Foot Conditions Lecture Slides PDF

RESPONDING TO SYMPTOMS FOOT CONDITIONS Leanne May [email protected]  Learn how to respond to patients presenting with the following conditions in a community pharmacy:  Athlete’s foot  Verrucae Corns and Calluses Apply the mnemonic WWHAM to different patient groups Recognise when to refer p...

RESPONDING TO SYMPTOMS FOOT CONDITIONS Leanne May [email protected]  Learn how to respond to patients presenting with the following conditions in a community pharmacy:  Athlete’s foot  Verrucae Corns and Calluses Apply the mnemonic WWHAM to different patient groups Recognise when to refer patients to the doctor Know which OTC products can be used to treat Provide practical advice to patients with foot conditions      LEARNING OUTCOMES Can be subdivided into those that result from   Opportunistic infection  Athlete’s foot  Verrucae Incorrect distribution of pressure  Corns  Callouses FOOT DISORDERS  Athlete’s foot – a form of ringworm (Skin lecture)  Interdigital most common Wet macerated areas between toes   Skin looks white and ‘soggy’ - secondary infection risk- or dry and scaly initially  Itchy  May occasionally involve sole and instep of foot Moccasin or dry  Vesicobullous — least common; multiple small vesicles and blisters mainly on the arches and soles of the feet TINEA PEDIS TINEA PEDIS ATHLETE’S FOOT HYGIENE POINTS  If a child is affected, it is not necessary to exclude them from school or nursery.  Powder for all socks and shoes  Cream/spray for feet  Tea tree oil not advised  Treatment failure:  Stopping too soon  Incorrect treatment method ATHLETE’S FOOT TREATMENT ATHLETE’S FOOT TREATMENT OPTIONS Antifungals Undecenoat es Imidazoles Terbinafine Tolnaftate – no longer available Benzoic acid Generally inhibit enzymes required for fungal growth Terbinafine 1% cream (children above 16 years of age) • Apply thinly to the affected area once or twice a day for up to 7 days. Clotrimazole 1% cream • Apply to the affected area 2–3 times a day and continue for at least 4 weeks. A strip of cream about half a centimetre long is enough to treat an area about the size of the hand. Miconazole 2% cream • Apply to the affected area twice a day for 2–6 weeks depending on the severity of the lesions, and continue for 10 days after all skin lesions are healed. Econazole 1% cream • Apply to the affected area twice a day and continue until all skin lesions are healed. CKS TOPICAL ANTIFUNGALS  Clotrimazole: Canesten® (all) +HC: Canesten HC® (10+)  Miconazole: Daktarin® (all) + HC: Daktacort® (10+)  Ketoconazole: Daktarin Gold® (all)  HC for severe inflammation/itching BUT licensed for only seven days then switch to plain form IMIDAZOLESCOMMON OTC PRODUCTS •May be better than Imidazoles at preventing reinfection •Dose: o Cream: od for 1 week (16+) o Spray: as above o "Once®": single dose (18+) (both feet) •Brand: Lamisil® ATHLETE’S FOOT - TERBINAFINE  Tolnaftate (Mycil®, Tinaderm®)  It appears to have the least amount of trial data supporting its efficacy  Undecanoates (Mycota®, Monphytol®) – no longer available  Benzoic acid (+ salicylic acid: Whitfield’s Oint)  Benzoic acid decreases the pH of dermatophytes  Salicylic acid causes keratin layer of skin to shed facilitating penetration of other drugs into epidermis ATHLETE’S FOOT OTHER ANTIFUNGALS • treatment failure • high level of discomfort • foot or leg is hot, painful and red (the redness may be less noticeable on brown or black skin) • the infection spreads to other parts of body such as hands or nails • diabetes • weakened immune system ATHLETE’S FOOT REFERRAL  Localised formations of thick, horny skin (hyperkeratinisation) on the feet CORNS AND CALLUSES  Combination of friction and intermittent pressure against the bony prominences of the feet  Frequently caused by inappropriate footwear  Pressure on nerve endings = pain  Hard corns – top of the toes  Soft corns – between the toes  Calluses – Balls of the feet, heel and lower border of the big toe CORNS AND CALLUSES AETIOLOGY Hard corns  Exhibit a central core of hard grey skin surrounded by a painful, raised, yellow ring of inflammatory skin Soft corns  Whitened appearance and remain soft due to moisture being always present between the toes, causing maceration of the corn Calluses  Depending on the cause and site involved, can range in size from mm to cm  Appear as flattened, yellow-white and thickened skin CORNS AND CALLUSES CLINICAL FEATURES  Site will determine the condition  Rule out Bunions: DIFFERENTIAL DIAGNOSIS  Epidermabration  Hydrocolloid plasters  Keratolytic agents  Correctly fitting footwear  Padded inserts/shields around affected area CORNS AND CALLUSES TREATMENT AND PREVENTION Do wear thick, cushioned socks wear wide, comfortable shoes with a low heel and soft sole that do not rub use soft insoles or heel pads in shoes soak corns and calluses in warm water to soften them regularly use a pumice stone or foot file to remove hard skin moisturise to help keep skin soft Don’t do not try to cut off corns or calluses at home do not walk long distances or stand for long periods do not wear high heels or tight pointy shoes do not go barefoot CORNS AND CALLUSES PRACTICAL ADVICE • you have diabetes • you have heart disease or problems with your circulation • it bleeds, or has any pus or discharge • it has not improved after treating it at home for 3 weeks • the pain is severe or stopping you doing your normal activities CORNS AND CALLUSES – SAFETY NET AND REFER  Benign growth of the skin caused by human papilloma virus (HPV)  Enters via defects in epidermis  Found on the sole of the foot, usually in weight-bearing areas  Owing to constant pressure grow inwards instead of outwards  Painful because of pressure exerted on nerve endings VERRUCA VERRUCA DIFFERENTIAL DIAGNOSIS Hyperkeratinisation, as in corns/calluses, BUT Small black dot (corns do not have) – thrombosed capillaries.  Over 50% of verrucae resolve spontaneously after 2 years  Treatment may take up to 12 weeks  Removal of hyperkeratotic skin layers and viral core by keratolytic agents  Soak skin and file skin surface prior to application  Occlusion with plaster/collodion  Localise application to affected area (ring with petroleum jelly)  Avoid naked flames!  Easily spread: direct contact and shed skin  Do not pick/scratch: viral shedding » multiple lesions VERRUCA TREATMENT  Salicylic acid  Primary treatment option  Reduces viral numbers by mechanical removal of infected tissue  Stimulates production of antibodies  75% success rates in clearing verrucas after a 12-week treatment period  E.g. Bazuka Extra Strength, Occlusal, Verrugon (all ®) VERRUCA TREATMENT  Lactic acid  Corrosive  Combined with salicylic acid  Eg Duofilm, Salactol, Cuplex, Salatac (all in collodion base), Bazuka (all ®)  Supposedly increases penetration of salicylic acid, but no evidence for this VERRUCA TREATMENT  Gluteraldehyde  More potent skin sensitiser  Stains skin brown  Eg Glutarol® paint VERRUCA TREATMENT  Silver nitrate  Caustic agent  Short treatment only-max 6 applications  Stains skin  Eg. AVOCA® set VERRUCA TREATMENT  Cryotherapy  Dimethyl ether/propane mixture (Wartner®)  ‘Freezes’ verruca by destroying cytosol and cell structure  Marketed as ‘once only’ treatment, but may need to be repeated after two weeks  Not as effective as medical cryotherapy: liquid nitrogen cools to 196ºC, Wartner® only -57ºC  Not cold enough to penetrate to core? VERRUCA TREATMENT Some of these may still be listed in the references but are no longer available OTC   Podophyllum resin  Potent corrosive action  Powerful irritant  Cytotoxic and caustic Formaldehyde   Antiviral Anhidrotic action Sustainability: Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment. All creams but particularly the above! VERRUCA TREATMENT WHEN TO REFER  Diabetics  Circulatory issues  Compromised immune system due to disease (HIV) or medication (ciclosporin)  Bleeding  Failed OTC treatment  Paul Rutter, Community Pharmacy: Symptoms, Diagnosis and Treatment, 5th edition 2020 ISBN : 9780702080210  Alison Blenkinsopp, Paul Paxton , John Blenkinsopp, Symptoms in the Pharmacy: A Guide to the Management of Common Illnesses 8th edition ISBN : 1-119-31797-5  BNF online  EMC website https://www.medicines.org.uk/  Counter Intelligence Plus 2023/4  NICE guidelines:  http://cks.nice.org.uk/warts-and-verrucae  http://cks.nice.org.uk/fungal-skin-infectionfoot REFERENCES