What causes burning feet and how is it treated?

Burning Feet: Causes and Treatment

Burning feet is most commonly caused by diabetic peripheral neuropathy from small fiber dysfunction, and treatment should focus on optimizing glucose control to prevent progression while using first-line neuropathic pain medications (pregabalin, duloxetine, or gabapentin) for symptomatic relief. 1

Clinical Presentation

Patients typically describe:

• Burning pain in the feet with uncomfortable tingling, numbness, and altered temperature perception 1
• Symptoms that worsen at night, causing sleep disturbance and subsequent fatigue 1
• Pain distribution in a "glove and stocking" pattern, starting distally and progressing proximally 2
• Associated dysesthesia, allodynia, and hyperalgesia in affected areas 2

Common Causes

Diabetic Peripheral Neuropathy (Most Common)

• Diabetic neuropathy is the leading cause of burning feet in clinical practice, resulting from small fiber dysfunction 1, 3
• Peripheral sensory neuropathy is present as a component cause in 78% of diabetic foot ulcerations 2
• Up to 50% of diabetic peripheral neuropathy may be asymptomatic, placing patients at risk for foot ulcers and amputations if preventive care is not implemented 2

Erythromelalgia

• Characterized by episodic burning pain with redness and warmth of the extremities, triggered by physical activity and warm temperatures 1, 4
• Can be primary (sporadic or autosomal-dominant hereditary) or secondary (associated with thrombocythemia, collagen-vascular diseases, diabetes, or certain drugs) 4

Other Causes

• Malnutrition and vitamin deficiencies (particularly B vitamins) 5
• Small fiber neuropathy from metabolic syndrome components or impaired glucose tolerance 3
• Chemotherapy-induced peripheral neuropathy (platinum compounds, taxanes, vinca alkaloids) 2
• Idiopathic cases when no underlying cause is identified 3

Diagnostic Approach

History

• Assess pain characteristics, aggravating/relieving factors (especially heat/cold), timing (worse at night), and associated symptoms 1
• Obtain history of diabetes, smoking, prior ulceration or amputation, vascular surgery, and current medications 2
• Screen for symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication) 2

Physical Examination

Perform comprehensive neurological assessment including: 2

• Small-fiber function testing: pinprick and temperature sensation 2
• Large-fiber function testing: lower-extremity reflexes, vibration perception (tuning fork), and 10-g monofilament testing 2
• Skin inspection for redness, warmth, dryness, cracking, or other changes 1
• Vascular assessment: lower-extremity pulses, capillary refill time, rubor on dependency, pallor on elevation 2
• Assessment of foot deformities and structural abnormalities 2

When to Consider Specialist Referral

• Atypical clinical features requiring neurophysiological testing 2
• Suspected erythromelalgia for specialized management 1
• Patients with foot ulcers, high-risk feet, or peripheral arterial disease requiring interprofessional podiatric care 2

Treatment Algorithm

1. Address Underlying Cause

For Diabetic Neuropathy:

• Optimize glucose control to prevent progression of neuropathy 1, 2
• Control other modifiable risk factors including lipids and blood pressure to slow disease progression 2

For Erythromelalgia:

• Aspirin may be effective for cases associated with thrombocythemia 1
• Identify and treat any secondary causes 4

2. Pharmacologic Pain Management

First-line medications for neuropathic pain: 1

• Pregabalin
• Duloxetine
• Gabapentin

Note: These interventions do not reverse underlying nerve damage but can significantly improve quality of life 2

3. Non-Pharmacologic Measures

For All Patients with Burning Feet: 1

• Avoid tight shoes or shoes with rough edges and uneven seams
• Use lubricating oils or creams for dry skin
• Wear appropriate footwear with socks
• Inspect feet daily for injuries or skin breakdown

Specifically for Erythromelalgia: 1

• Avoid triggers such as heat exposure and excessive exercise
• Elevate extremities during symptom flares
• Use cooling measures safely (avoid excessive cooling)
• Consider swimming instead of running for exercise

4. Address Sleep Disturbance and Psychological Impact

• Patients with burning feet often experience significant sleep disturbance, anxiety, and depression requiring appropriate management 1

Critical Pitfalls to Avoid

Excessive Cooling:

• Do not use ice water immersion or powerful fans, as these may cause tissue damage and ulcerations 1

Foot Care Errors in Diabetic Patients: 1

• Do not use footbaths that induce skin maceration
• Do not walk barefoot or wear shoes without socks if sensory loss is present
• Do not use chemical agents or plasters to remove corns and calluses without professional supervision

Delayed Recognition:

• Failure to recognize initial minor trauma and delays in seeking treatment increase risk of infection, extend healing time, and are associated with poor outcomes including amputation 2

Ongoing Monitoring

For Diabetic Patients:

• Perform comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations 2
• Individuals with evidence of sensory loss or prior ulceration should have feet inspected at every visit 2
• Monitor for development of foot ulcers in patients with loss of protective sensation 1
• Refer patients who smoke with history of lower-extremity complications, loss of protective sensation, or structural abnormalities to foot care specialists for ongoing preventive care 2