CRACKED HEELS

Cracked heels, or heel fissures, are caused by dry, thickened skin around the heels, often resulting in discomfort, pain, and potential complications like infections or cellulitis.

Common in elderly individuals, diabetics, and those with prolonged weight-bearing activities, contributing factors include dry skin, improper footwear, medical conditions like diabetes or hypothyroidism, and environmental or nutritional deficiencies.

Without intervention, complications such as chronic pain, infections, and ulcer formation may arise, underscoring the importance of proactive foot care, especially for high-risk groups.

Etiology

Dry Skin: Primary cause due to lack of moisture in the stratum corneum.

Increased Pressure: Excessive weight-bearing activities, obesity, prolonged standing.

Medical Conditions: Diabetes mellitus, hypothyroidism, and skin conditions like psoriasis or eczema.

Environmental Factors: Low humidity, harsh soaps, improper footwear.

Nutritional Deficiencies: Vitamin deficiencies (e.g., vitamin A, C, E) can compromise skin health.

CLINICAL FEATURES

The first sign of getting a cracked heel is the development of dry, hard, thickened skin around the rim of the heel. This is called a callus and maybe a yellow or dark brown discolored area of skin. Initially, small cracks over the callus are visible.

If left untreated and as more pressure is placed on the heel, these cracks become deeper and eventually walking and standing will be painful. The cracks may be so deep that they begin to bleed.

In severe cases, cracked heels can become infected, and lead to cellulitis. This must be treated with the elevation of the area, debridement of dead tissue, and antibiotics.

Cracked heels are of particular concern for diabetic patients, who may suffer neuropathic damage (loss of feeling, particularly of the feet), as the fissures may lead to diabetic foot ulcers.

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INVESTIGATIONS

Clinical Examination: Assessing the depth and severity of fissures.

Laboratory Tests:

· Blood Glucose

· Thyroid Function Tests: Hypothyroidism assessment if indicated.

· Check for deficiencies in vitamins A, C, and E.

TREATMENTS

The best form of treatment for cracked heels is to prevent cracks from occurring in the first place. This can be achieved by simply rubbing the heels with a moisturizing cream (Petrolatum or glycerin-based products) on a regular basis to keep the skin supple and hydrated.

Special heel balms are available that contain descaling (keratolytic) or water-retaining (humectant) agents, such as:

Topical Emollients: Urea-based creams
Keratolytic Agents: Salicylic acid or Lactic acid (5-12%) to reduce hyperkeratosis.
Alpha-hydroxy acids
Saccharide isomerate.

The fissures may be treated with a liquid, gel or spray bandage to reduce pain, protect and allow more rapid healing.

For severely cracked heels or if no improvement is seen after a week of self-treatment a visit to a podiatrist may be required. Treatments may involve the following:

Debridement – cutting away hard thick skin (this should not be attempted at home using scissors or razor blade as there is a risk of removing too much skin and infection occurring)
Strapping – bandage/dressings around the heel to reduce skin movement
Prescription for stronger softening or debriding agents, usually containing urea or salicylic acid
Insoles, heel pads, or heel cups to redistribute the weight of the heel and provide better support (prevent the fat pad from expanding sideways)

Special tissue glue to hold the edges of the cracked skin together so it can heal.

Antibiotics (topical/oral): For infected fissures; e.g., mupirocin 2% ointment for localized bacterial infection.

PREVENTION

Regular Moisturizing: Using emollients and occlusive agents to prevent dryness.
Proper Footwear: Wearing cushioned shoes with a closed heel.
Avoid Prolonged Standing: Minimizing prolonged pressure on the heels.
Hydration: Drinking adequate water to support skin hydration.

Protective Barriers: Use of heel pads or silicone heel protectors to reduce pressure.

USEFUL TIPS

Advise patients to avoid walking barefoot on hard surfaces.
Educate on the importance of regular foot care, especially for high-risk individuals (e.g., those with diabetes).