger. Understanding and recognising some early symptoms of diabetes can help us understand when we need to seek some form of medical consultation.

Early Symptoms Of Diabetes

The most common signs of diabetes mellitus (both type 1 and type 2) are frequent thirst, excessive urination and increased hunger. The excess glucose (sugar) in your blood that isn’t absorbed into your body due to diabetes is diluted by water and gotten rid of by the kidneys. This is the reason for frequent urination.

Because a lot of water is accompanying the glucose on the way out, the body gets dehydrated. You become thirsty and drink a lot of water to replace what was lost. Basically, glucose and other nutrients and food groups necessary for daily life from your everyday meals. Because there is now less glucose in your body (it has been flushed out), you start to feel hungry and crave food to compensate for the lack.

This leads to a cycle of always eating and drinking without actually getting any of the benefits. Controlling your blood glucose levels and keeping them optimal makes it possible to live life normally, eating and drinking whenever you wish without a condition forcing you to.

It is sad to see that these symptoms are so often written off as ‘normal’, but it is understandable. A busy person will not think thirst or a little nausea is a big deal, and even the more severe symptoms closely resemble the symptoms of a common cold or flu that goes away on its own after some days of rest and many bowls of chicken soup.

Not enough people realise that all these signs are hinting at the body’s inability to absorb glucose, which is caused by a lack of or resistance to insulin—the hormone that transports glucose to where it’s needed. To be on the safe side, if after being sick your thirst still lingers, a visit to the doctor should be the next thing on the list. One single blood test can clear years’ worth of doubt.

The human body extracts glucose from food to use it as fuel. Every process in the body requires it, like how a car needs gas to run. The cells, tissues and organs get the glucose that’s digested in the stomach after it has been transported out by insulin. Therefore, without insulin, there would be no energy for you to do work. The body would stop functioning properly.

The unique combo of continuous thirst, frequent urination, and sudden weight loss are key signs of an increased amount of glucose in the blood. These three symptoms are common in both type 1 and type 2 diabetes. Type 1 and Type 2 diabetes are different branches of the same disease. They are both caused by problems regarding insulin.This difference between the two types is the reason why the rest of the symptoms begin to vary after the early stages.

In Type 1 diabetes, the pancreas does not produce enough insulin to transport all the glucose you eat to where it is needed, so the rest remains in the blood.

In Type 2 diabetes, the pancreas produces enough insulin but the body does not recognise it so it cannot use it, and that causes the glucose to remain in the blood.

Symptoms Of Type 1 Diabetes

Type 1 diabetes happens suddenly and at any age in life—but usually it occurs before the age of 40. It happens when the pancreas stops secreting insulin. It is caused by degeneration of the cells of the pancreas, damage to the pancreas due to autoimmune diseases, congenital disorder of pancreas cells or destruction of those cells by viral infection.

what is dka (diabetic ketoacidosis)?
Diabetic Ketoacidosis)?

When it occurs in infancy or childhood, it is called ‘juvenile diabetes’. It can take weeks or months for the pancreas to completely stop secreting insulin, but eventually a normal, healthy person will become insulin-deprived and their glucose levels will shoot up to dangerous levels. A patient with Type 1 diabetes will become dependent on insulin injections for treatment so Type 1 diabetes is also called Insulin-dependent diabetes mellitus (IDDM).

Since the body can’t access the glucose in blood, it begins to find alternate sources of energy and starts breaking down fat and muscle. The end products of this are ketones (ketoacids).

The abundance of these acids makes the blood more acidic and leads to acidosis. This will cause fatigue, lack of appetite and confusion.  

When the ketone level in your blood is very high, your heart will begin to beat faster and your breathing rate increases. Your breath will have a sweet, fruity smell because of the many ketones present in the bloodstream—and at this stage the amount would have reached a life-threatening level that can cause unconsciousness.

 

Symptoms Of Type 2 Diabetes

Type 2 diabetes is caused by a partial deficiency of insulin caused by the body’s cells not being able to receive the hormone even after it has been produced. It is the more common type of diabetes and usually occurs after the age of 40. Only a few forms of it actually required insulin as treatment. It can be controlled by taking oral hypoglycemics (drugs that make the body more receptive to insulin/increase insulin production). Because of this, this type of diabetes is also called noninsulin-dependent diabetes mellitus (NIDDM).

Insulin Resistance can be caused by genetic factors, stress or lifestyle changes. Examples of these lifestyle changes are bad eating habits and lack of physical activity that leads to obesity. Physical activity helps a person burn glucose and makes their body more sensitive to insulin while being overweight increases insulin resistance (scientists aren’t completely sure why).

A patient with Type 2 diabetes does not need insulin in the beginning because the pancreas overproduces to compensate for the unreceptive cells—this is the reason why Type 2 diabetes often goes unnoticed for years. But eventually, the pancreas isn’t able to keep up and the glucose builds up in the blood even with insulin being constantly produced. Eating healthy, cutting back on sweets and losing excess weight helps control the glucose levels in a person with type 2 diabetes. Early treatment positively impacts and maintains a good quality of life.

Spotting Diabetes (Mellitus) Early: Signs and Symptoms

Complications Of Diabetes Mellitus

Diabetes Foot

Prolonged hyperglycemia (high blood glucose levels) damages the retinas of your eyes (which spoils your vision). When caught early, this condition is manageable, but if left untreated, Diabetic Retinopathy will cause permanent damage to the retina of the eyes. Not only this, high glucose levels can damage the kidneys (Diabetic Nephropathy) and nerves (Diabetic Neuropathy) of the body as well as hypertension and heart attack.

A person with diabetes is more prone to getting fungal infections, and when they are infected it is quite hard to treat. Yeast grows from sugar and is naturally occurring in the body but when too much yeast accumulates it causes pain and itching. It grows in moist and warm places like the mouth, the folds of the skin, the genitals, the eyes and the foot (especially the toenails).

Without treatment, such infections can lead to blindness or become life-threatening when the yeast manages to get into the bloodstream of a patient who has a depressed immune system and spreads to other parts of the body.

The high blood glucose also causes slow wound healing due to lack of energy and the neuropathy of the nerves will prevent you from feeling pain sensations, so a lot of tiny wounds become ulcers and if left untreated can cause problems later on.

For this reason, it is always good to pay close attention to the state of your body and catch these signs and symptoms before they progress too far and become deadly. Early intervention and correction of elevated blood glucose can promote proper circulation and healing while preventing the onset of all these complications.

 

Juvenile Diabetes:

Young children aren’t able to properly convey the changes that occur in their bodies due a lack of understanding or communication skills. Because of this, it’s hard for parents to tell whether their children are suffering from Type 1 diabetes, especially since the symptoms are so easy to miss—being very hungry and very thirst are easily noticeable signs but these are also just the normal behaviours of growing children and shouldn’t be a cause for alarm. 

The following are some behaviours observed in children with Type 1 diabetes:

  • Getting yeast infections (thrush).  
  • Acting out of character. Being moody or restless. Having mood swings. 
  • Losing weight despite having frequent meals.
  • Feeling tired, dull and lacking strength to play.
  • Peeing more, or even wetting themselves despite having been toilet trained.
  • Having a sweet smelling breath

If while watching their children grow, parents notice any of these symptoms of elevated blood glucose levels in their infants, toddlers or young children they should immediately seek their pediatrician’s guidance.

Type 1 diabetes can strike at any age. The sudden pause in Insulin production leads to a rapid rise in glucose levels which can quickly become Diabetic Ketoacidosis (DKA). Catching these signs early can ensure that insulin is given promptly and the quality of life is preserved. 

 

When to See a Doctor

The symptoms of diabetes in the early stages can easily be confused as a minor illness, so it can be hard to pinpoint exactly whether you, or someone you care about, has it. But that’s okay.

If you are want to confirm whether what you have been experiencing could have been diabetes, you can ask yourself these questions:

  • After getting a cold or the flu. Do you recover quickly? Do you still feel sick?
  • Have you noticed any cuts and grazes that seem to be taking longer than usual to heal?  
  • Do you experience numbness and tingling in your hands or feet? Is this a recent development or a long term condition?
  • Have you always wrestled with yeast infections, or are recurring infections a new struggle?
  • Have you noticed weight loss you can’t explain? Are you overweight?
  • Have you felt thirstier, or found yourself drinking more than usual in recent weeks or months?
  • Have you noticed any changes in your vision?

 

Catching It Early Makes All The Difference

If you are concerned about your health, visit your physician and tell them your concerns. A simple test strip or lab draw, can supply you both with a wealth of information about if necessary, treatment can be started. Early diagnosis and treatment by a professional makes all the difference between managing your condition and having to suffer unknowingly.

Since 2012, our goal at mySugr has always been to make diabetes suck less for people within the diabetes community.  We have long endeavored to educate, advocate, and elevate the global working knowledge of living life with both type 1 and type 2 diabetes to the fullest. Utilizing our combination approach of sound coaching and advancing tech, we’ve made huge strides at creating an environment that lets all people with diabetes maintain optimum health while living their best life!

 

Diabetetic And Unaware

According to the World Health Organization (WHO), the number of people with diabetes rose from 108 million in 1980 to 422 million in 2014—”About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.6 million deaths are directly attributed to diabetes each year.”

According to the American Diabetes Association, in 2018, 10.5% (34.2 million American adults) of the American population had diabetes. 24.8 million were diagnosed and 7.3 million were undiagnosed. And 1.5 million Americans are diagnosed with diabetes every year.

This means that right now millions of people walking around with a dangerously high amount of glucose in your blood, experiencing complications and receiving no treatment for them. We hope that everyone reading this gains an understanding of diabetes, whether they have it or not.

We know that it is improbable to reach everyone, but if you can help spread awareness and educate those around you on the symptoms of early stage diabetes, that means an increased awareness in your community, which can reduce the number of undiagnosed diabetic patients in your direct environment.

If you have a family member or relative who has been diagnosed as being diabetic, to be on the safer side, you should visit your doctor to discuss the possibility of being at risk. A bi-annual blood test can provide a constant baseline for your doctor to monitor for any unusual increase in blood sugar levels. 

 

Dr. Babajide Ogunlana

If you or your child struggle to maintain a healthy weight, ask your doctor and/or your child’s pediatrician for pre-screening and lab work to look out for early signs of diabetes. By working hand in hand to achieve optimum health, you and your medical team can be proactive partners in warding off any symptoms of diabetes before they begin to damage peripheral systems.

If you or your child have other genetic factors (such as other auto-immune conditions), you should ask your doctor for pre-screening lab work to rule out any signs of diabetes. Auto-immune conditions tend to breed additional auto-immune conditions. Still, by creating a team-work approach to full-body care, you can provide a protective screening system that stands sentry against the early warning signs of diabetes. In this way, you can begin any treatment at the earliest possible opportunity and set the stage for successful long-term health.

 

 

 

African Women’s Health Project International #AWHPI – Fight Cancer Global.

Join Dr. Babajide Ogunlana this month of October, on the African Women’s Health Project International #AWHPI in collaboration with Fight Cancer Global. AWHPI 2020 Learn Pink Breast Cancer Awareness campaign initiative for the entire month of October.

Throughout the month of October on each Monday, we will be disseminating vital information via all our Social Media platforms, and will be making and sharing videos relating to the fight against Breast Cancer. Additionally, we are showcasing our AWHPI Learn Pink Breast Cancer Awareness campaign Champions.
We are delighted to have the partnership collaboration of Fight Cancer Global – the leading global corporation on the fight against Cancer with operations in over Sixty Countries worldwide!
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