Step into summer

The arrival of summer means an increase in customer queries about foot complaints. Take a look at the most common conditions and how to deal with them

Most people experience foot problems at one time or another – whether it’s blisters caused by ill-fitting shoes, fungal infections picked up from communal changing rooms or more serious issues such as those relating to diabete

With foot issues having the potential to be unsightly and uncomfortable, people will often call on their local pharmacy for advice and recommendations, particularly in the summer months when their feet are more likely to be on show. So what are the most common problems and what advice can be passed onto customers to help manage and prevent them?

Blisters

These fluid-filled lesions are a result of pressure and friction. They can be caused by poorly fitting shoes, socks that rub or by having sweaty or wet feet. Unless a customer has diabetes, they can safely self-treat.

How to treat:

Advise customers to attend to any sore patches immediately, applying a plaster or padding to help prevent a blister from developing. If the blister has already developed, advise them not to pop it, as this can result in infection. An open blister should be cleaned with soapy water and antiseptic ointment applied. Then it should be covered with a blister plaster to protect it and speed up healing.

Self care tips:

• Make sure socks fit well and are changed daily
• Check footwear is comfortable
• Keep feet dry
• For sweaty feet, use a spray or powder to tackle moisture.

Athlete’s foot

“This highly infectious fungal skin condition is transmitted via skin cells. Walking barefoot in public places is a common way to spread it,” explains Emma McConnachie, media and communications officer at the Royal College of Podiatry. “It typically presents as very dry skin around the toes or arch of the foot. This will often look like the skin has been blistered, with small, dried jagged edges. It may also appear with a red mottling of the skin and red pinpricks or bubbles of fluid under the skin.” Left untreated, athlete’s foot can quickly spread to toenails, causing a fungal nail infection.

How to treat:

Treatment is via OTC topical antifungals, which are available as sprays, liquids, creams and powders. It is important to continue treatment for one to two weeks after the rash has gone to prevent recurrence. If topical treatments are not effective, antifungal tablets are available on prescription.

“Both feet need to be treated, even if only one shows signs,” says Emma. “Most treatments need to be applied once or twice daily for two weeks.” If compliance is an issue, a single-application treatment can be recommended.

Self care tips:

• Ensure feet are totally dry before putting on socks and shoes
• Alternate footwear daily to give shoes a chance to dry out
• Wear flip-flops in communal changing areas.

Verrucas

Verrucas are warts on the soles of the feet, often with black dots under a ring of hard, white skin, which can be painful. They are caused by the human papilloma virus (HPV) and spread in warm, damp environments.

How to treat:

In many cases, verrucas will disappear without treatment – this takes about six months in children and two years in adults. Until they have gone, it is important to cover them with a plaster to prevent spread in communal areas. 

If verrucas are painful, they can be treated with OTC products containing salicylic acid or freeze treatments. Salicylic acid needs to be applied daily for up to three months and dead tissue filed away. Freeze treatments can give faster results as they work by destroying dead tissue.

Self care tips:

• Wear flip-flops in communal areas
• Don’t share towels
• Wear waterproof plasters or socks when swimming
• If verrucas don’t respond to treatment or get worse, refer the customer to a podiatrist.

Cracked heels

These are common in people with very dry skin and among those who wear slip-on and backless shoes. Deep cracks can become painful and infected.

How to treat:

Recommend applying a urea-based foot cream daily and removing hard skin regularly. If there is a thick yellow layer of skin over the heels, referral to a podiatrist may be needed to get it removed. 

Self care tips:

• Avoid wearing slip-on shoes
• Moisturise feet daily.

Corns and calluses

“Corns and calluses are caused by areas of high pressure and friction. Even when professionally removed, they will recur if pressure to the feet continues,” says Emma. “They appear as yellowish, hard lumps on pale skin and darker brown lumps on dark skin. Avoid corn plasters containing salicylic acid as these can cause wounds, even in healthy skin. A corn can only be removed by a trained podiatrist.”

How to treat:

A cushioning pad applied to a corn can help to relieve pressure and discomfort. “For calluses, these can be buffed with a foot file or pumice and moisturised to keep them supple. A podiatrist can remove them safely,” says Emma. Older customers may benefit from additional padding to the ball of the foot to compensate for loss of natural padding.

Self care tips:

• Use a foot file or pumice regularly to prevent hard skin
• Avoid ill-fitting shoes that cause friction.

Sweaty feet

There are more sweat glands per inch of skin on the feet than anywhere else in the body. Overactive sweat glands are common in those aged under 25 and are triggered by changing hormone levels. When bacteria breaks down the sweat, it can cause foot odour.

How to treat:

Specialist anti-perspirants with aluminium chloride can be used daily, and then as needed, to help improve symptoms. Medicated shoe insoles can minimise odour. An anti-fungal spray or powder can help to prevent athlete’s foot, which thrives in warm, damp conditions.

Self care tips:

• Change socks and shoes daily
• Stick to shoes and socks made of natural fibres
• Wash and thoroughly dry feet daily.

Fungal nail infection

This is most common in people over 60 and those who use communal showers and changing rooms. It is often caused by the spread of athlete’s foot, but it can also be triggered by other fungi, such as the candida yeast. Over time, the nails become thickened, flaky and discoloured.

How to treat:

Topical amorolfine is a popular OTC treatment, but usually needs to be used for between nine and 12 months before results are seen. “OTC treatments are generally only licensed for use on the top half of the toenail, so if the infection has spread further, customers should be referred to a podiatrist,” Emma advises. For stubborn cases, prescription antifungal tablets are available.

Self care tips:

• Keep nails short and file down thickened nails
• Use separate clippers to trim infected nails to prevent the fungus spreading
• Treat athlete’s foot early to stop it spreading to the nails.

Plantar fasciitis

This is the most common cause of heel pain, and mainly affects the over-40s, as well as athletes. It is characterised by pain around the heel, bottom of the foot or the arch of the foot.

How to treat:

Customers can be advised to rest with their feet up as much as possible. Using an ice pack for up to 20 minutes can help to relieve pain. Non-steroidal anti-inflammatory drugs (NSAIDs) can be taken if appropriate.

Self care tips:

• Choose wide, comfy shoes with low heels and soft soles
• Don’t walk barefoot on hard surfaces
• Do regular stretching exercises
• Avoid exercise that puts pressure on the feet.

Ingrown toenails 

Ingrown toenails occur when the corner of the nail pierces the flesh of the toe as it grows. They can be painful and inflamed, and may become infected.  

How to treat: 

Customers should be advised to bathe the affected foot in a salty footbath three to four times a day for a few days to soften the skin and stop the nail growing into it. This can also help to prevent infection. Paracetamol or ibuprofen can be taken to ease the pain. A podiatrist can remove the ingrown spike of nail safely. 

Self care tips: 

• Cut nails straight across using clippers, not scissors
• Choose natural materials for shoes and socks.

When to refer customers 

There are times when it’s not safe for customers to treat foot problems themselves. Emma McConnachie, media and communications officer at the Royal College of Podiatry, says the following customers should be referred to a podiatrist: 

• Any customer with diabetes, poor circulation or neuropathy 
• A fungal nail infection where more than half the nail is affected 
• Any ingrown toenail
• Open wounds, ulcers or pressure sores
• Heel pain lasting longer than three weeks. 

Footcare and diabetes

Having diabetes puts people at much greater risk of developing foot problems and complications. This is because raised blood glucose levels can reduce sensation and circulation in the feet, impacting the healing of minor issues and causing pain.

“During the pandemic, the way diabetes care was delivered had to change considerably, with many routine appointments cancelled or postponed,” says Esther Walden, senior clinical advisor at Diabetes UK. “Foot services prioritised those who were most at risk, so people with diabetes who didn’t have existing problems may have waited longer for their checks. Pharmacy staff can play their part by engaging with people with diabetes and questioning them about their feet if they are making enquiries about footcare products. Doing something as simple as asking customers about their general foot health when they are ordering or collecting diabetes medication is also a good approach.” 

Esther says that people with diabetes should inspect their feet daily and urgently access help at the first sign of a problem. “It really is essential,” she adds.

When recommending foot treatments, pharmacy staff should be aware of the symptoms of foot neuropathy (numbness and tingling) and ischaemia (tight or burning pain), both of which require further investigation. Esther says it is also important to be aware of which foot products are not suitable for people with diabetes, such as corn plasters, callus knives and verruca treatments. “Staff should be aware that dry skin is a risk factor for ulceration, and urea-based emollients are more effective for people with diabetes. Signpost them to trusted information sources, such as Diabetes UK.”

Red flags that warrant referral include changes in foot colour, temperature or shape, and Esther adds that “other things to watch for are skin breakages, especially blisters or cuts the customer can see but can’t feel, and foul-smelling wounds”.

Podiatry in practice

Prestwich Pharmacy: Gold Standard Foot Clinic

The podiatry clinic in Prestwich Pharmacy was set up four years ago by Gold Standard Foot Care, which also operates other podiatry clinics in the Lancashire and Greater Manchester area. The company was initially approached by one of the pharmacists at Prestwich Pharmacy, who has a special interest in podiatry.

“Pharmacy is the ideal location for a foot clinic, with the pharmacy team referring customers on to us. They might come into the pharmacy for foot and leg treatments, or about an injury, then they find out about or get referred to our clinic. The pharmacy location is great for raising awareness of our service,” explains practice manager Jessica Stuart. “We have a great relationship with the pharmacy staff and they are open to learning more about what we do. It’s definitely a partnership that works both ways.”

Jessica says that ingrown toenails are currently the most common complaint she sees, mainly due to customers getting back to playing sports after lockdown or going back to wearing tight or restrictive footwear. “We saw a big increase in patient numbers during the pandemic, with even more people coming in now restrictions are easing,” she adds.

Godalming Pharmacy Podiatry Clinic 

Podiatrists Hannah Jackson and Ami Lundie set up their clinic in Godalming Pharmacy, Surrey, in 2019. The most common reasons for patients to visit include corns, calluses and routine care such as nail cutting and hard skin removal. “Currently, 54 per cent of our patients book our podiatry follow up appointment, which includes all of these,” says Hannah, who is the clinic’s clinical director.  

The clinic has proved to be a good fit with the pharmacy setting. “As podiatry has many medical issues and the public come into a pharmacy for various medical products, it links in very well,” she says. “We are finding that more patients are returning now that restrictions have eased.”