What causes hot feet and how is it managed?

Causes and Management of Hot Feet

Hot feet can be caused by peripheral neuropathy (especially diabetic neuropathy), erythromelalgia, Charcot neuroarthropathy, peripheral arterial disease, or infections, with management focusing on treating the underlying cause and implementing appropriate foot care practices to prevent complications.

Common Causes of Hot Feet

1. Diabetic Peripheral Neuropathy

• Most common cause of hot feet sensation in diabetic patients
• Results from nerve damage due to prolonged hyperglycemia
• Presents with burning, tingling sensations, and temperature dysregulation 1
• Often accompanied by loss of protective sensation (LOPS)

2. Erythromelalgia

• Characterized by episodes of severe burning pain in distal limbs
• Accompanied by striking redness and warmth of the skin
• Precipitated by heat or activity and relieved by cooling 2
• Can be primary (sporadic or hereditary) or secondary (associated with thrombocythemia, collagen-vascular diseases, diabetes)

3. Charcot Neuroarthropathy

• Presents as a red, hot, swollen foot in patients with diabetes and neuropathy
• Requires immediate attention to prevent deformities and complications
• Temperature difference between affected and unaffected foot is a key diagnostic sign 1
• Requires prompt immobilization/offloading while diagnostic studies are performed

4. Peripheral Arterial Disease (PAD)

• Can cause temperature changes in the feet
• Often coexists with neuropathy in diabetic patients
• Presents with decreased walking speed, leg fatigue, claudication 1
• Assessment includes inspection and palpation of pedal pulses

5. Infections

• "Hot-foot syndrome" can be caused by Pseudomonas aeruginosa
• Presents with painful plantar erythematous nodules
• Occurs after contact with contaminated water from pools, hot tubs, etc. 3

Diagnostic Approach

Initial Assessment

1. Comprehensive foot examination:

   • Visual inspection for skin integrity, deformities, erythema, warmth
   • Neurological assessment using 10-g monofilament test plus at least one other test:
     • Pinprick sensation
     • Vibration perception using 128-Hz tuning fork
     • Temperature sensation
     • Ankle reflexes 1

2. Vascular assessment:

   • Inspection and palpation of pedal pulses
   • Ankle-brachial index testing if symptoms or signs of PAD present 1

3. Temperature assessment:

   • Compare temperature between affected and unaffected foot
   • Temperature difference ≥2°C may indicate active inflammation or Charcot 1

Management Strategies

1. Treatment of Underlying Cause

• For diabetic neuropathy: Optimize glycemic control
• For Charcot neuroarthropathy: Immediate offloading and immobilization 1
• For erythromelalgia: Cooling measures, aspirin for cases associated with thrombocythemia 2
• For infections: Appropriate antimicrobial therapy 3

2. Foot Care Education

All patients with hot feet, particularly those with diabetes, should receive education on:

• Daily foot inspection, including between toes
• Proper washing with water temperature below 37°C
• Thorough drying, especially between toes
• Appropriate moisturizing (avoiding between toes)
• Proper nail cutting (straight across)
• Avoiding barefoot walking, even indoors 1

3. Appropriate Footwear

• Well-fitted walking or athletic shoes that cushion feet and redistribute pressure
• Extra wide or deep shoes for those with bony deformities
• Custom-molded shoes for severe deformities or Charcot foot
• Avoidance of tight socks or those with seams 1

4. Regular Follow-up

• Annual foot examination for all patients with diabetes
• More frequent examinations (every 1-6 months) for high-risk patients
• Immediate referral to foot care specialist for any open ulceration, unexplained swelling, erythema, or increased skin temperature 1

Special Considerations

Caregiver Education

• Caregivers play crucial role in foot care for patients unable to self-examine
• Education should include proper foot examination techniques, cleaning, and recognition of warning signs 4

Prevention of Complications

• Preventative foot care programs significantly reduce ulcer incidence, especially in patients with less severe neuropathy 5
• Compliance with preventative programs reduces relative risk of ulceration by 8-22 times 5

Warning Signs Requiring Urgent Attention

• Acute onset of red, hot, swollen foot (possible Charcot neuroarthropathy)
• Open ulcerations
• Signs of infection (increased warmth, redness, swelling, drainage)
• Markedly increased foot temperature
• New blisters, cuts, or sores 1

By addressing the underlying cause of hot feet and implementing appropriate foot care practices, patients can experience symptom relief and prevent serious complications such as ulceration, infection, and amputation.