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Chapter 15
Feet
Abstract This chapter provides an overview of the common dermatological condi-
tions such as tinea pedis, psoriasis and contact dermatitis that can occur on the
feet. The chapter discusses mainly from their clinical perspective. It provides details
about the clinical presentation of these conditions and ways to diagnose them; where
feasible, it provides clinical information regarding how to diagnose them clinically.
It also discusses their treatment options and when appropriate the circumstances as
to when the patients need to be referred to the dermatologist.
Keywords Tinea pedis · Athlete’s foot · Psoriasis · Callosity and corns · Warts ·
Erythrasma · Candidal intertrigo · Pompholyx
15.1 Tinea Pedis (Athlete’s Foot)
– Dermatophytic infection of the feet.
15.1.1 Clinical Manifestations
Can manifest as either interdigital or chronic hyperkeratotic (moccasin) or bullous
–
).
(vesicular) or ulcerative form (Ilkit and Durdu
– Interdigital form is the most common form. It presents with scaling, erythema,
maceration affecting the lateral toe clefts.
– Moccasin type (Fig. 15.1) presents as diffuse or focal scaling on the soles and
the medial and lateral aspects of the feet, in a distribution similar to a moccasin
footwear. The erythema is usually mild but is variable (Craddock and Schieke
2019
).
The vesicular form (Fig. 15.2)manifestsasvesiclesorpustulesorbullae
–
commonly involving either mid anterior plantar surface or near the instep.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
D. K. Yellumahanthi, Manual of Primary Care Dermatology,
https://doi.org/10.1007/978-3-031-68406-7_15
2014
227
228 15 Feet
Fig. 15.1 Tinea pedis (moccasin distribution)
Fig. 15.2 Tinea pedis, blister form
15.2 Psoriasis 229
– The ulcerative type is an exacerbation of the interdigital form. It is most often
seen in diabetics or immunocompromised individuals (Legge et al.
2008).
15.1.2 Diagnosis
– A potassium hydroxide (KOH) prep can be performed in the office to confirm the
diagnosis.
– A culture for fungus can also be done.
– A skin biopsy can also be done to confirm the diagnosis.
15.1.3 Management
– Topical antifungal therapy is the mainstay of treatment for superficial or localized
2023
tinea pedis (Leung et al.
– Topical clotrimazole, miconazole, ketoconazole, oxiconazole, sulconazole, serta-
conazole, luliconazole, terbinafine and ciclopirox are the options.
).
– Oral treatment can be considered if topical antifungal treatment is not effective or if
the condition is extensive or in immunocompromised patients or if onychomycosis
).
coexists (Rajagopalan et al.
– Oral terbinafine daily (250 mg for adults) for two weeks and fluconazole 150 mg
po q weekly for 2–6 weeks are among the regimens used (Mahajan and Sahoo
).
2016
–
Supportive measures such as limiting the use of occluded footwear need to be
discussed.
2018
15.2 Psoriasis
– Palms and plantar surface (Fig. 15.3) can be involved with psoriasis as a part of
chronic plaque type of psoriasis or as a separate entity, palmoplantar psoriasis
(PP). PP can manifest as psoriasis localized to the palms and soles; it can occur
in various forms ranging from predominant pustular form to hyperkeratotic scaly
plaques (Engin et al.
2017; Farley et al. 2009; Menter and Griffiths 2007).
230 15 Feet
Fig. 15.3 Plantar psoriasis: erythematous plaques with minute superficial pustules
15.2.1 Diagnosis
–
Differentiation from tinea pedis (T. pedis): Psoriasis of feet is easy to differentiate
from tinea pedis if other classical sites such as back of elbows, front of knees,
lumbosacral region are involved. If not, sometimes diagnosis can be challenging.
–
Even if all other classical areas are not involved, usually palms are involved with
plantar psoriasis as a part of palmoplantar psoriasis. Therefore, examination of
the palms needs to be done.
– Nail changes such as subungual hyperkeratosis and onycholysis can be present in
both T. pedis and psoriasis. Nail pitting could favor the diagnosis toward psoriasis.
15.4 Corns (Fig. 15.4) 231
– KOH prep or culture for fungus can rule in or rule out T. pedis.
– Skin biopsy can confirm psoriasis.
15.2.2 Management
– Topical ultra(super)potent steroids such as clobetasol ointment are often first line
of drugs used. Calcipotriene or calcineurin inhibitors can also be used as steroid
sparing agents. The combination of corticosteroids with calcipotriol is found to
be more effective than monotherapy (Handa
– If topical therapy is not effective, phototherapy, systemic retinoids and biological
drugs can be used. Often it is best to refer to dermatology if not effective with
topical medications.
– Please see Chap. 3, ‘Papulosquamous Disorders’, for more details on its clinical
presentation and management.
2010).
15.3 Contact Dermatitis
–
Involves the dorsal area of the feet more than the plantar side.
– Can manifest as either erythematous patches or blisters (in acute cases).
–
If contact dermatitis is suspected, allergic dermatitis to footwear needs to be ruled
out, first.
15.3.1 Management
– Avoidance of potential allergen is a key component of management. Topical potent
steroids such as betamethasone dipropionate 0.05% ointment can be used to treat
the skin lesions.
15.4 Corns (Fig. 15.4)
–
It is cone-shaped with circumscribed hyperkeratosis of the skin over the bony
prominence. Its apex is pointed inward and presses on the surrounding structures.
It can cause pain while walking due to pressure on the nearby nerves. For the
same reason, applying pressure vertically can elicit pain, a sign often aids in the
diagnosis of corn (Farndon et al.
2013).
232 15 Feet
Fig. 15.4 Corn
15.4.1 Diagnosis
Diagnosis is made clinically. Paring of the surface can make the underlying central
–
white core of the corn visible.
– The fact that they are painful, the presence of central white core of corn and
absence of black dots (thrombosed capillaries) should help in differentiating from
warts.
15.4.2 Management
– Avoidance of ill-fitting shoes to relieve pressure on it is recommended. Gentle
paring of the lesion can help. Topical 40% salicylic acid plasters can be used
2013
(Farndon et al.
– If not responding to conservative measures, a referral to podiatrist may be needed
to explore for any surgical intervention.
).
15.5 Callosity (Fig. 15.5)
– It is formed as a result of repeated pressure or friction at a particular site.
15.5 Callosity (Fig. 15.5) 233
Fig. 15.5 Callosity
– It is manifested as an area of circumscribed hyperkeratosis of the skin. The thickest
part is usually in the center. It gradually tapers off to the periphery merging to the
surrounding normal skin (Mehtha et al.
2013).
15.5.1 Diagnosis
– Diagnosis is made clinically. Unlike corn, it is not painful and is devoid of the
central white core. It can be differentiated from warts by the fact that they do
not disrupt the normal skin lines and are devoid of the black dots (thrombosed
capillaries) on its surface.
15.5.2 Management
– It includes making sure that the repeated friction is minimized or stopped. Topical
application of urea paste and salicylic acid can help.
234 15 Feet
15.6 Plantar Warts (Fig. 15.6)
Warts can also occur near nail folds—periungual warts (Fig. 15.7).
– Please see Chap. 6, ‘Common Cutaneous Infections’, for details on its clinical
presentation and management.
Fig. 15.6 Plantar wart
Fig. 15.7 Periungual wart
15.9 Candidal Intertrigo (Fig. 15.8) 235
15.7 Pompholyx (Dyshidrotic Eczema)
– Manifests as vesicles only on the sides of the fingers or toes.
– It can be associated with recurrences.
15.7.1 Management
– It includes usage of super potent topical corticosteroids like clobetasol propionate
0.05% ointment.
– Please see Chap. 11, ‘Upper Extremity Including Hands’, Fig. 15.9 for a picture
of pompholyx and Chap.
diagnosis and management.
5, ‘Eczema’, for more details on its clinical presentation,
15.8 Erythrasma
– Please see Chap. 6, ‘Common Cutaneous Infections’, for details on its clinical
presentation, diagnosis and management.
15.9 Candidal Intertrigo (Fig. 15.8)
Please see Chap. 6, ‘Common Cutaneous Infections’, for more details on its
–
clinical presentation and management.
236 15 Feet
Fig. 15.8 Candidal
intertrigo
15.10 Cutaneous Small Vessel Vasculitis (CSVV) (Fig. 15.9)
Please see Chap. 14
–
management.
, ‘Legs’, for details on its clinical presentation, diagnosis and