What are the best management strategies for a patient with fissuring heels, particularly those with underlying conditions such as diabetes?

Management of Fissuring Heels

For patients with fissuring heels, particularly those with diabetes, apply emollients containing urea, glycerine, and petrolatum daily to dry skin (avoiding between toes), have a trained foot care specialist regularly debride callus and treat pre-ulcerative signs, and ensure proper footwear to prevent progression to ulceration. 1

Risk Stratification and Assessment

Fissuring heels represent a pre-ulcerative condition requiring immediate attention, especially in diabetic patients. The depth of fissures determines urgency and risk:

• Superficial fissures (limited to epidermis) correlate with autonomic neuropathy 2
• Deep fissures (extending to dermis) correlate with both autonomic neuropathy AND angiopathy, carrying significantly higher ulceration risk 2

Assess for underlying conditions that increase risk: peripheral neuropathy, peripheral arterial disease (check pedal pulses and consider ankle-brachial index if pulses absent), foot deformities, and history of previous ulceration 1

Core Management Strategy

Daily Skin Care and Moisturization

• Use emollients/lubricating oils or creams for dry skin, but never between the toes 1
• A moisturizer containing urea, glycerine, and petrolatum demonstrates efficacy in healing deep open fissures, with significant improvement in open fissure healing by 2 weeks and continued improvement through 4 weeks 3
• Wash feet daily with water temperature always below 37°C, drying carefully especially between toes 1
• Apply moisturizer after washing and before bed, ideally after hydrating skin for at least 5 minutes 4

Professional Foot Care

Callus and pre-ulcerative pathology must be treated regularly by a trained foot care specialist 1. This includes:

• Removing abundant callus through debridement (with scalpel) 1
• Treating thickened nails 1
• Prescribing antifungal treatment for fungal infections 1
• Treatment should be repeated until the pre-ulcerative sign resolves and does not recur 1

Critical caveat: Patients should NOT use chemical agents or plasters to remove corns and calluses themselves—this must be done by a healthcare provider 1

Footwear Optimization

Inappropriate footwear is a major cause of progression to ulceration 1. Proper footwear requirements:

• Inside of shoe should be 1-2 cm longer than the foot 1
• Internal width should equal the width of the foot at the metatarsal phalangeal joints 1
• Height should allow enough room for all toes 1
• Evaluate fit with patient standing, preferably at end of day 1
• Avoid tight shoes, shoes with rough edges or uneven seams 1
• Never walk barefoot indoors or outdoors 1

If signs of abnormal loading exist (hyperemia, callus, or fissuring), refer for special footwear including insoles and orthoses 1

Sock Selection

• Wear socks without seams (or with seams inside out) 1
• Never wear tight or knee-high socks 1
• Change socks daily 1

Special Considerations for Diabetic Patients

Vascular Assessment

Deep fissures in diabetic patients correlate with angiopathy 2. If deep fissures are present:

• Palpate pedal pulses 1
• If pulses absent or fissures not improving, measure ankle-brachial index 1
• Consider toe pressure or transcutaneous oxygen pressure (TcPO2) measurements, as ankle pressure may be falsely elevated due to arterial calcification 1

Patient Education and Self-Monitoring

• Perform daily foot inspection, including areas between toes 1
• If patient cannot perform inspection (e.g., visual impairment), identify someone to assist 1
• Notify healthcare provider immediately if foot temperature markedly increases or if blister, cut, scratch, or ulcer develops 1
• Inspect and feel inside all shoes before putting them on 1

Additional Precautions

• Do not use heaters or hot-water bottles to warm feet 1
• Cut toenails straight across 1
• Have feet examined regularly by healthcare provider 1

Topical Keratolytic Agents (Use with Caution)

Salicylic acid 6% can be used for hyperkeratotic conditions but requires careful consideration 4:

• Apply to affected area at night after washing, cover treated area, wash off in morning 4
• Avoid prolonged use over large areas, especially in patients with renal or hepatic impairment or in children, due to risk of salicylism 4
• Do not apply occlusive dressings or petrolatum-based ointments to prevent excessive systemic absorption 4
• Monitor for signs of salicylate toxicity: nausea, vomiting, dizziness, tinnitus, lethargy 4

When to Escalate Care

Refer urgently if:

• Deep fissures progress despite treatment 1
• Signs of infection develop 1
• Fissures evolve into ulceration 1
• Peripheral arterial disease is suspected or confirmed 1

Common pitfall: Treating fissures as purely a dermatologic problem without addressing underlying neuropathy, vascular disease, or biomechanical factors will lead to treatment failure and progression to ulceration 2. The correlation between deep fissures and angiopathy means vascular assessment and control of blood supply is essential for preventing ulceration 2.