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IPKs and salicylic acid

Discussion in 'General Issues and Discussion Forum' started by Jaimee Brent, Feb 19, 2014.

  1. Jaimee Brent

    Jaimee Brent Active Member

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    HI everyone,

    I have been reading the article about the use of salicylic acid on HD treatment.

    I have a no. of patients w stubborn IPKs that react well to debridement and AgNO3 applications but only if it is carried out very regularly.
    These pts have either refused orhtotic therapy or have orthoses but the problem (although calmed) is still apparent.

    I was wondering if anyone has tried that use of sal acid on intractable plantar keratoses, and if you could give me an idea of effectivenes.

    I wasnt sure if it would be an option due to the IPKs not having a core?

    any thought would be great.


  2. davidh

    davidh Podiatry Arena Veteran

    We used sal acid 40-odd years ago, before we had easily accessible good orthotic therapy available.

    I can't advise you on sal acid, other than it is a keratolytic, non-cumulative in it's effect, and if the pressure is still there it will do absolutely nothing long-term.

    I can advise you to re-look at your orthotics (find something better to prescribe), and your return times for patients, and to ditch the patients who won't have orthotics, or ensure they return before the IPKs build up to painful levels.
  3. Lab Guy

    Lab Guy Well-Known Member

    From my experience, intractable plantar keratomas have a deep core as the proximal phalanx is dorsiflexed and applying a retrograde force on the lesser metatarsal head. Pressure is increased as the area is decreased due to the MPJ dorsiflexion.

    I like to use a #64 blade to remove the core. I do it gently and carefully without local anesthetic. With the core removed, they feel tremendous relief. I apply as well as dispense aperature pads for the patient so they may off-load the plantar condyle.

    I may also dispense a bilateral heel lift if they have equinus that is causing loading of their forefoot prematurely and increasing the pressure.

    You can also excavate the insole of the shoe in the area of the depressed metatarsal head to decrease the pressure. You may also insert a prefabricated over the counter orthotic and apply a metatarsal pad to decrease GRF acting on plantar condyle.

    Check their shoes and advice appropriate shoes for their problem. Shoes like the Hoka One provide a lot of cushioning due to their extra thick air blown EVA and they incorporate a forefoot rocker. Patients with pain on the ball of their foot love them as do I for my symptomatic cavus feet.

    If they are overweight, motivate them to lose weight. Seems like a lot of pts that develop IPKs also smoke. Another good reason to quit smoking if they do.

    Have them return to your office once a month for debridement, no big deal. If they get tired of it and healthy, they can have surgery to take care of it. Good luck.

  4. Cameron

    Cameron Well-Known Member

    James et al

    All is revealed in the Pharmacopoeia for chiropodists by J N Le Rossignol and An introduction to therapeutics for chiropodists by PJ Read . No longer in print but you may well get them through an inter-library loan. From the mid 50s onwards these were standard bench text for corn operators in the UK, South Africa, NZ and Australia.

    Depending on the strength sal acid can be either keratoplastic (up to 3% is keratin softener) or keratolytic (damages the side salt linkages of keratin). According to Read and Le Rossignal it does have a cumulative action on the skin (really Dave you should have listened to Mama Dewar's lectures more intently :)) and should be removed regularly after application. Sal acid was at one time the active ingredient of most commercial corn cures.

    Provided it is used with supervision sal acid can assist the practitioner in the routine management of hard corns (IPK) but needs to be used sparingly and not on a continuous basis.

    The Patho-mechanics of IPK

    Once the keratin cells are damaged by shear and friction there appears to be a biochemical mechanism which governs the epithelial growth specific to that area. As I understand it once this mechanism kicks in then you cannot reverse the accelerated keratinisation process. Depending on the type of stress will determine physiological callus from IPK or corn. In essence however both lesions arise from similar pathophysiology but the IPK is defined by a corkscrew pressure which on weightbearing pushes downward causing a conical shaped lesion, shaped like an ice cream cone. Early descriptions of corns were the shape of a carpenters nail (clavus). Simple Newtonian physics helps understand the corkscrew reaction on prominent areas.

    Management of IPK
    There are two specific etiological factors
    Changes to skin physiology with a poor long term prognosis, and .
    the more easily managed exciting factor such as ill fitting footwear or high shear surfaces .

    From the few independent published studies on IPK management by orthoses alone -The outcome was poor.

    Corns and callus have been written about since antiquity and the Greeks were the first to acknowledge the only successful management was regular reduction of the hyper keratotic plaques. They developed a tool to this effect which was the forefather of the modern surgical scalpel. Most 20th century text promotes routine skin reduction with or without chemical assistance. AgNo3 for example precipitates protein (dries the moist keratin) and forms a barrier to its own penetration. This assists the practitioner with their enucleation.

    Frequency of care
    Skill cells have a life span of approx 28 days (so no matter what is removed will return in that time period) Depending on individual's pain thresh hold dictates whether the client feels discomfort in four weeks or beyond (the average is about 6 weeks with chronic IPK).

    Hope that helps
  5. davidh

    davidh Podiatry Arena Veteran

    You are of course correct - I hang my head in shame:D .
    I was mentally comparing with the cumulative effect of other acids such as pyro, where not much happens for several applications, then everything happens all at once!

    It may also be worth mentioning silicone plugs, in which silicone (toe-prop stuff) is pasted into the hole left after enucleation. I did this for a year or so in the 70's and the results were mixed (one I remember was spectacularly good), but I know there is at least one published study out there which may be worth searching for.

    I found that with a good custom orthosis it was usually the case that IPK patients could double or even treble their normal visit times without recourse to topical treatment.
    Sometimes a toe prop would be useful, sometimes not.
    Generally though I feel that lightweight shell materials like carbon and poly combined with superior cushioning materials like poron or poron/plastazote can be made into a device which will relieve symptoms far faster than any topical treatment out there.
  6. Rob Kidd

    Rob Kidd Well-Known Member

    I love reading this stuff - its a trip down memory lane! I can hear (the late) Irene Clowes saying to me" "You wasn't watching was you, take if off!" She would have turned in her grave at the discovery that I was her heir (displaced twice) as padding and strapping tutor. I know this thread is about material medica, but she taught me that also! Rob
  7. Cameron

    Cameron Well-Known Member

    Dave , Bod and other toe hounds

    All is fair in love and war and trying to chronic IPKs. Padding and strapping now there is a gem from the past. Might look out a powerpoint I have a post it on Slideshare. I did like you Dave work with silicone plugs (originally latex plugs) with Jim Black back in the dark and dim. He moved onto medial grade silicones and for a year or so I worked as his research assistant. Initially I did a retrospective review of clients recorded as previously having latex plugs fitted after careful enucleation and compared that to the post experiences with a conglomerate of treatments for their chronic corns. To a person they all recalled a time when they had significant relief and comfort which they rated as the best experience of attending the training clinics. That time corresponded exactly to the latex treatments.

    I also worked with Jim on three toe props but we fell out over clinical evaluations. I started working with sb talar joint neutral as the universal reference point for the setting silicone and was much happier with subsequent evaluations. :)

    All those years ago.

  8. davidh

    davidh Podiatry Arena Veteran

    I did mine without holding the foot in STJ neutral - ignorance being bliss. At that time (1973/4) I was vaguely aware of the STJ, but totally unaware of planes of motion, or what happened when the foot hit the ground. I still worked from dear old R McRae's tripod.

    So silicone is worth a go if the OP wants to try a topical treatment, and TS will know more about it's application and use than me, I'm sure;).

    As an aside, I saw a nice case of Policemans Heel today:drinks
    Ostlers Toe came up in conversation, but I haven't seen one of those for a few years.......:D
  9. Cameron

    Cameron Well-Known Member


    In 1979 I fell in with the Langer casting chart and bingo the penny dropped STJN may be many things but it did provide the basis for a universal reference position when fitting silicone props. Jim's (& Coates) approach was pull and set using dental elastomers. Working on the principles of Wolfe and Davidson correction would occur. Personally I was not so sure and wanted to explore muscle control. Improve the tone of the extrinsic muscles (which are rarely damaged) and improved toe position (dependant on QOM will follow) Increased surface plantar contact given by the prop combined with sufficient mod E in the material increased windlass action during toe off. Used as serial toe orthoses changes in bone position are easily monitored just by comparing the molds. Gives a reasonable result and offers a non surgical correction of lesser toes. Can be used in conjunction with orthodox orthotic therapy and seems to increase the planar surfaces available to the foot after heel lift.

    Ostlers toe not so much but gryphosis yes a fair few.

    Hope you are keeping dry as we swelter in temps of 36 down under. BTW I have a daily conversation with John Dalzell who seems to relive his college days lamenting all the paramour opportunity that never quite came his way :)
  10. davidh

    davidh Podiatry Arena Veteran

    Is he still going on about those Swedish girls?
    It was the liberal 60's John, but for you my friend, it may as well have been the 50's:D.
    Please pass on my best regards when you talk next.

    Living on a hill in a secluded valley here everything is fine. I have concerns about the new lambs (not mine) which are due out any day now, but otherwise we are dry and comfortable.

    The STJ position still works for me, and I made silicone props with the foot held in an approximate position of STJ neutral after reading something you had written. It worked nicely, so a belated thanks for that.
  11. Judith004

    Judith004 Member

    I have used a combinaltion of Verzone (monochlorocetic acid liquid) and a 60% sal acid within an aperature pad made from moleskin. I have done this for over 20 years. For the IPK's that are not directly at a pressure point, but may be from shearing forces, such as in the 1st intermetatarsal space area plantarly where you see the linear diffuse callus with multiple punctate lesions, sometimes this treatment will last for up to a year before the patient is back. Obviously, if the lesion is in a pressure area, the offloading is needed, but for those lesions not directly in a pressure point, this is an option I give my patients. They keep the foot dry and take it off after 48 hours and are instructed to remove it if it does get wet. I have had very good luck. The one drawback is that we can no longer get these chemicals, and I am still using the batches from when I bought this practice in 1993!! It is still working, and I only use one drop of the Verzone and less than a gram of the Sal Acid paste per treatment, but one day I'll run out and have to find another treatment

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