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by Mark H. Tompkins
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There a numerous dermatologic (skin-related) conditions which commonly occur in/on the lower legs, ankles, and feet. This section will give a brief description (and treatment) of some of the most common podiatric dermatologic conditions.
Impetigo: A common bacterial skin infection caused by Group A Strep, or Staph aureus. Predominantly pre-school and school age children. Begins as blisters that ooze fluid and become honey-colored crusted lesions. Causes extreme itching and is highly contagious. Treatment involves the use of topical and/or oral antibiotics.
Cellulitis: A potentially serious bacterial skin infection caused predominantly by Staph or Strep. Occurs from breaks in the skin and is common in the foot and lower legs. Characterized by redness (erythema), swelling (edema), warmth, and tenderness/pain. Can be superficial or spread to deeper tissues. Treatment includes local skin/would care, oral and/or intravenous antibiotics, and sometimes hospitalization.
Abcess: A potentially serious bacterial skin infection caused by predominantly by Staph/Strep, or more serious Gram negative and/or anaerobic bacteria. Appears as a fluid-filled (pus) swelling or fluctuance. Can lead to progressive cellulites or cause osteomyelitis (bone infection). Also, erythema, edema, warmth, and tenderness can be present. Treatment includes incision and drainage (I & D), local skin/wound care, oral and/or intravenous antibiotics, and occasionally hospitalization.
A common small skin growth that often forms on the toes. Bacterial infections/chronic
ingrown nails are commonly associciated with these lesions. Appear as elevated,
red-colored (hamburger meat) circular lesions. May develop into more serious
infections if untreated. Treatment includes, I & D, debridment, chemical-lysis,
local wound care, and oral antibiotics.
Verruca Plantaris: Please see Common Foot Problems Section - Plantar Warts.
Molluscum Contagiosum: Viral infection caused by the Poxvirus. Occurs most frequently in children. Lesions appear as ‘warty-like’ bumps on the skin. May work in connection with viral warts, and is contagious via direct skin contact. Treatments are limited and often frustrating. Excision, topical medications, and new electrolysis treatments are available for treatment.
Fungal Skin Diseases
For Athletes Foot, please see Common Foot Problems Section - Athlete's Foot.
For Onychomycosis (nail fungus), please see Common Foot Problems Section - Toenail Fungus.
Atopic Dermatitis: The most common form of dermatitis. ‘Allergic’ synergy with hay fever and asthma, and develops as a result of interaction of genetic and environmental factors. Common in children only. Appears as inflamed, red, weeping patches that are often itchy-may become infected with bacteria. Treatment involves removal of offending stimulus, topical steroid medications, and occasionally antibiotics and/or phototherapy.
Contact Dermatitis: True ‘allergic’ dermatitis. Erythematous skin eruption secondary to contact with allergic stimulus. Fluid-filled bumps or blisters, tenderness and redness of the skin often occur with contact dermatitis. May also notice oozing cracks and fissures. Is not contagious, and occurs in all age groups. Treatment includes testing for allergic stimuli and avoidance. Also, topical and/or oral steroids are used.
Drug Reactions: Adverse drug reactions to certain medications which occur on the skin. Drugs that most frequently cause problems include sulfa drugs, antibiotics such as penicillin’s and tetracycline’s, and phenytoin (a drug that prevents convulsions).Typical reactions appear as a red, itchy rash, or hives. However, severe reactions may occur that lead to tissue death (necrosis). Treatment includes discontinuation of the allergic medication, oral and/or topical corticosteroids, antihistamines, and occasionally epinephrine for severe reactions.
Dishydrotic Eczema: Recurrent skin reaction which occurs on the bottom of the foot. Early lesions are clear to pink, deep blisters associated with sweaty feet and itching. Later lesions cause severe scaling. Can become bacterially infected. Unknown cause, but associated with hyperhidrosis (sweaty feet), and emotional stress. Treatment involves foot soaks with burrows solution, topical and/or oral corticosteroids, and antibiotics if necessary. Prevention involves adequate lubrication of the skin.
Lichen Planus: A papulosquamous skin disease which appears purple, or redish-purple bumps on the skin, commonly with scales on top. Occurs most commonly in middle-aged individuals around the ankles. Relatively unknown cause, but has been linked to Hepatitis C, and may be contagious. There is no cure for this skin disease. Topical and/or oral corticosteroids are utilized with varying success. Also, a treatment called PUVA (Psoralen and UltraViolet light) may be effective.
Extremely common (1% of US population) skin disorder caused predominantly by
hereditary factors. Many types, but Plaque Psoriasis is most common. Characterized
by circular to oval, red (salmon) plaques (rash) with silver-colored scales.
Fairly common in the foot, especially around the ankles. But can occur on the
dorsum (top) and plantar (bottom) foot surfaces. Most common secondary foot malady
is Psoriatic Arthritis. The affects the joints of the forefoot and toes. Achilles
tendonitis at the back of the heel and classic heel pain are common findings
also. Treatment includes topical and/or oral corticosteroids, phototherapy, and
PUVA treatments. There is no known cure for Psoriasis, and can lead to disabling
skin and/or joints problems. “The Heartbreak of Psoriasis.”
Peripheral Vascular (PVD)-Related Skin Diseases
Arteriosclerosis Obliterans (Vascular Ulcers): Foot ulcers are ‘openings’ of the skin that arise from a multitude of conditions. Vascular (foot) ulcers are caused by a limitation of normal circulation. The most common cause is arteriosclerosis, or narrowing from hardening of the arteries, that supply the foot and lower leg. Vascular ulcers are very serious conditions that can lead to major soft tissue and/or bone infections (osteomyelitis). Partial toe and/or foot amputations, as well as BK (below the knee) amputations often occur as a result of vascular foot ulcers. They appear as extremely painful, darkish-colored openings (commonly on weight-bearing areas) and many times lead to complete skin necrosis (gangrene). Successful treatment depends primarily on revascularization treatment involving medication and/or surgical intervention, as well as intravenous and/or oral antibiotics, and meticulous wound care. Hospitalization is commonly necessary for severe conditions.
Thrombophlebitis: Superficial or deep inflammation of the veins of the upper (and most commonly, the lower) legs. Most common cause is long periods of immobilization from previous trauma or surgery. Can lead to DVT (Deep Vein Thrombosis), which is a blood clot that forms in the (deep) veins of the legs and can travel to the heart and lungs and cause a pulmonary embolism (blood clot in the lungs which often time is fatal). Appears as a red, hot, swollen extremity which is painful to touch, or squeezing of the area. Successful treatment is dependent upon early diagnosis and administration of anticoagulation medication(s). Antiembolic stockings, warm-moist extremity wraps and light/limited physical therapy is also commonly used. Many times leads to chronic swelling (venous stasis) of the extremity that may be a lifetime problem.
Stasis Dermatitis: Inflammatory skin manifestation caused by chronic edema (swelling) of the lower legs, ankles, and feet. Commonly caused by previous thrombophlebitis or previous trauma. Appears as a reddish-colored, irritation which may drain and be extremely itching.
Varicose Veins: Enlarged veins commonly found in the upper/lower legs, ankles, and rear-foot regions. Other than being unsightly, they can become enlarged and lead to veinous aneurysms that can rupture and bleed profusely. Most common causes are previous history of thombophlebitis, trauma, lower extremity surgery, and obesity. Treatments include elevation at times of rest, anti-embolic stockings, sclerosing injections, and surgery. Can lead to venous ulcerations (below)
Venous Ulceration: Foot, ankle, or lower leg ulcerations (openings) that occur as a result chronic edema from previous thrombophlebitis, stasis dermatitis, varicose veins, obesity, heart and/or lung disease, or may be hereditary in nature. Appear as reddish-colored, many times non-painful, openings around the ankle and/or rear-foot regions. Successful treatment includes adequate edema control, appropriate local wound care, and preventative measures as reoccurance is extremely common.
Raynaud’s Disease: A vasospastic (blood vessels constrict) condition that commonly affects the toes. Either primary (most common and less severe) or secondary (less common, more severe). “Attacks” that cause discoloration (white, blue, or red) and sensation changes (coldness, numbness, tingling, or throbbing). Treatment depends on severity. Mild cases can be controlled with warming measures, cease smoking, stress control, and exercising. Severe condition often require medical treatment with or without medications, and appropriate control of associated disease(s) such as lupus, scleroderma, etc.
Frostbite: Freezing of the skin and/or bodily tissues under the skin. Commonly occurs with the toes of the feet due to improper warmth measures in lower temperature. Factors include: degree/length of exposure, wind chill, humidity, wetness of clothing, altitude, and alcohol ingestion. Most cases are reversible, but can lead to severe blistering, tissue death (gangrene) and loss. Treatment includes removal of offending stimuli and slow warming with moist heat for mild conditions; and appropriate medical attention for severe cases.
Gangrene: Necrosis (tissue
death) that commonly occurs in the toes and/or foot. Caused my inadequate blood
supply from a number of causes ranging from arteriosclerosis (hardening/narrowing
of blood vessels that supply the leg/foot/toes to diseases processes such as
diabetes, to trauma. Different types-wet, dry, gas, and internal. Appearance
depends on type-please see www.mayoclinic.com/invoke.cfm?id=HQ00737 . Treatment(s)
vary depending upon type, but all successful treatments depend upon (re) establishing
normal blood supply, and appropriate wound care by a medical specialist.
Infestations, Bites, and Stings
Mites: Commonly referred to as ‘chiggers’ or ‘chigger bites’. Causes a severely itchy rash due to mite larvae under the skin. Common on the lower legs and feet. Mild cases can be treated with OTC hydrocortisone creams and benedryl, with more severe cases needing medical attention and treatment with a permethrin cream and/or lindane solution.
Spiders: Many different types of spider bites depending upon geographical location. For more information see this website or perform a internet search of you own. Most severe types include black widow, brown recluse, and tarantulas. Brown recluse spider bites are common in South Texas and can lead to severe tissue death/loss and deserves immediate medical attention. Allergic conditions can become serious.
Ants: Many types of ants, but most common in South Texas are fire ant bites. Initially painful, then become red eruption(s) that become intensely itchy. OTC hydrocortisone creams are helpful as well as calamine lotion and alcohol. Allergic conditions can become serious.
Ticks: Tick bites are common in South Texas due to significant rural areas with tall grass. Most commonly affect animals, but humans also. Bite itself is relatively harmless and asymptomatic, but ticks can carry and spread diseases. The most common are Lymes disease, Rocky Mountain Spotted Fever, Tularemia, Q-fever, and Erhlichiosis. Immediate medical attention should be sought if any symptoms appear within 48 hours after any tick bite. Treatment is dependent upon eradication.
Fleas: Similar to ticks-can also carry associated diseases (typhus/bubonic plague). Treatment again dependent upon eradication in the household.
Jelly Fish: Jelly fish ‘stings’ are common along the Texas coast region. Most common is Portuguese Man-of-war. Extremely painful stings caused by nematocysts tentacles imbedded within the skin. Immediate treatment includes removing the victim from danger zone, washing with salt-water only, and removal of remaining tentacles. Medical treatment if victim demonstrates progressive symptoms.
Sea Urchin: Not as common as jelly fish along Texas coast. Stings are caused
by venom-filled spines that become imbedded within tissues of the foot. Treatment
involves immersion in warm to hot water, and the removal of the spines from the
skin. If numerous stingers are present, infection may occur. Medical treatment
should be attained in serious cases.
Benign Tumors, Cysts, and Lesions
Cutaneous Horn: An elevated growth of hard (cornified) skin. Commonly involved with various lesions of the toes and/or feet. Relatively harmless, but may cause pain with increased pressure from shoe gear. Treatment usually involves the local excision of the lesion, and/or sometime chemical cauterization.
Dermatofibroma: Common benign soft tissue tumor which occurs on the foot and, or leg. Round, brownish, to red-purple colored lesion that feels like hard lumps under the skin. No treatment is necessary unless they cause pain with shoe gear/ambulation. Treatment involves local excision or use of keratolytic chemicals, including liquid nitrogen.
Epidermal Inclusion Cyst: Occurs secondary to traumatic or surgically implanted epidermal cells into deeper tissues. Common following nail avulsion procedures in the foot. Appear as elevated lesions. Treatment ranges from incision and drainage, to local excision.
Fibroma: Extremely common on the bottom (plantar fibromatosis) of the foot. Nodular lesions that arise on the midline of the foot in the arch region. May be small, or become elongated, or multiple in nature. Excision is usually necessary if the fibroma increases in size, or become painful upon ambulation.
Ganglionic Cyst: Common on the dorsum (top) of the foot, but also may occur plantarly (bottom). Soft-to-firm cystic swellings that occur via herniation of tendon sheaths. Most remain asymptomatic. Location usually determines pain, and treatment is either via aspiration (and sclerosing treatment), or surgical excision.
Hemangioma: Well-defined (bright red-to purple), smooth, raised, dome-shaped lesions common on the foot and toes. Relatively harmless with little to no malignant degeneration. Symptomatic lesions are typically removed by either cauterization and, or surgical excision.
Nevi (mole): Classic mole-type lesions that occur anywhere on the body. Numerous types with numerous appearances and prognosis’ (Blue, Compound, Congenital-Pigmented, Intradermal, Junctional). Treatment depends upon diagnosis. Any lesion which changes color or size over time, should be removed with/without the use of a biopsy.
Papules: Normally asymptomatic ‘piezeogenic papules’ that
appear as fat herniations around the periphery of the heels during weight-bearing.
If they become larger and symptomatic, they can be surgically excised.
Premalignant and Malignant Skin Tumors
Treatment for any/all premalignant and/or malignant skin tumors of the foot (and any site) involves immediate biopsy of the suspected site/lesion. If the lesion is relatively small and can be completely excised with the initial biopsy (excisional biopsy), this is preferential. If not, and the biopsy is positive for malignant degerneration, the patient should be referred to an oncologist for appropriate consultation and treatment.
Keratosis: Excessive growth of cornified tissue. Many different types affect the human foot. Seborrheic-, Stucco-, Actinic-, Arsenical-.Treatment depends upon the particular diagnosis, and symptoms. Malignant degeneration has been noted, and must be excluded by biopsy and/or excision.
Radiation Dermatitis: Relatively uncommon in the foot/ankle. Secondary to exposure to ionizing radiation. Skin becomes thinned, dry, and scaly. Central ulcerations can also occur.
Verrucous Carcinoma: A type of squamous cell carcinoma that can occur on the bottom of the foot (plantarly). May be the malignant degeneration of a previous verrucoid (wart) lesion. Appears as a warty-surfaced lesion with sinuses that are odoriferous (smell badly).
Basal Cell Carcinoma: Most common malignant cutaneous (skin) neoplasm. Most common in sunlight exposed areas (face), but fairly common on the lower legs and feet. Numerous types (Nodular, Cystic, Pigmented, Morpheic, Superficial, Nevoid). Characteristics are dependent upon particular neoplasm present. May metastasize and be fatal. For more information regarding basal cell carcinoma, visit www.skinsite.com/info_basal_cell_carcinoma.htm
Squamous Cell Carcinoma: Very common primary malignant neoplasm of the keratinizing cells of the epidermis. Risk factors include radiation exposure, carcinogens, chronic skin wounds (foot!!), scars (foot!!), genetic disorders (foot!!), and human pappillomaviruses (foot!!). May metastasize and be fatal.
Kaposi’s Sarcoma: Common neoplasm involving the legs, ankles, and feet of older men of European or Mediterranean origin, or Jewish heritage. Also associated with patients with Acquired ImmunoDeficiency Syndrome (AIDS)-but most commonly the upper vs. the lower body.
Malignant Melanoma: One of the most dangerous neoplasms to occur on the lower
extremities and feet. Many different types (Superfical Spreading, Lentigo, Acral,
Nodular, Advanced). Characteristics are dependent upon particular neoplasm present.
May metastasize and be fatal. For more information regarding malignant melanomas
and their treatments, please visit matrix.ucdavis.edu/tumors/tradition/melanoma.html
Corn/Callus: Please visit Common Foot Problems Section - Corn/Callus
Blister: A fluid-filled ‘sac’ that forms over areas of increased pressure/friction. Very common in the foot and toes, especially with runners and athletes. Most are relatively small, but may become larger and secondarily infected. Treatment includes puncturing the outer tissue and expressing the fluid. Apply antiseptic and cover with a bandaid. If this is done soon after the blister forms, many times it will heal primarily and the outer layer of skin will not slough.
Bruise: A contusion, or injury to the soft tissues only. Discoloration is due to rupture of underlying blood vessels (veins). May be very mild to severe with internal hemorrhaging. Treatment includes R.I.C. E. (Rest, Ice, Compression, Elevation) of the affected area. Length of treatment dependent upon location and severity.
Bursa (bursitis): A bursa is a fluid-filled ‘sac’ that overlies bony prominences or areas of high friction (between tendons and ligaments) throughout the body. They commonly become irritated and inflamed and lead to bursitis. Extremely common in the foot, especially under the heel (refer to www.drtompkins.com/conditions/heel_pain.htm ) and forefoot region (refer to www.drtompkins.com/conditions/bunions.htm ). Treatment involves removing, or reducing the amount of friction or irritation over the affected area, anti-inflammatory medications-oral and/or injection, physical therapy, shoe inserts, and occasionally surgical intervention in severe, resistant cases.
Decubitus Ulcer: An ulcer is an opening from the outside of a structure to the inside. Cutaneous ulcers occur in/on the skin and develop to various depths (from Stage 1- Stage 5). Decubitus Ulcers are caused by increased pressure or friction over a given area (usually over/under a boney prominence). Very common in diabetics and patients with circulation problems. The skin and/or bone causing the ulcer can become infected leading to hospitalization, surgery, and occasionally amputation. Treatment includes aggressive wound care, off-loading the area, and antibiotics if necessary.
Foreign Body: Any abnormal or foreign object that becomes imbedded within the tissues of the body. Extremely common in the plantar foot. Can be only superficial (epidermal to dermal tissue depth), or deep (subcutaneous, fascial, or bone tissue depth). May become secondarily infected or cause a foreign body granuloma, or inclusion cyst. Treatment is excision/removal for more severe cases, or use of warm salt-water soaks for mild conditions.
Puncture Wound: Traumatic injury (opening) within the external cutaneous tissues caused by a foreign object. Very common in the plantar foot. As with foreign body injuries, can be superficial or deep. Deep puncture wounds are susceptible to developing secondary soft tissue and/or bone infections (osteomyelitis). Also, potential for introduction of foreign body. Treatment is dependent upon severity. Thorough cleansing and debridement of wound is vital. Local wound care, and appropriate antibiotic therapy. Medical attention is advised in most situations, especially of traumatic object is dirty, rusty, or possibility of a foreign body is present.
Excessive cornified skin build-up in a particular area secondary to increased
pressure and/or friction. “Corns’ are specialized
hyperkeratosis that forms on the top of the lesser (2-5) toes. “Tylomas’ are
specialized hyperkeratosis that forms on the ball of the foot under the metatarsal
heads. Vary severities exist from mild to no pain, to severe soft tissue and/or
bone infections. Treatment depends upon severity. Debridement, removing offending
stimulus (accommodative padding, shoe modification), corticosteroid injections,
and surgical procedures are common treatments.
Scratch-superficial cut-type injury of the skin caused by a sharp instrument or device. Abrasion-superficial injury involving the ‘wearing-away’ of tissue as a result of a friction force.
Burn-thermal injury caused by excessive temperature. First degree-superficial (epidermis) injury/redness-pain-swelling/healing time 3-6 days;
Second degree-superficial to deep (epidermis and dermis involved) injury/blisters-severe pain/redness/healing time multiple weeks to months; Third degree-deep (epidermis, dermis, subcuateous layers) injury/waxy-leathery-charred appearance-little to no pain initially/healing time-months to years-skin grafts.
Subungual Hematoma: Injury to nail bed tissue leading to bleeding occurring under the nail plate. Usually painful after initial injury. Severe injuries lead to nail lysis (nail plate coming loose-off). Treatment involves draining the underlying blood/fluid, and local wound care. Normally the nail is avulsed (totally removed) and treated with salt-water soaks and topical antibiotics. Occasionally, the bone (distal phalanx) may become fractured with severe injuries.