What is the appropriate management for foot fissures (cracked foot)?

Treatment of Foot Fissures (Cracked Feet)

Foot fissures should be treated immediately by an appropriately trained healthcare professional with debridement of excess callus, protection of the fissure, and application of a moisturizer containing urea, glycerine, and petrolatum, particularly in patients with diabetes where fissures are strong predictors of ulceration. 1

Immediate Management Approach

For All Patients with Foot Fissures:

Professional treatment is essential - do not attempt self-treatment of deep fissures. The IWGDF 2024 guidelines explicitly state that pre-ulcerative lesions including fissures require immediate treatment by an appropriately trained healthcare professional 1. This is critical because:

• Fissures are strong predictors of future ulceration, especially in diabetic patients 1
• Deep fissures extending into the dermis create entry points for bacteria and significantly increase infection risk 2
• Improper treatment can cause harm 1

Treatment Protocol:

1. Callus removal: Remove excess callus around the fissure, as this reduces plantar pressure (a major risk factor for ulceration) 1

2. Fissure protection and treatment: Protect the fissure and treat it appropriately based on depth 1

3. Moisturizer application: Apply a moisturizer containing urea, glycerine, and petrolatum. A randomized controlled trial demonstrated that this combination significantly improved deep open fissure healing in diabetic patients:

   • After 2 weeks: 24.7% still had deep open fissures vs. 42.7% with placebo (P = 0.027)
   • After 4 weeks: 6.4% still had deep open fissures vs. 24.1% with placebo (P = 0.002)
   • The cream was well tolerated and also improved xerosis (dry skin) 2

Special Considerations for Diabetic Patients

Diabetic patients require heightened vigilance because:

• Deep fissures in diabetics are associated with both autonomic neuropathy AND angiopathy (OR 2.88 and 3.29 respectively) 3
• The combination of neuropathy and vascular disease creates particularly high ulceration risk 3
• Fissures can progress to ulcers, which may lead to infection and amputation 1, 2

Additional Management for Diabetics:

• Treat fungal infections: Prescribe anti-fungal treatment if present, as fungal infections contribute to skin breakdown 1
• Address ingrown or thickened toenails: These require professional treatment 1
• Continue treatment for the full duration: Treatment must continue for the entire time that fissures are present 1
• Assess vascular status: Given the association between deep fissures and angiopathy, evaluate blood supply 3

Common Pitfalls to Avoid

• Do not use OTC salicylic acid on fissures in diabetic patients: While salicylic acid is mentioned for corns and calluses 4, it should only be used by trained professionals on diabetic feet due to risk of chemical burns and ulceration
• Do not delay treatment: Fissures are pre-ulcerative lesions that require immediate attention 1
• Do not assume superficial fissures are benign: Even superficial fissures indicate underlying problems (autonomic neuropathy) and can progress 3
• Avoid self-treatment in high-risk patients: The benefit-harm ratio is only positive when performed by appropriately trained professionals 1

Long-term Prevention

• Address xerosis (dry skin): Continue moisturizer use to prevent recurrence, as xerosis is a contributing factor 2
• Proper footwear: Ensure adequate fit to prevent repetitive stress 1
• Regular foot examinations: Particularly for diabetic patients, as early detection prevents progression 5