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Issue Number: Volume 27 - Issue 1 - January 2014
Author(s): M. Joel Morse, DPM
At this wintry time of year, more patients may be presenting with cracked heels and itchy feet due to dry
skin. Accordingly, this author discusses the diagnosis and treatment of different forms of dry skin, including
dry skin concomitant with common diseases.
How many times a day do you see any of these conditions: stasis eczema, eczema,
atopic dermatitis, contact dermatitis, xerosis, psoriasis or stucco keratosis? To some
podiatrists, the skin is just a structure you have to get past in order to get to the bones.
However, the skin problems are what bring patients into your office with symptoms like
tightness, tingling, itchiness, burning, scaling, flaking and lichenification. When you
cannot concentrate on your work because you are scratching, when your sleep is
interrupted because of burning, when you have noticeable dry skin patches on your legs, then dry skin is
in the fast lane.
Dont look past the skin for other podiatric concerns. The skin can be a mirror of what is going on in the
body. The lower legs and heel are notoriously problematic with dry skin symptoms. However, just because
we do not treat the hands and forearms, we still need to evaluate those areas so we get the big picture.
The feet do not exist in a vacuum.
The skin acts as a barrier and protects underlying tissues from infection, desiccation, chemicals and
mechanical stress. Disruption of these functions results in increased transepidermal water loss and
deceases in the stratum corneums water content, and is associated with conditions like atopic dermatitis,
eczema, xerosis, contact dermatitis and other chronic skin diseases. Moisturizers can improve these
conditions through restoration of the integrity of the stratum corneum, acting as a barrier to water loss and
replacement of skin lipids and other compounds.1 Despite the knowledge of well recognized aggravating
factors, the etiology of dry skin conditions is an enigma and the management of the condition is often
suboptimal.2
In the foot and ankle region, we have three types of skin: plantar skin, which has no oil glands and the
largest number of sweat glands anywhere; dorsal skin, which is normal skin; and the skin overlying the
shin, which is the thinnest and more prone to injury.
Dry skin occurs when the stratum corneum is depleted of water. The skins outer layer consists of dead,
flattened cells that gradually move toward the skins surface and slough off. The cells of the stratum
corneum have lost their nucleus, are rich in keratin and are known as corneocytes. 3 Intercellular lipids
bind the corneocytes together. When this layer is well moistened, it minimizes water loss through the skin
and helps keep out irritants, allergens and germs. However, when the stratum corneum dries out, it loses
its protective function. This allows greater water loss, leaving your skin vulnerable to environmental
factors.
intact.4
Under normal conditions, skin requires a water content of 10 to 15 percent to remain supple and
This water gives the skin its soft, smooth and flexible texture. The water comes from the atmosphere, the
underlying layers of skin and sweat. Oil produced by skin glands and fatty substances produced by skin
cells act as natural moisturizers, allowing the stratum corneum to seal in water. The skin contains natural
moisturizers: ceramides, glycerol, urea and lactic acid. These help rehydrate skin to prevent water loss,
which is the reason that many of the products out on the market contain urea, lactic acid, salicylic acid and
glycol. They are trying to mirror the skin. The essential ingredient of an emollient is lipid (fats, waxes and
oils).5
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Ceramides are the natural moisturizing factors and are the major lipid constituents of the intercellular
spaces of the stratum corneum. These lipids theoretically provide the barrier property of the epidermis.2
The link between skin disorders and changes in barrier lipid composition, especially in ceramides, is
difficult to prove because of the many variables involved. However, most skin disorders that have a
diminished barrier function present a decrease in total ceramide content with some differences in the
ceramide pattern. Patients with skin diseases such as atopic dermatitis, psoriasis, contact dermatitis and
some genetic disorders have diminished skin barrier function. 6
We continuously lose water from the skins surface by evaporation. Under normal conditions, the rate of
loss is slow and the water is adequately replaced. Characteristic signs and symptoms of dry skin occur
when the water loss exceeds the water replacement, and the stratum corneums water content falls below
10 percent.7
Any factor that damages the stratum corneum can interfere with its barrier function and lead to dry skin.
TOPIC CENTER
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Achilles Tendonitis
AFO
Amputation
Ankle Arthrodesis
Ankle Replacement
Athletic Shoes
Bioengineered Alternative
Tissues
Biomechanics
Bunionectomy
Calcaneal Fractures
Charcot
Coding
Custom Orthosis
Dermatology
Diabetic Foot
Diabetic Foot Infection
Diabetic Foot Ulcer
Diabetic Peripheral
Neuropathy
EMR/EHR
Fall Prevention
Flatfoot
Hallux Valgus
Hammertoe
HBOT
Heel Pain
Jones Fracture
Limb Salvage
Metatarsal Fractures
MRSA
NPWT
Offloading
Onychomycosis
Orthotics
Osteomyelitis
PAD
Peripheral Neuropathy
Plantar Fasciitis
Practice Management
Pressure Ulcers
Sever's Disease
Split Thickness Skin Grafts
Sports Medicine
Staff Management
Stress Fractures
Tinea Pedis
Venous Ulcers
Wound Care
Wound Debridement
Wound Dressings
POLL
What is the best course of treatment for
plantar warts?
Surgical
Non-surgical
One popular moisturizer is shea butter. Shea butter is a yellow fat or oil extracted from the nut of the
African shea tree. Complications of the use of occlusive emollients such as Vaseline and shea butter used
on the dorsal foot and lower leg can result in oil folliculitis if the leg is hairy.
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However, when dry skin occurs on the feet, the symptoms of discomfort are magnified due to shoe wear,
the stretching of the skin on the feet each time we step down and by certain synthetic materials in the
socks and shoes that dry the skin out even more. Due to the confining nature of the shoes we wear and
the lack of fresh air that hits the skin of the feet due to our socks and shoes, dry feet need specialized care
in order to prevent pain. In many cases, shoes we wear can also protect our feet from dry skin and
fissures if they fit properly and are made of breathable material.
Abnormal foot mechanics and deformities cause abnormalities in the way we walk. This subsequently
causes certain areas of the feet to bear abnormal amounts of weight, which may result in dry patches,
calluses, corns and fissures. Orthotics and wearing correct shoes help to spread out abnormal weight and
reduce friction.
One must remember that the skin of the feet has no oil glands and must rely on the sweat glands to
moisturize the skin. Sweat glands operate by secreting a substance comprised mostly of water, sodium
chloride and electrolytes. Accordingly, sweat is more drying than moisturizing.
Each of our feet is densely covered with approximately 250,000 eccrine sweat glands, making feet one
of the sweatiest places on the body. The lack of oil glands makes preventing dry skin difficult but if we had
oil glands on our feet, we would slip and slide with each step we took. Socks absorb sweat and are
supposed to prevent blisters. It is known that certain synthetic socks can decrease the temperature of the
foot as much as 3 and that is enough to prevent blister formation by limiting sweating. Dry feet are not the
same as dry skin of the feet.
One study looked at fabric softeners and surmised that fabric softeners provide
benefits to individuals with dry skin because of the decreased friction of the garments
against the skin.12 Since friction results in heat, the heat will dry your feet out faster. It
is known that nylon and rayon socks cause dryness to the skin.
In one study, the prevalence of Type IV hypersensitivity to rubber allergens was
evident in patients with stasis eczema and/or venous leg ulcers over an 18-month
period.13 Accordingly, vascular hose in some patients may result in a dry, itchy skin response and when
not wearing the hose at night, patients must moisturize.
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When discussing the choice of emollients, a continuum exists between oily ointments and water-based
creams and lotions. Ointments are best for the driest of skin conditions and for use at home when patients
are not wearing tight clothes or working with others. The application of ointments can cause folliculitis in
hairy areas, an unusual issue in the foot and ankle. The frequent use of emollients reduces the need for
steroids. 20 To avoid or treat xerosis, patients should moisturize their feet right after a bath or shower. They
should avoid soaking their feet in hot water for long time periods, using drying soaps on the feet or
scrubbing feet dry.
Anecdotal and limited data suggest that gabapentin, cutaneous field stimulation, serotonin antagonists
and ultraviolet B phototherapy may reduce itch in some of these patients.
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Diabetes. PeopleGet
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While assessing for predictors of foot lesions in patients with diabetes, one study found that 82.1 percent
25
of their patients had skin with dryness, cracks or fissures. An unpublished survey of 105 consecutive
patients with diabetes conducted by one of the authors revealed that 75 percent had clinical manifestation
of dry skin. Dry skin often leads to cracks and fissures, which can serve as a portal of entry for bacteria.
Despite possible dry skin definition discrepancies across the studies, it is clear that the skin dryness is
one of the earliest and most common manifestations of type 1 diabetes. The clinical observations are
supported by objective findings of a reduced hydration state of the stratum corneum and decreased
sebaceous gland activity in patients with diabetes without any impairment of the stratum corneum barrier
function. 26
Liver disease. The liver neutralizes toxins and filters bile salts. If the livers function is impaired, these
materials can accumulate in the body and deposition in the skin causes irritation and itching. In cholestatic
liver disorders such as primary sclerosing cholangitis and obstructive gallstone disease, pruritus tends to
be generalized but is worse on the feet and hands.27
In Conclusion
Dry skin can be persistent and recurring due to the long list of possible causes. Clinicians often treat dry
skin with hydrophilic and/or lipophilic moisturizers. Hydrophilic moisturizers must penetrate the stratum
corneum deeply to function properly whereas lipophilic moisturizers should remain in the upper stratum
corneum layers.28
Traditionally, clinicians used humectant and occlusive technologies to treat dry skin. Originally,
non-lamellar forming ingredients such as petrolatum were in use but recent research has shown an
advantage of using lamellar-forming factors such as ceramides, pseudoceramides and phospholipids.29
As with all topical treatments, adherence is the great challenge one faces in the management of skin
diseases. Strong odor from ingredients and greasy compositions may be disagreeable to the patients.
Furthermore, low pH and sensory reactions, from lactic acid and urea for example, may reduce patient
acceptance.30
The number of studies on skin barrier function and hydration is endless. There is a long list of products
available and some may work better depending on certain skin characteristics of the person. Many
podiatry friendly companies have products that include CeraVe (Valeant), Eucerin, AmLactin (Upsher
Smith), Cetaphil (Galderma), Borage Therapy (ShiKai), Uramaxin (Medimetriks), Carmol 40, Lubriderm
(Johnson and Johnson), and Aveeno (Johnson and Johnson).
Dr. Morse is the President of the American Society of Podiatric Dermatology. He is a Fellow of the
American College of Foot and Ankle Surgeons, and the American College of Foot and Ankle Orthopedics
and Medicine. Dr. Morse is board certified in foot surgery. He is on the Podiatric Residency Educational
Committee at the MedStar Washington Hospital Center in Washington, D.C.
References
1. Nolan K, Marmur E. Moisturizers: Reality and the skin benefits. Dermatologic Therapy. 2012;
25(3):229-233.
2. Coderch L, Lpez O, de la Maza A, Parra JL. Ceramides and skin function. Am J Clin Dermatol. 2003;
4(2):107-29.
3. Watkins P. Using emollients to restore and maintain skin integrity. Nursing Standard. 2008;
22(41):51-57.
4. Pons-Guiraud A. Dry skin in dermatology: a complex physiopathology. J Eur Acad Dermatol Venereol.
2007; 21(Supp 2):1-4.
5. Vorgeli D. The vital role of emollients in the treatment of eczema. Br J Nursing. 2011; 20(2):74-80.
6. Choi MJ, Maibach HI. Role of ceramides in barrier function of healthy and diseased skin. Am J Clin
Dermatol. 2005; 6(4):215-23.
7. Johnsen G, Haugsnes A. A new approach for an estimation of the equilibrium stratum corneum water
content. Skin Research Technology. 2010; 16(2):142-145.
8. McKinley-Grant L. VisualDx: Essential Dermatology in Pigmented Skin. Lippincott, Philadelphia, 2011,
pp. 322.
9. Aziz N. Xerosis and eczema craquele. In McKinley-Grant L (ed): VisualDx: Essential Dermatology in
Pigmented Skin. Lippincott, Philadelphia, 2011, pp. 316.
10. Johnson B, Moy R, White G. Ethnic Skin Medical and Surgical. Mosby, St Louis, 1998, p. 4.
11. Jiang ZX. DeLaCruz J. Appearance benefits of skin moisturization. Skin Research & Technology. 2011;
17(1):51-5.
12. Fujimura T, Takagi Y. Real-life use of underwear treated with fabric softeners improves skin dryness by
decreasing the friction of fabrics against the skin. Int J Cosmet Sci. 2011;33(6):566-571.
13. Gooptu C, Powell SM. The problems of rubber hypersensitivity (Types I and IV) in chronic leg ulcer
and stasis eczema patients. Contact Dermatitis. 1999; 41(2):89-93.
14. Arndt K, Hsu J. Manual of Dermatologic Therapeutics, seventh edition. Wolters Kluwer, Philadelphia,
pp. 72-74.
15. Sippel K, Mayer D, Ballmer B, Dragieva G, Lauchli S, French LE, Hafner J. Evidence that venous
hypertension causes stasis dermatitis. Phlebology. 2011; 26(8):361-5.
16. Hazin R. Recognizing and treating cutaneous signs of liver disease. Cleve Clin J Med. 2009;
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76(10):599-606.
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17. Bigliardi PL. Pruritus--causes, diagnostics and treatment. Revue Medicale Suisse. 2006; 2(63):1115-8.
18. Yosipovitch, G. Dry skin and impairment of barrier function associated with itch - new insights. J
Cosmet Sci. 2004; 26(1):1-7.
19. Scott S. Atopic dermatitis and dry skin. In: Krinsky D. Berardi R, Ferreri S, et al (eds). Handbook of
Nonprescription Drugs, 17th edition. American Pharmacists Association, Washington, DC, 2012, pp.
615-630.
20. Domino F. 5-Minute Clinical Consult 2014, 22nd edition. Lippincott Williams and Wilkins, Philadelphia,
2013.
21. Available at http://www.scientificamerican.com/article.cfm?id=how-does-sunscreen-protec . Published
May 7, 2007. Accessed Dec. 6, 2013.
22. Ward JR, Bernhard JD. Willan's itch and other causes of pruritus in the elderly. Int J Dermatol. 2005;
44(4):267-273.
23. Lynde C, Kraft J. Skin manifestations of kidney disease: Conditions range from benign to
life-threatening. Parkhurst Exchange. 2007; Vol.15, No.02
24. Nunley JR, Elston DM. Dermatologic manifestations of renal disease. Available at
http://emedicine.medscape.com/article/1094846-overview . Published April 11, 2012. Accessed Dec. 9,
2013.
25. Litzelman DK, Marriott DJ, Vinicor F. Independent physiological predictors of foot lesions in subjects
with NIDDM. Diabetes Care. 1997; 20(8):1273-1278.
26. Pavlovi MD. The prevalence of cutaneous manifestations in young patients with type 1 diabetes.
Diabetes Care. 2007; 30(8):1964-1967.
27. Ballmer-Weber BK, Dummer R. Pruritus in frequent skin diseases and therapeutic options. Praxis.
2007; 96(4):107-11.
28. Caussin J, Rozema E, Gooris GS, Wiechers JW, Pavel S, Bouwstra JA. Hydrophilic and lipophilic
moisturizers have similar penetration profiles but different effects on SC water distribution in vivo.
Experimental Dermatol. 2009; 18(11):954-61.
29. Pennick G, Chavan B, Summers B, Rawlings AV. The effect of an amphiphilic self-assembled lipid
lamellar phase on the relief of dry skin. Int J Cosmet Sci. 2012; 34(6):567-74.
30. Loden M. Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders. Am
J Clin Dermatol. 2003; 4(11):771-88.
Editors note: For related articles see Keys To Differentiating Eczematous Eruptions In The Pedal Skin
in the April 2009 issue of Podiatry Today, What You Should Know About Atopic Dermatitis in the
September 2005 issue, A Guide To Skin Conditions Of The Diabetic Foot in the September 2004 issue or
Treating Psoriasis In The Lower Extremity in the February 2011 issue.
To access the archives, visit www.podiatrytoday.com. For an enhanced online experience, check out
Podiatry Today on your iPad or Android tablet.
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