Heel fissures

Heel fissures are disruptions in the skin that can be caused by epidermis that has dried excessively, backless shoe gear, and numerous systemic diseases

• mechanical strain, caused by weight bearing by the affected area, can lead to deepening of the fissure, which increases discomfort and mobility
• diabetes and/or vascular compromise may lead to additional complications, such as cellulitis and ulcerations
  • diabetic patients are often insensate and unaware of the dry skin condition and progressing fissures until the skin opens, resulting in a full-thickness ulcer formation
    
    
• Management (1,2,3):
  • prevention is the most effective treatment for cracked heels
    • can be achieved by simply rubbing the heels with an emollient (moisturising cream) on a regular basis to maintain suppleness and hydration in the skin
      • special heel balms are available - these contain descaling (keratolytic) or water-retaining (humectant) agents (e.g. urea, salicylic acid, alpha-hydroxy acids, saccharide isomerate)
        
        
  • if cracked heels
    • a moisturising routine 2-3 times a day may be all that is needed to heal the heel
      • emollient cream may alleviate pain and dryness and improve the appearance of heel cracks (2)
    • a pumice stone can be rubbed gently against the callus to take away some of the thick hard skin before applying moisturiser
    • foot soaks followed by mechanical debridement and topical petrolatum may decrease the depth of cracks and thickness of calluses
    • fissures may be treated with a liquid, gel or spray bandage to reduce pain, protect and allow more rapid healing
    • maintenance therapy with emollients and appropriate footwear also may help heel cracks
      
      
  • for severely cracked heels or if no improvement is seen after a week of self-treatment a visit to a podiatrist may be required (1)
    • treatments may involve the following
      • debridement - cutting away hard thick skin
        • must not not be attempted at home as there is a risk of removing too much skin and precipitating infection
      • strapping - bandage/dressings around the heel to reduce skin movement
      • prescription for stronger softening or debriding agents, e.g. urea or salicylic acid creams
        • keratolytic agents, such as salicylic acid (e.g. 6% salicylic acid controlled-release cream), may reduce hyperkeratosis, cracks, and pain (3)
      • insoles, heel pad or heel cups
        • in order to redistribute the weight of the heel and provide better support
      • special tissue glue - in order to hold the edges of the cracked skin together and allow the crack to heel
        • cyanoacrylate tissue adhesives, such as Superglue or Krazy Glue, may reduce pain and speed closure of heel cracks (3)

Notes:

• cyanoacrylate (glue) skin protectant barriers are transparent, flexible film-forming products that adhere to the skin at a molecular level - examples include 'Superglue' and 'Krazy glue'
  • has a high affinity for moisture and bond to surfaces that contain any degree of moisture, such as skin
    • on application to such a water-rich or water-containing surface, the monomeric substance present in the applicator immediately sets up a 'chain reaction' to form a robust polymeric barrier, protecting the underlying intact or damaged skin from moisture, and friction-related breakdown
    • these protective films may also have the capacity to maintain the integrity of newly healed skin
    • once set on the skin, the film is claimed to provide up to 3 days of wear, subsequently shedding during normal skin surface turnover, thus avoiding the need for daily reapplication
      
      
  • there are key differences between the traditional solvent-based protectants (commonly called skin preps) and newer materials such as the cyanoacrylates
    • newer-generation products contain no solvents; therefore there is no potential for solvent-related stinging
    • the lack of solvent presence, most of the product remains on the skin, leading to a robustness of the deposited film not seen with solvent-containing products
    • cyanoacrylate skin protectants can be used on at-risk skin to prevent and manage certain types of skin tears, friction-related breakdown of skin, and shear- and moisture-related assault on skin in at-risk patients (4)
      
      
  • an adverse effect of application of cayanoacrylate was the temporary discolouration at the site of application:
    • purple stain accumulates after each application, but this color was found to be eliminated with epidermal turnover and had no lasting effect (4)
      • coloring of the treated skin was deemed to be actually beneficial because some of the patients or their caregivers used the presence or absence of color to judge when to reapply the product

Reference:

• Ngan V. Cracked heels. New Zealand Dermatological Society, 2006. Updated June 29th, 2013. Available at: http://dermnetnz.org/scaly/cracked-heels.html. Accessed July 2nd 2014..
• Smillie S, Landorf K, Keenan A. The effect of a 25% urea cream and sorbolene in the treatment of heel fissures: a double blind randomised controlled trial. Australas J Podiatr Med. 2004;38:56
• O'Sullivan G et al. What treatments relieve painful heel cracks? J Fam Pract. 2012 October;61(10):622-623.
• Vlahovic TC et al. A Review of Cyanoacrylate Liquid Skin Protectant and Its Efficacy on Pedal Fissures .J Am Col Certif Wound Spec. Dec 2010; 2(4): 79-85.