How should a deep fissure of the foot be treated?

Treatment of Deep Foot Fissures

Deep foot fissures require aggressive topical management with propylene glycol 50% under occlusion, combined with pressure redistribution, regular debridement by a trained podiatrist, and intensive moisturization with urea-based creams. 1

Immediate Topical Treatment for Deep Fissures

The most effective treatment for deep fissures is propylene glycol 50% in water applied for 30 minutes under plastic occlusion every night, followed by hydrocolloid dressing application. 1 This approach directly addresses the dermal-level damage characteristic of deep fissures and accelerates wound closure.

Alternative Antiseptic Options

If propylene glycol is unavailable or not tolerated:

• Potassium permanganate baths at 1:10,000 concentration can accelerate wound closure 1
• Topical silver nitrate solutions may be applied to promote healing 1
• After antiseptic treatment, apply moisturizer to the surrounding skin to prevent further cracking 1

Essential Debridement and Callus Management

Deep fissures must be debrided by a trained podiatrist using manual debridement or scalpel paring, as hyperkeratosis and callus surrounding fissures perpetuate the problem. 1 Self-management with an emery board is insufficient for deep fissures that extend into the dermis. 1

• Debridement should be performed regularly until the fissure heals, as thickened tissue prevents proper wound closure 1
• In diabetic patients, debridement can usually be performed without anesthesia due to neuropathy 1

Intensive Moisturization Protocol

Apply urea-based keratolytic creams daily to weekly (depending on skin thickness) to reduce hyperkeratosis and maintain skin suppleness. 1

• Urea-containing moisturizers are superior to standard aqueous cream for hydrating foot skin and preventing fissure recurrence 2
• Moisturizers should be applied at least once daily to the entire foot, using oil-in-water creams or ointments rather than alcohol-containing lotions 1
• After soaking feet in warm saline water, file thickened areas with an emery board before applying moisturizer 1

Critical Pressure Redistribution

Pressure redistribution and cushioning are essential to prevent fissure progression and allow healing. 1 Deep fissures develop from repetitive mechanical stress combined with loss of skin elasticity. 2

• Footwear must be 1-2 cm longer than the foot with adequate width at the metatarsal heads 1
• Custom orthoses or accommodative padding should redistribute pressure away from fissured areas 1
• Avoid walking barefoot both indoors and outdoors during treatment 3

Special Considerations for Diabetic Patients

In diabetic patients with deep fissures, assess for both autonomic neuropathy and peripheral arterial disease, as deep fissures are significantly associated with angiopathy (OR 3.29). 4 This association suggests impaired healing capacity requiring more aggressive intervention.

Vascular Assessment

• If pedal pulses are absent or fissures fail to heal despite optimal treatment, measure ankle-brachial pressure index 1
• An ABI <0.9 indicates peripheral arterial disease requiring vascular evaluation 1
• Toe pressure or transcutaneous oxygen pressure (TcPO2) measurements are more reliable than ankle pressure in diabetic patients due to arterial calcification 1

Infection Monitoring

Inspect fissures frequently for signs of infection (increased redness, warmth, purulent drainage, or worsening pain), as deep fissures extending to the dermis compromise skin barrier function and increase infection risk. 4, 3

• If infection develops, obtain bacterial cultures and initiate appropriate antibiotics 1
• Severe infections require urgent surgical consultation for possible debridement 1

When Conservative Treatment Fails

If fissures do not improve after 4 weeks of appropriate therapy, re-evaluate the patient and reconsider alternative diagnoses or treatments. 1

• Consider immobilization with a cast or fixed-ankle walker device for 6-8 weeks if fissures persist despite optimal conservative management 5
• Surgical consultation may be warranted for chronic non-healing fissures with significant functional impairment 3

Common Pitfalls to Avoid

• Never use chemical agents or plasters to remove callus in patients with compromised sensation or circulation 6
• Avoid hot water soaks, as excessive moisture causes maceration and worsens fissures 6
• Do not apply topical antibiotics or antiseptics routinely to non-infected fissures, as they do not improve healing 6
• Ensure patients understand that fissure treatment requires ongoing maintenance even after healing, as recurrence is common without continued moisturization and pressure management 1