What is the best course of treatment for a patient with a callus on the bottom of their foot, considering potential underlying conditions such as diabetes?

Treatment of Plantar Calluses

Calluses on the bottom of the foot should be professionally debrided with a scalpel by a trained healthcare provider, combined with addressing the underlying mechanical causes through proper footwear and orthotic devices. 1

Immediate Management

Professional Debridement

• Sharp scalpel debridement is the gold standard treatment that reduces plantar pressure and prevents complications, particularly ulceration in diabetic patients 1, 2
• Remove all callus tissue during debridement, as this provides immediate symptomatic relief and reduces pressure on underlying tissues 3, 1
• In neuropathic patients, debridement can usually be performed without local anesthetic 4
• Never allow patients to self-treat with chemical corn removers or plasters, as this significantly increases infection and ulceration risk 1

Critical Assessment for Diabetes

• In diabetic patients, calluses are pre-ulcerative lesions requiring immediate treatment to prevent ulceration 3, 1
• Evaluate for loss of protective sensation (neuropathy) and peripheral arterial disease, as these dramatically increase complication risk 4
• Check if bone can be palpated through the callus, as this suggests deeper pathology requiring urgent intervention 4

Addressing Underlying Mechanical Causes

Footwear Intervention

• Ill-fitting shoes are the most frequent cause of callus formation, even in patients with vascular disease 4
• The shoe should be 1-2 cm longer than the foot, with internal width equal to the foot width at the metatarsal phalangeal joints 4
• Fit must be evaluated with the patient standing, preferably at the end of the day when feet are most swollen 4

Orthotic Devices

• Prescribe custom-made insoles or orthotic devices for patients with foot deformities or recurrent calluses to redistribute pressure 3, 1
• Toe silicone and semi-rigid orthotic devices effectively reduce callus formation by redistributing mechanical forces 3, 1

Follow-Up Schedule

Diabetic Patients

• High-risk diabetic patients require professional foot care every 1-3 months 3, 1
• Moderate-risk diabetic patients need care every 3-6 months 3, 1
• Integrated foot care should include professional callus removal, appropriate footwear, and structured education 1

Non-Diabetic Patients

• Repeat debridement as needed based on callus recurrence 1
• Most lesions will disappear following removal of causative mechanical forces 5, 6

Prevention Strategies

Daily Self-Care

• Apply emollients daily to maintain skin elasticity, but never between toes to avoid maceration 1
• Daily foot inspection to identify early callus development 3, 1
• Never walk barefoot, in socks only, or in thin-soled slippers, whether at home or outside 1

Footwear Habits

• Wear appropriate, well-fitting footwear both indoors and outdoors 4, 3
• Daily inspection and palpation of the inside of shoes before wearing 4
• Avoid tight shoes or shoes with rough edges and uneven seams 4

Surgical Options for Refractory Cases

• Consider digital flexor tenotomy for calluses associated with hammertoes when non-surgical treatments fail 3, 1
• Achilles tendon lengthening, joint arthroplasty, or metatarsal head resection may be indicated for recurrent plantar forefoot calluses 1
• Surgery should only be considered after full evaluation of non-surgical treatment options and should specifically correct the abnormal mechanical stresses 3, 5

Critical Pitfalls to Avoid

• Do not use chemical agents or plasters to remove calluses at home 4, 1
• Avoid footbaths where feet are soaked, as they induce skin maceration 4
• Do not debride ischemic or neuro-ischemic ulcers without signs of infection, as this can worsen tissue damage 4
• Never delay treatment in diabetic patients, as calluses can rapidly progress to ulceration 3