What is the first‑line treatment for cracked heels, and should urea‑containing products be used?

Treatment of Cracked Heels with Urea-Containing Products

Urea-containing emollients at concentrations of 10-20% applied twice daily are the first-line treatment for cracked heels, effectively reducing hyperkeratosis, improving hydration, and alleviating pain without compromising skin barrier function. 1, 2

Recommended Treatment Protocol

Initial Therapy

• Apply 10% urea cream or lotion twice daily to affected heel areas as first-line therapy 1
• For optimal absorption, apply after bathing when skin is slightly damp 1
• Continue regular application until symptoms resolve, typically requiring several weeks of consistent use 2

Escalation for Severe Cases

• Increase to 20% urea concentration for severe hyperkeratosis with deep fissures or thick scale 1, 2
• For extremely localized thick areas, concentrations up to 40% may be used specifically on the heels 1
• The 20% concentration demonstrates superior efficacy compared to 5% or placebo in reducing skin thickness and improving hydration 3, 4

Mechanism and Evidence Base

How Urea Works

• At 10-20% concentrations, urea provides both keratolytic action (breaking down thick scale) and moisturizing properties 1, 5
• Improves skin barrier function rather than weakening it, making skin more resistant to external insults 2
• Reduces thickness of hyperkeratotic skin while simultaneously increasing hydration 2, 4

Clinical Efficacy

• A randomized controlled study of 50 patients with hyperkeratotic feet demonstrated that 15% urea formulations efficiently relieved xerosis, removed scales, and reduced skin thickness 2
• No difference in efficacy between once-daily versus twice-daily application was found, though twice-daily remains the standard recommendation 2
• Emollient creams containing urea alleviate pain, dryness, and improve the appearance of heel cracks 6

Critical Application Guidelines

Where to Apply

• Apply to affected heel areas, avoiding the face, flexures, inflamed skin, or open fissures 1
• Safe for use on intact hyperkeratotic skin and areas with superficial cracking 1

Where NOT to Apply

• Never apply to actively inflamed skin, deep open fissures, or areas of active bleeding 1
• Keratolytics may cause irritation, burning sensation, or stinging on damaged or sensitive skin 1

Expected Side Effects

• Mild smarting or stinging is common, particularly with higher concentrations 2
• Itching, burning sensation, and irritation at application sites may occur but are generally mild 1
• These effects typically diminish with continued use as the skin improves 2

Special Populations

Pediatric Considerations

• Do not use urea ≥10% in children under 1 year of age except once daily on very limited areas like palms and soles 1
• This restriction is due to immature epidermal barrier, higher body-surface-to-mass ratio, and increased risk of systemic absorption 1

Diabetic Patients

• Urea-containing products are safe and effective for diabetic patients with cracked heels 5, 4
• However, if infection is present (redness, warmth, purulent drainage), appropriate wound care and antibiotics take priority over cosmetic treatment 7

Adjunctive Measures

Complementary Interventions

• Proper footwear to reduce pressure on heels 7
• Weight loss if indicated to reduce mechanical stress 7
• Regular debridement of callus by a healthcare professional may enhance urea penetration 7

Combination Therapy

• Urea can be used as monotherapy or combined with topical corticosteroids if inflammation is present 1
• Urea enhances penetration of other topical medications when used in combination 1

Common Pitfalls to Avoid

• Do not apply to open, bleeding fissures - this will cause significant pain and may delay healing 1
• Do not expect immediate results - consistent application for several weeks is typically required 2
• Do not use concentrations below 10% for therapeutic effect on hyperkeratosis, as 5% concentrations show minimal difference from placebo 3
• Do not discontinue prematurely - continue treatment until complete resolution of hyperkeratosis and fissuring 2

When to Seek Further Evaluation

• If no improvement occurs after 6-8 weeks of appropriate treatment, consider referral to podiatry 7
• If signs of infection develop (increasing redness, warmth, purulent drainage, fever), urgent evaluation is required 7
• Deep fissures with bleeding or severe pain may require professional debridement before topical therapy 7