What is the initial management for a callus on the foot in the emergency department (ED)?

Management of Calluses on the Foot in the Emergency Department

The primary management for a callus on the foot in the emergency department setting is sharp debridement with a scalpel to remove the callus, followed by application of appropriate dressings and patient education on proper foot care.

Assessment and Initial Management

1. Evaluate the callus:

   • Determine location (plantar surface, toes, lateral border)
   • Assess for signs of infection or inflammation
   • Check for underlying blisters or ulceration beneath the callus
   • Evaluate peripheral circulation (especially in diabetic patients)

2. Debridement procedure:

   • Clean the area with saline or clean water 1
   • Use sharp debridement with a scalpel to remove the callus 1
   • Focus on removing the hyperkeratotic tissue while avoiding damage to healthy skin
   • Be conservative in approach to prevent excessive tissue removal 1

3. Post-debridement care:

   • Apply sterile, inert dressing if needed 1
   • Select dressings based on exudate control, comfort, and cost 1
   • Consider application of emollients after debridement 1

Special Considerations for Diabetic Patients

For diabetic patients with calluses, additional precautions are necessary:

• Assess for peripheral neuropathy and vascular status before debridement 1
• Be more conservative with debridement in patients with poor circulation 1
• Consider referral to podiatry for ongoing management 1
• Evaluate footwear as ill-fitting shoes are a common cause of callus formation 1

Patient Education

Provide the following instructions to prevent recurrence:

• Proper footwear selection that accommodates foot shape 1
• Regular use of emollients or moisturizers (but not between toes in diabetic patients) 1
• Self-monitoring for signs of skin breakdown or infection
• Avoidance of over-the-counter chemical callus removers 1
• Regular foot inspection, especially for diabetic patients 1

Pharmacological Options

• Topical keratolytic agents containing salicylic acid may be considered as adjunctive therapy for ongoing management 2
• Application instructions: apply to affected area at night after washing, cover treated area, and wash off in the morning 2
• Caution patients about potential skin irritation with these products

Follow-up Recommendations

• For non-diabetic patients with simple calluses: self-care with periodic professional debridement as needed
• For diabetic patients or those with recurrent calluses: referral to podiatry for regular care every 1-3 months 1
• For patients with underlying foot deformities: consider referral for orthotic devices or specialized footwear 1

Pitfalls and Caveats

1. Avoid aggressive debridement in patients with:

   • Peripheral arterial disease
   • Severe ischemia
   • Anticoagulation therapy
   • Immunocompromised status

2. Do not confuse calluses with other conditions such as:

   • Warts (look for disrupted skin lines and capillary dots)
   • Foreign body granulomas
   • Early malignancies

3. Be cautious with chemical treatments as they can cause:

   • Skin irritation
   • Chemical burns
   • Damage to surrounding healthy tissue

While research shows that the immediate pain relief from scalpel debridement may be modest 3, it remains the standard first-line treatment for symptomatic calluses in the emergency department setting, particularly for providing immediate relief and preventing complications like ulceration in high-risk patients.