Patients should be referred to their GP if there has been no improvement after one week of treatment. However, depending on the product used, treatments can sometimes take longer than one week to work. Detailed information on various types of warts, their presentation and treatment can be found in a previous article .
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Verrucae are plantar warts, located on the sole or toes of the foot and are caused by the human papillomavirus HPV infection of keratinocytes, the most dominant cell type in the epidermis, which results in development of epidermal thickening and hyperkeratinisation  , . HPV infection is acquired from direct contact, which may be person-to-person or from the environment e.
Around half of verrucae in children disappear on their own within a year, and two-thirds resolve within two years, but they can take many years to resolve in adults see Infographic. Often painful when they first start, verrucae have an encapsulated appearance and skin striations appear to punctate areas of haemorrhage black dots. Treatment is recommended to lessen symptoms which may include pain , decrease duration and reduce transmission . Treatment options include salicylic acid, often in combination with lactic acid, formaldehyde, glutaraldehyde and cryotherapy see below.
See previous Learning article for more information on treatment of patients who may be immunocompromised . Pharmacists and pharmacy teams should advise patients to read the relevant instructions and use a product for only a week or two. However, some patients may require continuous application for 2—3 months, sometimes longer. Salicylic acid based OTC products are most commonly used and may take a few months of consistent application .
Its exact mechanism of action is not known but it acts as a keratolytic, resulting in the removal of epidermal cells infected by HPV . Salicylic acid preparations are available in a range of treatments, including gels, paints, plasters, solutions and ointments, and they often also include lactic acid.
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Gel treatments may also contain colophony, which may cause an allergic reaction in some patients . Salicylic acid should not be applied to warts on the face, intertriginous areas where skin rubs together, such as the axilla , anogenital warts, moles or birthmarks, warts with hair or red edges, or to open lesions or broken skin .
When using salicylic acid, patients should be advised to protect the surrounding skin to avoid irritation; this can be done by coating the area with soft paraffin or by using plasters. Salicylic acid is not recommended for use in patients with diabetes, as these patients often have peripheral neuropathy and poor circulation, leading to poor wound healing . The NHS states that salicylic acid can be used to treat warts in pregnancy but only on a small area for a limited period of time.
Formaldehyde and glutaraldehyde are applied in a similar way to salicylic acid. Glutaraldehyde can stain the skin brown, and should be discontinued if skin irritation is severe. Patients using OTC treatments can be advised to debride the surface of the wart gently with a file e. However, this should be done carefully as there is a risk of further spread of the infectious material.
Patients should also soak the wart for five minutes before treatment to soften it. Cryotherapy with liquid nitrogen can be offered by trained clinicians, and can be suitable for adults and older children who are able to tolerate it under local anaesthetic.
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It rapid cools the cells, causing ice crystals to form on the cell surface, disrupting membranes. When thawing occurs, extracellular fluid becomes hypertonic, with the rapid flow of water into cells causing cell death . There are also some OTC treatments available that are based on cryotherapy. Advice on how to assess skin lesions can be found in a previous article .
Other treatments, such as bleomycin and imiquimod cream, are available on prescription and have an increased success rate, but there can be associated sensitisation  , . Cover verrucae and warts with an adhesive bandage while swimming. Wear flip-flops when using communal showers, and do not share towels . Patients who are resistant to OTC treatments and at-risk patients e. A blister may form when the skin has been damaged by friction, heat, cold or chemical exposure. Fluid collects between the epidermis and the layers below, and protects from further damage, allowing the skin below it to heal.
Friction is the most usual cause of a blister on the feet, mainly after walking long distances or by wearing poorly fitting shoes . Blisters form more easily on moist skin than on dry or soaked skin  , and are more common in warm conditions.
Micropore tape can be used as an excellent preventative measure. Other available OTC products include blister plasters, and antiperspirants can be recommended to patients experiencing excessive sweating. Socks that wick sweat may also be useful. Patients should be advised not to burst blisters and that they can be covered with plaster or gauze if additional protection or cushioning is required.
Pharmacists, pharmacy teams and healthcare professionals should advise patients to wear well-fitted footwear. Footwear should ideally be laced so that the foot is held securely when walking down- or uphill. Use of surgical spirit interdigitally will help keep the skin dry, reducing potential for blistering. Patients with signs of infection, those experiencing pain, or those with large blisters should be referred to their nurse or GP. A common condition causing pain and disability, onychocryptosis is caused by the actual penetration of flesh by a sliver of nail. Most commonly found in the big toe, patients are usually male, aged between 15 and 40 years .
Cases of ingrown nail have a reported male-to-female ratio of . Trauma appears to play a major role  , but common causes also include poor nail-cutting, chemotherapy, moist skin, toe deformities, abnormal nail growth and fleshy toes. Patients may experience pain, redness, inflammation and infection as a result of nails growing into the nailbed. Exudate and hypergranulation tissue may also be present .
Differential diagnosis may also include subungual exostosis, periungual fibroma, amelanotic melanoma, glomus tumours and corn in sulci. Pharmacists, pharmacy teams and healthcare professionals should advise patients to wear well-fitting shoes, cut nails straight across and promote good foot hygiene practices see Box 2. At the initial signs of an ingrown toenail, before the nail pierces the skin, patients can use a nail clip and spray that helps to train the nail to grow straight.
However, once the nail has pierced the skin, effective treatment can involve either partial or total nail removal and, if the condition is recurrent, either ablation or excision of the nail bed may be required. Pharmacists, pharmacy teams and healthcare professionals should refer patients who are in severe pain, have infection, swelling, exudate or there is bleeding from the wound  , if there is a recurrent problem requiring repeated antibiotics, and also at-risk patients.
Referral to a podiatrist should be made if the patient requires a nail to be removed.
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If neglected, paronychia may occur or spread and lead to osteomyelitis, systemic infection, sepsis or amputation. Hallux valgus HV , often referred to as a bunion, is a common and progressive deformity of the first metatarsophalangeal joint. A UK study reported a prevalence of HV is a condition more common in the elderly.
The big toe deviates laterally and the first metatarsal moves medially. It is the head of the first metatarsal that gives rise to the bunion prominence. The overlying soft tissue, owing to footwear pressure, can become inflamed and swollen, and can often develop painful bursitis. HV deteriorates over time and can lead to severe deformity in early middle age.
It is associated with bursitis, functional disability, foot pain, impaired gait patterns, poor balance, and falls in older adults . This can also lead to excessive lateral loading of the metatarsal heads and associated lesser toe deformities. Most shoes do not accommodate the resulting protrusion and put pressure on the misaligned joint. Eventually, the bursa a fluid-filled sac that surrounds and cushions the joint becomes inflamed, and the entire joint becomes stiff and painful.
Conservative measures may help relieve symptoms, although there is no evidence they can correct the underlying deformity.
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Exercises, such as calf stretches to counteract the shortening of the calf, can help to keep feet supple. Orthoses can help control the alignment of the foot and help accommodate deformity, reduce pain and help increase mobility. Shoe alterations or night splints, which hold toes straight during sleep, can help to slow the progression of bunions in children. Toe alignment splints will not correct bunions but can give temporary relief from discomfort.
Bunion shields may help reduce friction and a degree of pressure from the enlarged joint. Orthoses do not prevent the progression of the deformity but may be helpful for those with joint pain. If conservative management fails, there is surgical correction. Procedures now make use of cuts in bone, which are intrinsically stable, and many internal fixation devices are available to maintain alignment leading to early mobilisation. This is often carried out as a day case.
Footwear has a direct impact on foot function and if the footwear does not fit properly, foot function is compromised. Wearing sensible shoes that fit well is a good preventative measure. For example, a shoe with a strap or lace over the instep holds the foot secure and helps stop it sliding forward. Wider shoes provide toes with room to move and heel height should be no more than 4cm for maximum comfort.
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