What is the recommended treatment for a diabetic patient with a callus using salicylic acid 24 percent cream?

Salicylic Acid 24% Cream for Diabetic Callus: Not Recommended

Do not use salicylic acid 24% cream for callus treatment in diabetic patients—this concentration is dangerously high and inappropriate for this indication. The recommended approach is professional debridement combined with appropriate footwear and integrated foot care, with salicylic acid reserved only for specific formulations at much higher concentrations (40-50%) applied as plasters under professional supervision, not as a cream 1, 2.

Why 24% Salicylic Acid Cream is Inappropriate

Wrong Formulation and Concentration

• Salicylic acid for corns and calluses should be used as 40% plasters, not 24% cream 2
• The 24% concentration falls into a problematic middle ground—too high for general dermatologic use (which uses 0.5-2% for acne or 6% for hyperkeratosis) but too low and in the wrong vehicle for effective callus treatment 1, 3
• Cream formulations at this concentration lack the controlled, localized delivery that plasters provide, increasing risk of inadvertent application to surrounding healthy tissue 2

Critical Safety Concerns in Diabetic Patients

• Diabetic patients have impaired wound healing, peripheral neuropathy, and increased infection risk—making them particularly vulnerable to salicylic acid complications 1, 4, 5
• Systemic salicylate toxicity can occur when applied to more than 20% of body surface area, especially in patients with impaired hepatic or renal function (common in diabetes) 1, 6, 2
• The combination of sensory neuropathy means diabetic patients cannot feel excessive irritation, erosion, or early ulceration that may result from improper salicylic acid application 4, 5

Recommended Treatment Approach for Diabetic Callus

First-Line: Professional Debridement and Prevention

• Provide appropriate treatment for excess callus through professional debridement by a trained healthcare professional 1
• This is a strong recommendation from the International Working Group on the Diabetic Foot (IWGDF) 2023 guidelines for all diabetic patients at risk of foot ulceration 1
• Regular professional foot care should be repeated every 1-3 months for high-risk patients (IWGDF risk 3) and every 3-6 months for moderate-risk patients (IWGDF risk 2) 1

Pressure Redistribution is Essential

• Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effects for patients with callus formation, as increased plantar pressure (especially beneath metatarsal heads) is the primary driver of callus development 1, 4, 5
• Consider extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses for patients with foot deformity or pre-ulcerative lesions 1
• Callus develops due to persistent abnormal pressure on the foot, which results from motor neuropathy causing deformity and sensory neuropathy preventing protective responses 4, 5

If Salicylic Acid is Considered (Under Strict Conditions)

• Only use 40% salicylic acid plasters (not cream), applied by a healthcare professional to the specific callus area after paring down hyperkeratotic tissue 2
• The British Journal of Dermatology recommends paring or abrading the hyperkeratotic tissue before plaster application to enhance penetration 2
• Avoid use in patients with poor healing sites (such as lower leg), impaired hepatic/renal function, or when combined with oral salicylate medications 1, 2
• Monitor for systemic salicylate toxicity signs: tinnitus, dizziness, headache, mental confusion, hyperventilation 2

Critical Pitfalls to Avoid

Never Self-Apply High-Concentration Salicylic Acid

• Diabetic patients should never self-apply salicylic acid products above 2% concentration due to neuropathy preventing detection of tissue damage 6, 4
• The risk of creating an iatrogenic ulcer from chemical injury is substantial in this population 1, 4

Address the Underlying Cause

• Callus treatment without addressing abnormal pressure points will result in rapid recurrence 4, 5
• Xerosis (dry skin) with scales, fissures, and impaired barrier function commonly accompanies diabetic callus and requires emollient therapy 4
• Optimal glycemic control is essential, as the relationship between hyperglycemia and hyperkeratosis may contribute to callus formation 5

Integrated Foot Care is Mandatory

• Provide integrated foot care including professional foot care, adequate footwear, and structured education about self-care 1
• Educate patients to examine feet daily and rapidly contact a healthcare professional with any pre-ulcerative lesions 1
• The lifetime incidence of diabetic foot ulceration is 19-34%, with callus being a significant risk factor—prevention is paramount 1