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Hi all,

I am seeking any ideas on prevention of severe mechanical blisters for a 32YO female patient of mine.

The blisters she typically suffers from occur on the lateral plantar surface of the heel, medial 1st MPJ, medial longitudinal arch and around the plantar digit/webbing area. They can be quite large - 5cm+ diameter - and deep and are incredibly painful so that the patient literally can't walk. She usually gets them when she walks around a lot which is always on holiday. It has got to the point where she feels she can't travel anywhere as most of the trip she is unable to get around.

Her skin is moist and she suffers with hyperhidrosis which I feel is the cause of most of the blistering however given her history, I wondered if there was a skin blistering disorder component. Her visits to a dermatologist have not suggested this as a cause.

She has been completely compliant with all instructions and trials including footwear changes, topical antiperspirants and Iontophoresis - at great expense I may add! We are now almost at the end of her options. She is going to try oral medication and/or botox next. After that, we are fresh out of ideas.

I wondered whether wearing a shoe similar to the Vibram five fingers would help as I imagine there would be little friction in these - could anyone confirm that?

If anyone out there has any experience with this type of thing or has any thoughts, we are open to every idea.

Thanking you in advance

RachWadd

 

It is certainly unusual. Either you have got unusually high amounts of friction (anything unusual in gait?) or exceptionally fragile skin (pemphigus?) For dermy things I usually defer to others (is Belinda out there?)

If you have fragile skin I could see the finger shoes causing more problems than helping. Much more skin contact and potential for friction around toes. I'm assuming you've tried the usual things like moleskin and acrylic socks on a vinyl sock liner. (That will really reduce plantar friction, but you will get more friction where the foot slides into the sides of the shoes. )

 

Hi Rach,

I'm not 100% clear on where the heel blisters are. They sound like edge blisters https://www.blisterprevention.com.au/blister-blog/heel-edge-blisters-free-lesson. Or are they more plantar surface? Do you have any photos. I'd like to be clearer about where the toe blisters are too - are they pinch blisters that extend proximally to the webspace? Photos would help. Take a look at these images - it might help: https://www.blisterprevention.com.au/blister-blog/brr2016-three-most-common-blisters

For the majority of blisters, the thing that helps most is reducing friction levels. Not reduce rubbing - I mean make it more slippery. Because the more slippery over the blister-susceptible area, the less the skin stretches (shears) and the less the tear in the stratum spinosum that kick-starts blisters.

Of course, it's not great to have everything slippery-slidey in the shoe, because your foot still needs traction - and it gets traction form high friction levels. So it can get tricky when people seem to blister "everywhere".

Check out Engo patches for targeted friction management. Check out Armaskin socks for more overall friction management. This is assuming you've tried all the basics - like moisture management, shoe fit, taping, biomechanics.

Reducing friction levels under the heel is not great due to reduced traction. I'd go something more like Spenco or poron to absorb the blister-causing shear. And silicone gel toe devices absorb LOTS of shear and can be excellent for the majority of toe blisters. But silicone will absorb too much shear under the heel where it's important to have more traction rather than less, so I'd stick with Speco/poron.

Rebecca

 

Thanks so much for your replies efuller and Rebecca. I was waiting to get back to you both after discussing your suggestions with the patient but she went on holiday and I only just touched base with her last week.

The patient had previously been to see a dermatologist on my suggestion as I had also thought of a blistering/skin disorder. Only iontophoresis and botox was suggested by the dermatologist however.

Gait assessment showed nothing unusual, also the blistering is often everywhere over the sole of the foot, heels and around digits which suggests basically any kind of weight-bearing!

I had a look at your website Rebecca - you have some fantastic information available, thank you! I'll definitely refer back to it :-D I have also suggested my patient check it out if she has any more issues with her blistering. She has actually decided to go for a sympathectomy to stop the sweating altogether. It appears to be effective and reasonably safe so I hope the patient finally gets relief and can travel without having to worry about being laid up for days with painful feet.

Thanks once again.

Regards
Rachael