Plantar Warts: How Did I Get Them? What Can I Do About Them?

Plantar warts are caused by a few of the 120 types of human papillomavirus, or HPV.  The virus affects the superficial areas of the skin, especially on the pressure points of the foot such as the heel and the ball of the foot.  Since it is a virus, it is contagious.  It typically enters through small cuts or irritated areas in the skin, or areas  that are constantly exposed to water.

What does a plantar wart look like?

McDermott footcare   plantar wart

A lifeguard/swim instructor developed a plantar wart on the ball of the foot as a result of long hours working in constantly wet, bare feet.

Plantar warts are small, grainy, callus-like lesions on the bottom of the foot.  There may be a single wart measuring about 2 – 3 cm; a large “mother wart” surrounded by several smaller warts; a cluster of warts grouped together, otherwise known as a mosaic wart. The centre of the wart(s) have tiny red or black dots caused by trapped capillaries.  On weight-bearing surfaces, the warts may be flattened.

How do you get plantar warts?

  • the virus enters through tiny cracks in dry skin
  • through cuts, scrapes and other skin irritations
  • through wet, softened skin from prolonged exposure to water

Who usually gets plantar warts?

  • children and teenagers since their immune system is not fully developed and since they are more likely to go barefoot
  • people with weakened immune systems

Home remedies for plantar warts

  • apply a doughnut-shaped pad (available at drugstores) around the plantar wart to reduce pressure on the area when weight-bearing
  • try an over-the-counter medicated wart remover.  Since these preparations may chemically burn the skin, protect the area around the wart with a light coating of petroleum jelly.  This remedy is not recommended for young children or diabetics.
  • gently rub the callused area with a pumice stone after soaking in a vinegar-water solution for 10-15 minutes
  • apply duct tape over the wart.  Change as needed if it becomes wet.  Re-assess the area after 3 – 4 days and leave the tape off overnight if the skin underneath appears wet.  You may apply a drop of tea tree oil before applying the tape.  It may take 6 – 7 weeks to eradicate the wart using this treatment.

When to see your doctor

  • if after 2 weeks of applying home remedies, there is no noticeable change
  • if new growths keep appearing
  • if you are unsure the growth is a wart
  • if you have a previous history of skin cancer or have a close family member with a history of skin cancer
  • if you are diabetic

How to prevent plantar warts

  • avoid walking barefoot in public shower stalls, change rooms, swimming pools, saunas
  • change your socks daily
  • check the bottom of your feet daily.  If needed, use a mirror.

    If needed, use a mirror to check the bottom of the feet.

  • keep feet clean and dry
  • do not touch warts on other people
  • if you touch a wart on yourself or on someone else, wash your hands thoroughly for at least 15 seconds using warm, soapy water
  • don’t scratch warts since this encourages their spread
  • don’t share shoes and socks
  • cover warts with waterproof tape while in swimming pools or shower stalls

Diabetes and plantar warts

If you are diabetic, always have your doctor treat plantar warts. Complications such as poor nerve functioning(neuropathy) and decreased blood circulation (micro/macroangiopathy) make home treatments dangerous for people with diabetes.

Since diabetics have concerns with decreased nerve functioning in their feet (neuropathy), it may not be possible to feel discomfort from a plantar wart.  Daily checking the entire foot to detect new growths or lesions is important.

Over – the – counter wart removers should not be used by diabetics since there is the strong possibility that harsh chemicals in the preparation may irritate healthy skin surrounding the wart.  These irritations may aggravate the area and cause skin infections.  Because of poor circulation, any skin infection in the feet of diabetics must be treated aggressively.

See also:  Lifeguards and Plantar Warts:  A Love Story

Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author

Extreme High Heels

Extreme high heels seem to be the norm this year in women’s shoes.   Shoe store shelves are lined with them; women everywhere totter somewhat awkwardly and uncomfortably in them. 

Historically, women have had a love affair with high heels.  They will always be in fashion.  However, it seems that the heel heights of today are pushing the limits of comfort and safety.

The pictures in this blog post are the result of a visit to the local mall for an informal survey of what most shoe stores are offering for high heel aficionados.  Along with taking pictures, I tried on a variety of  shoes to find out what wearing these extreme heels feels like.

Some women argue that the platform sole in these shoes serves to soften the angle at which the shoe tilts (the pitch).  However, at heel heights of 5 and 6 inches, the pitch of the shoes is still high.

With each pair of shoes I tried, my body was thrust forward.  I could feel my toes being shoved into the front of the toe box even in shoes that were properly sized.  Balancing was precarious as I made a conscious effort to maintain proper posture.  I didn’t even attempt walking.  In the booties shown here, I overturned my ankle.

Fans of these heels often say that they are comfortable and easy to walk in when you get used to them.  Again, an informal survey watching women wearing very high heels indicates to me that they struggle to walk in them and facial expressions show some degree of discomfort.

In a previous high heel blog (here), I outlined the harmful effects of frequently wearing high heels.   These included bunion formation, hammer toes, crowding together of toes and ingrown toenails. As well, the calf muscles, knees, hips and back are strained as the body tries to maintain balance.

The McDermott Footcare client who agreed to have these pictures taken of her feet stated that she wore high, ill-fitting shoes for many years.  Now in her later years, she finds walking very difficult.

Note how the toes are permanently shortened and crowded together.  This is the result of toes being pushed forward in a narrow toe box for many years.  As well, the shape of the foot indicates that my client constantly wore shoes that were too small.

Realistically, women will continue to wear high heels.  This is understandable since a fashionable pair of shoes elevates an outfit and makes women feel attractive.

The same survey of shoes confirmed that there are many attractive, more comfortable options in high heels available at the same stores.  It’s not that women should stop wearing heels all together; it’s that we should be making more reasonable choices, keeping in mind the health of our feet, ankles, knees, hips and back.  We should also be alternating reasonably high heels with flatter shoes.

Fashion and health can co-exist quite well in the wardrobe of a stylish woman.  Many choices are available in a range of styles and prices.  There is no need to sacrifice comfort, health and safety for fashion.

.Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author

Skin Cancer And Your Feet

May is Skin Cancer Awareness month.   People of all skin colours and ethnicity should be aware of the signs and symptoms of skin cancer.  We often forget to give our feet the same care we give to other parts of our body.  When it comes skin cancer, this is especially problematic since skin cancer in the feet is often not detected until the later stages and the outcome is poor.

Three Types of Skin Cancer

Malignant Melanoma  is the most serious type.  A change in the appearance of a mole or pigmented area is an early sign.

Malignant melanoma. Photo courtesy of National Cancer Institute.

Look for a change in size, shape, and colour.  Watch for irregular, ragged edges, a mole that has more than one colour, is asymmetrical, oozing, bleeding or feels itchy.  While some melanomas may be tiny, most are larger than 6 millimeters.  In dark-skinned people, it usually occurs under the fingernails, the palms of the hands, under the toenails or on the soles of the foot.

In its early stage, Squamous Cell Carcinoma may appear as a small, scaly bump or plaque which may be inflamed.  It may look like a callus and have a history of repeated bleeding or cracking.

Common symptoms of basal cell and squamous cell carcinoma. Photo courtesy of National Cancer Institute.

It may resemble a plantar wart, fungal infection, eczema, or a skin ulcer that doesn’t heal.  According to the National Cancer Institute, in dark-skinned people this cancer usually occurs in areas that are not exposed to the sun, such as the feet.   In light-skinned people, it is more common on the head, face, neck and ears.

Basal Cell Skin Cancer usually occurs on areas that are exposed to the sun.  The National Cancer Institute describes it as a bump that is small, shiny, pale or waxy.

It may also be firm and red or appear as a sore or lump that bleeds or develops a crust or scab.  Alternatively, it may show up as a scaly, itchy, tender spot.

Common symptoms of basal cell and squamous cell carcinoma. Photo courtesy of National Cancer Institute.

Risk Factors

  • For all types of skin cancer, exposure to sunlight is a major risk factor.  Having even one blistering sunburn increases the risk.  Redhead or blonde, grey or blue-eyed, fair-skinned people have a higher risk of sunburn but dark-skinned and people who tan well are also at risk because of total lifetime sun exposure.
  • Having a family history of skin cancer increases the risk as does a personal history of earlier skin cancer.
  • Having a large number (over 50) of common moles is a risk factor.
  • Old scars, inflammation, burns, skin ulcers as well as exposure to arsenic increase the risk for squamous cell and basal cell carcinoma.

    Common symptoms of basal cell and squamous cell carcinoma. Photo courtesy of National Cancer Institute.

Protect Your Feet

The single, most effective way to prevent skin cancer in the feet is to avoid sun exposure, especially between 10 a.m. and 4 p.m.  For most of us, this is unrealistic as is keeping the feet covered.

A broad-spectrum sunscreen applied diligently and liberally to all areas of exposed skin is the most practical solution to sun protection.  Re-apply every two hours and don’t forget the kids who may need to re-apply more often if they have been in the water.

Check Your Feet

It is important to check your feet daily. Look carefully at all areas, including between the toes, the soles of the feet and the nail bed underneath the nails. Make note of any changes to existing moles or the appearance of new moles and other skin markings.  The same applies to skin tags.  If needed, use a mirror held under the foot to check the soles of the feet.  Similarly, ask someone to help you check areas that are difficult to see.  If you find anything suspicious or worrisome, see your doctor immediately.

The warm weather is finally here.  Enjoy it!  But remember to be kind to your feet!

Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author

Why Athlete’s Foot Is Dangerous In Diabetes

Athlete’s Foot (tinea pedis) commonly occurs in diabetics.  Since the flaking and peeling skin symptomatic of this fungal infection can resemble large areas of dry skin, affected clients often mistake it for very dry skin.  At McDermott Footcare, monitoring the presence of Athlete’s Foot in diabetic clients is part of the routine, on-going assessment.

What does Athlete’s Foot look like?

The appearance of Athlete’s Foot was described in this earlier blog post (read here), but it bears repeating.

In its beginning stage, Athlete’s Foot shows up as flaky, scaly, peeling skin between the toes, most likely between the fourth and fifth toes.  There may also be  superficial cracking or fissures of the skin between the toes.  It may or may not be itchy.  It is odourless.  If there is a noticeable odour, this indicates a bacterial infection which is different from Athlete’s Foot but of equal concern.

The flaky, scaly area may spread down the soles of the foot.  As it spreads, the affected area often becomes reddened and may feel itchy or burning.  It may develop into moccasin-type Athlete’s Foot, covering an area that would typically be covered by a moccasin-type shoe.

Athlete’s Foot concerns for diabetics

Athlete’s Foot that remains untreated may cause abrasions, small cuts and bleeding in the skin.  This provides an opportunity to develop a bacterial infection known as cellulitis.

Cellulitis is a non-contagious bacterial infection that may occur secondary to Athlete’s Foot.  Diabetics are more prone to developing cellulitis because of a weakened immune system.  It is characterized by redness, swelling, warmth, tenderness and tightness of the skin in the affected area.  Oral antibiotics are prescribed as treatment.  If cellulitis does not respond well to antibiotic therapy, areas of blackened, necrotized or dead tissue may develop, which may result in amputation.

The circulatory system is weaker in people with diabetes.  Poor circulation causes weakening of the immune system, which causes increased risk of infection.  Any infection left untreated can be dangerous.  For a diabetic, the danger increases since unresolved infections in the feet and lower limbs are a leading cause of amputations.  That’s why even mild Athlete’s Foot becomes a concern.

Steps to prevent and treat Athlete’s Foot at home were addressed in a previous McDermott Footcare blog (read here).  It is important for everyone, but especially diabetics, to understand these steps for preventing the fungal infection.  For diabetics, the home remedies should be used as part of a comprehensive treatment plan which includes prescribed anti-fungal creams or ointment from your doctor.

Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author

Diabetic Foot Screening

People with diabetes are at a higher risk for foot-related wounds, ulcers and lower limb amputation.  This is because of nerve and circulatory changes (read here) which occur in diabetes.  For this reason, it is important to regularly assess the feet of diabetic clients.

At McDermott Footcare, the tool used for this assessment is Inlow’s 60-Second Diabetic Foot Screen, obtained from the Canadian Association of Wound CareThe screening tool consists of a mono-filament device and accompanying checklist.  The frequency of assessment is determined by the initial and subsequent assessment scores.  The higher the score, the more frequent the assessment.  The quick but thorough assessment covers all important areas.

Visual:

The first part of the assessment involves looking to see the condition of the skin and nails.  Are the skin and nails fungal?  Are there calluses or open ulcers?  Are the nails thickened?  Is footwear appropriate or causing trauma?  Look for Charcot’s Deformity, bunions and previous amputations.

Touch:

Next, the temperature of the foot is recorded.  By touching the feet, a comparison is made of the temperature of both feet.  Are they equal in temperature or is one foot colder/hotter than the other?  Are they colder/hotter in relation to the environment?

The range of motion of the great toe is assessed.  Things to look for include how easily the toe can be moved or is it rigid.  What degree is the rigidity?

Sensation And Other Assessment:

Next comes testing with the mono-filament tool.  10 sites on the foot are touched with the mono-filament and the client’s ability to feel the touch is rated.  The client is also asked whether they feel numbness, tingling, or burning in the feet.  The pedal pulses are felt.  The presence of dependent rubor (redness when the feet are down; pallor when they are elevated) and erythema (reddened areas of the skin) complete the assessment.

Clients respond favourably to Diabetic Foot Screening.  They are advised that it is part of the overall nursing plan of care for keeping their feet healthy.  It is also a good springboard for discussion and health teaching about foot health.  As needed, clients have been advised to see their doctor for further treatment based on the findings of the assessment.

The 60-Second Diabetic Foot Screen is very convenient and quick to complete.  Regular screening gives clients peace of mind that their foot health is monitored appropriately.

Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author

The Importance of Nursing Foot Care for Diabetics

According to a 2009 report by the International Diabetes Federation, 7% of the world’s population has diabetes.  That’s approximately 300 million people worldwide with the majority of cases (85% – 95%) having Type 2 Diabetes.  Type 2 Diabetes is preventable in 60% of cases, according to the IDF.

At McDermott Footcare, almost half of the clientele have Type 2 Diabetes.  All of the clients exhibit neuropathic and circulatory deficits which negatively affect the health of their feet and lower legs.  Read here about neuropathic and circulatory changes.

The following case studies illustrate the importance of regular nursing foot care for diabetics:

Case Study #1

Client A is a nursing home resident.  He was a McDermott Footcare client when he lived at home; at the family’s request, McDermott Footcare has continued his foot care in the nursing home.  On a recent foot care visit, he told me that he had stubbed and cut his toe.  He noticed some discharge coming from the cut.  He did not tell the staff nurses and they did not notice the injury.  On closer inspection, I noticed redness, inflammation and a white discharge when I squeezed the toe, all symptoms indicative of infection.  I cleaned and bandaged the injury site.  I reported the injury to Client A’s family, the Charge Nurse, the Director of Care and requested that my client be seen ASAP by the doctor-on-call.  Within 2 hours, Client A’s family received a phone call informing them that the doctor had just seen their father and antibiotics were now prescribed.  

Case Study #2

When I first saw Client B  12 weeks ago, he exhibited Tinea Pedis (Athlete’s Foot).  The fungal infection completely covered the bottom of both feet, as well as along the sides and top of the feet.  It was starting to spread upwards towards his ankles.  He had large areas of peeling, scaling, redness and itching.  Upon inquiry, I learned that Client B likes to sleep with his socks and shoes on because his feet are extremely cold at night.  During the day, he continues to wear the same shoes.  I discussed a Plan of Care with Client B and his caregivers.  I recommended thick, cotton, breathable diabetic socks for nighttime use and advised my client to stop wearing shoes to bed.  I suggested leather or cloth slippers for daytime use at home.  Athlete’s Foot fungus (read here) thrives in dark, moist places.  Constantly wearing shoes provides the perfect opportunity for the fungus to grow.  I taught the caregivers how to make a vinegar-water foot soak, how to properly dry Client B’s feet and advised Client B to get a prescription anti-fungal medication from his doctor.  6 weeks later, most of the Athlete’s Foot infection was gone, with only a small amount of scaling and peeling on the bottoms of his feet.

Diabetics are at a higher risk for foot-related infections leading to lower limb amputation.  This is because of neuropathy and micro/macroangiopathy.  Since their feet have decreased sensation, diabetics may not realize that they have an infected cut or open sore on the feet.  Decreased eyesight in diabetics means that they may not be able to see the cut or open sore. Poor circulation means that the ability to fight the infection is compromised.

My main concern with both clients was eliminating the infection.  The whitish discharge, redness and inflammation of Client A indicated a bacterial infection in his toe.  Client B’s Athlete’s Foot could have progressed to cellulitis with open sores.  Knowing the appropriate nursing actions and referring both clients to their physician addressed their needs in a timely and effective fashion.

Being in regular contact with both clients, knowing their complete medical history and having up-to-date knowledge in diabetic nursing foot care prevented two situations from worsening.  Regular visits from a certified foot care nurse effectively addresses the needs of diabetics.

On-going nursing assessments during visits are able to identify problem areas that the client and their family are unaware of.  One of these assessments, mono-filament testing for neuropathy, determines changes in the client’s ability to detect sensations in the feet.  Physically checking the client’s feet for abrasions,cuts, sores, blackened areas is important for the nurse to do since diabetic clients have poor eyesight and may not be able to see them.  That is why it is important for diabetic clients and/or their families and caregivers to rely on the skills and knowledge of a certified foot care nurse.

Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author

Getting A Safe Manicure/Pedicure

 In the interest of researching how thoroughly mani-pedi establishments sterilize their instruments, I donned my very best undercover-I-am-not-a-foot-care-nurse disguise and conducted an informal survey.  I walked a distance of about 1.5km on a busy Toronto street and counted 12 mani-pedi places and 2 more that had closed down. 

Bacterial, viral and fungal infection risks are present with any procedure that can potentially break skin, such as accidentally cutting a client with improperly sterilized nail or cuticle nippers.  Transmission may also occur between client-technician through improper glove use by the technician.  Infection risks are even greater and have more serious effects for diabetics and anyone with lower immunity or circulation issues.

At all 12 places, staff were happy to answer my questions about how they clean their instruments and soaking tubs.  Each place said they use bleach or isopropyl alcohol to soak instruments and soaking tubs.  About half use a UV light machine after chemical soak, a couple of places have an ultrasonic machine to soak instruments, a few just use soaking, and only one establishment has an autoclave sterilizer. 

 All establishments claim to have been passed by the Toronto Public Health.  Although I didn’t ask to see documented proof of this, no one voluntarily showed me any documentation and no one has a certificate of approval on display. 

In preparation for this survey, I did some preliminary reading of Canadian sources.  The first study I read was the Survey of Infection Control Procedures at Manicure and Pedicure Establishments in North York, published in the Canadian Journal of Public Health, March – April, 2001.  The second study was Personal Service Establishments:  Looking at Infections Risks, by Prabjil Barn and Tina Chen at the National Collaborating Centre for Environmental Health Seminar, October 27, 2011 for the British Columbia Centre for Disease Control.

Disinfection is not the same as sterilizing. Disinfection eliminates all pathogenic organisms except bacterial spores.  Bacterial spores may revert back to the multiplying form of the bacteria and cause infection.

Sterilizing destroys all pathogenic organisms, including spores.

Isopropyl alcohol and solutions that contain quaternary ammonium materials are used in mani-pedi places as a chemical cleaner. According to both studies,  they are all classified as low-level disinfectants and should not be the only method of cleaning instruments which can pierce the skin, such as nail and cuticle nippers.  Their efficacy also depends on the amount of time instruments are soaked or how well tubs are wiped down.

 UV light machines and a glass bead sterilizers are not approved methods of sterilization and should be discouraged, according to the North York survey of mani-pedi establishments, and seconded by the Barn and Chen study.  

The only establishment that properly sterilizes their tools is the one with the autoclave sterilizer.   At McDermott Footcare, autoclave sterilization is the method we use as well.

Each place claimed that the method they use thoroughly sterilizes their instruments and soaking tubs.  It seems that the people I spoke with don’t know the difference between disinfecting and sterilizing, which indicates a lack of knowledge in this area.

How can we be assured of a safe manicure/pedicure?

  • find a place that uses an autoclave sterilizer, not a UV light machine or glass bead sterilizer and not an ultrasonic machine for soaking.  Only an autoclave will eliminate all pathogenic organisms including spores.
  • find out if all tools, files and sponges used on you are autoclaved between clients
  • make sure the technician uses gloves while working with you.  If he/she attends to another client at the same time, make sure the gloves get changed between clients.
  • Do not let the technician push back your cuticles or cut them.  Cuticles are the main line of defense that prevent bacteria and fungus from infecting the nail bed.  Read about fungal infections, here.
  • ask if you can bring your own tools to use.  If using your own personal tools, there is no need to autoclave because you are not sharing them with anyone else.

In Toronto, Canada, mani-pedi establishments are not regulated; there is no set protocol or best practice guideline for disinfecting and sterilizing.  It might be the same where you live.  Check with your Department of Health.

I went back to the only establishment that had an autoclave sterilizer and got a pedicure.  It was the one place where I felt that I could get a safe pedicure. The technician honoured my request to not push back or cut my cuticles after I explained that cuticles protect the nails from bacterial and fungal infections.  I never did tell them that I’m a certified foot care nurse. 

Buyer beware.  A representative from Toronto Public Health told me that since they do not regulate mani-pedi establishments, the onus is on the consumer to ensure their health and safety.   Know the risks.  Ask questions.  Protect yourself.

*I’m linking this post to http://www.findafootnurse.com/.  Find A Foot Nurse.  Check it out!