Skin fissures, commonly referred to as cracks in the skin, are a prevalent concern in podiatry. These fissures often manifest on the feet, particularly around the heels and between the toes, leading to discomfort and potential complications if not addressed promptly. This article delves into the etiology, clinical presentation, diagnostic approaches, treatment modalities, and preventive strategies associated with skin fissures, with a focus on their relevance to podiatric practice.

Etiology and Pathophysiology

Skin fissures develop when the skin loses its elasticity and becomes dry, leading to cracks that can penetrate the dermal layers. Several factors contribute to the formation of these fissures:

Dry Skin (Xerosis): A primary contributor to skin fissures, xerosis results from decreased moisture in the skin, leading to reduced elasticity and increased susceptibility to cracking. Environmental factors such as low humidity, excessive bathing, and exposure to harsh soaps can exacerbate dryness. Pharmaceutical Journal

Mechanical Stress: The feet endure significant mechanical stress during activities like walking and standing. This stress is particularly pronounced in individuals who are overweight or obese, as the increased body weight exerts additional pressure on the feet, especially the heels. Over time, this pressure can cause the skin to expand sideways, leading to cracking. 

Footwear Choices: Wearing open-back shoes or sandals can allow the fat pad under the heel to expand sideways, increasing pressure on the skin and leading to fissures. Additionally, footwear that does not provide adequate support or cushioning can exacerbate the problem. 

Dermatological Conditions: Certain skin disorders, such as eczema, psoriasis, and atopic dermatitis, can predispose individuals to skin fissures due to the compromised integrity of the skin barrier. These conditions often lead to dry, inflamed skin that is more prone to cracking. HMP Global

Systemic Conditions: Medical conditions like diabetes mellitus can impair skin health and healing, making individuals more susceptible to fissures. Diabetes can lead to peripheral neuropathy and reduced blood circulation, both of which can compromise skin integrity and delay healing processes.

Clinical Presentation

Patients with skin fissures typically present with:

Visible Cracks: Linear breaks in the skin, often on the heels or between the toes. These cracks can vary in depth and length, with deeper fissures potentially reaching the dermal layers and causing significant discomfort. 

Pain and Discomfort: Fissures can be painful, especially when weight-bearing or during ambulation. The pain may be sharp and localized to the area of the fissure, often exacerbated by pressure. 

Bleeding: In severe cases, fissures may bleed, indicating deeper skin involvement. Bleeding suggests that the fissure has penetrated the dermal layer, which can increase the risk of infection. 

Inflammation: Surrounding skin may appear red, swollen, and tender, indicating an inflammatory response. This inflammation can further compromise skin integrity and delay healing. 

Callus Formation: Thickened, hardened skin (callus) often surrounds heel fissures, contributing to the problem. The presence of a callus indicates chronic pressure and friction in the area, which can exacerbate fissure formation. 

Diagnostic Approaches

Diagnosis of skin fissures is primarily clinical, involving:

Patient History: Assessing factors such as footwear habits, occupational hazards, underlying medical conditions, and skincare routines. A thorough history can help identify contributing factors and guide treatment strategies.

Physical Examination: Evaluating the location, depth, and severity of fissures, as well as assessing for signs of infection or underlying dermatological conditions. Examination should also include an assessment of skin hydration, texture, and the presence of calluses.

Laboratory Tests: In cases where infection is suspected, swabs for bacterial or fungal cultures may be warranted. Additionally, blood tests to assess glucose levels can be useful in patients with suspected diabetes.

Treatment Modalities

Management of skin fissures involves a multifaceted approach:

Debridement: Careful removal of callused or dead skin by a podiatrist to reduce pressure and facilitate healing. This procedure should be performed using sterile instruments to minimize the risk of infection. 

Moisturization: Regular application of emollients, particularly those containing urea or salicylic acid, to enhance skin hydration and promote elasticity. These agents help to soften the skin and reduce the formation of calluses. 

Protective Dressings: Utilization of liquid, gel, or spray bandages to shield fissures, reduce pain, and expedite healing. These dressings create a barrier that protects the fissure from external irritants and potential pathogens.

Footwear Modification: Advising patients to wear supportive, closed-back shoes with appropriate cushioning to minimize mechanical stress on the heels. Orthotic devices may also be recommended to redistribute pressure away from vulnerable areas.

  Topical Therapies:

    • Emollients and Moisturizers: Regular application of urea-based or salicylic acid-containing creams enhances skin hydration and promotes desquamation of hyperkeratotic tissue. 

       

    • Keratolytic Agents: Topical treatments containing agents like urea or salicylic acid can help soften and debride thickened skin, facilitating healing. 

       

  • Mechanical Debridement: Podiatrists may perform debridement using scalpels or rotary files to remove thickened skin, reducing pressure and facilitating healing. 

     

  • Wound Care: For deep or infected fissures, appropriate wound dressings and, if necessary, topical or systemic antibiotics are indicated.

  • Offloading Devices: Orthotic devices, heel cups, or padding can redistribute pressure away from affected areas, promoting healing and preventing recurrence.

  • Patient Education: Guidance on proper foot hygiene, moisturizing routines, and appropriate footwear is crucial in both treatment and prevention.

 Preventive Strategies

Preventing skin fissures involves:

  • Regular Moisturization: Daily application of appropriate moisturizers to maintain skin hydration.

  • Footwear Selection: Wearing well-fitting shoes that provide adequate support and reduce excessive pressure on vulnerable areas.

  • Routine Foot Care: Regular inspection and care of the feet, including gentle removal of calluses and avoidance of walking barefoot in environments that may predispose to skin dryness or injury.

  • Management of Underlying Conditions: Effective control of systemic diseases like diabetes and dermatological conditions to reduce the risk of fissure development.

 

If left untreated, skin fissures can lead to:

  • Infections: Including cellulitis or abscess formation.

  • Ulceration: Particularly in patients with diabetes, where fissures can progress to full-thickness ulcers.

  • Chronic Pain: Affecting mobility and quality of life.

Skin fissures are a common podiatric concern requiring a comprehensive approach to diagnosis, treatment, and prevention. By addressing underlying causes and implementing appropriate therapeutic strategies, podiatric practitioners can effectively manage skin fissures, alleviating patient discomfort and preventing complications.