What is the treatment for white spots on the heel that occur with pressure?

White Spots on Heel with Pressure: Treatment Approach

White spots on the heel that occur with pressure represent pre-ulcerative lesions requiring immediate professional debridement, pressure offloading, and appropriate footwear modifications to prevent progression to full ulceration. 1, 2

Immediate Treatment Actions

Professional Debridement

• Remove all hyperkeratotic tissue (callus) and any necrotic material immediately through sharp debridement performed by an appropriately trained healthcare professional 1
• Sharp debridement with scalpel, scissors, or tissue nippers is the preferred method as it is most definitive and controllable 1
• Debridement reduces pressure at the affected site, removes colonizing bacteria, and permits full examination of tissue involvement 1
• Repeat debridement sessions as often as needed if nonviable tissue continues to form 1

Pressure Offloading (Critical Priority)

• Ensure complete offloading of pressure from the heel immediately - this is the single most important intervention to prevent ulcer development 2, 3
• Elevate the heel off the underlying support surface to eliminate both pressure and shear forces 4
• Consider wedge-shaped viscoelastic foam cushions, which show superior efficacy compared to standard foam pillows 4
• Instruct the patient to limit standing and walking; use crutches if necessary 2

Footwear and Orthotic Management

Immediate Footwear Modifications

• Prescribe properly fitted footwear with adequate depth, width, and length that accommodates the foot shape without causing pressure points 1, 5
• For patients with foot deformities or significant pressure increases, prescribe extra-depth shoes, custom-made footwear, or custom-made insoles 1
• Ensure therapeutic footwear demonstrates plantar pressure-relieving effects (≥30% reduction in peak pressure or in-shoe peak pressure <200 kPa) 5

Ongoing Footwear Requirements

• Educate the patient to wear appropriate footwear consistently, both indoors and outdoors - not thin-soled slippers 1
• Check inside shoes for foreign objects before each use 1
• Wear seamless socks of natural materials, preferably light-colored to detect drainage 1

Wound Care Protocol

Dressing Selection

• Select dressings based on wound characteristics: hydrogels for dry wounds, alginates or foams for exudative wounds 1, 2
• Establish a moist wound-healing environment 6
• Avoid topical antimicrobials unless infection is clinically evident 1

Infection Surveillance

• Assess daily for signs of infection: increasing pain, erythema, warmth, or purulent drainage 2
• If infection develops, initiate empiric oral antibiotics targeting S. aureus and streptococci for superficial infection 2
• Consider parenteral broad-spectrum antibiotics for deep infection 2

Patient Education and Monitoring

Daily Self-Care Instructions

• Examine feet daily for any changes or new lesions 1
• Wash feet daily with careful drying, particularly between toes 1
• Apply emollients to moisturize dry skin 1
• Contact a healthcare professional immediately if the lesion worsens or new symptoms develop 1

Temperature Monitoring (For High-Risk Patients)

• Consider coaching patients to self-monitor foot skin temperatures daily 1
• If temperature difference between corresponding regions exceeds 2.2°C (4.0°F) on two consecutive days, reduce ambulatory activity and seek professional evaluation 1

Follow-Up and Advanced Interventions

Regular Monitoring

• Measure and document wound size weekly at minimum using objective planimetry 6
• Re-evaluate every 1-3 months for ongoing risk assessment 1
• If no improvement within 6 weeks, evaluate for vascular compromise 2

Vascular Assessment

• Assess arterial supply if healing is delayed - palpate dorsalis pedis and posterior tibial pulses 1
• If pulses are not palpable, obtain ankle-brachial index (ABI); values <0.50 suggest ischemia that will impair healing 1
• Consider revascularization if vascular compromise is identified 2

Advanced Therapies for Non-Healing Lesions

• Consider hyperbaric oxygen therapy for poorly healing wounds 2
• Evaluate for cellular therapy or growth factors if standard treatment fails 6

Critical Pitfalls to Avoid

• Never allow continued pressure on the affected heel - inadequate offloading is the primary cause of progression to ulceration 2, 3
• Do not delay professional debridement - early intervention prevents progression 1, 6
• Avoid continuing to use tight, poorly fitted shoes which perpetuate symptoms 5
• Do not perform debridement without appropriate training, as improper technique can cause harm 1