Physiological callus

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I have had the feeling lately that decisions to reduce callus are based more and more upon a single factor. Is the callus 'physiological' or 'pathological'?

Differentating between 'physiological' and 'pathological' seems to be down to a single factor. No pain and it's physiological and requires no treatment. Pain and it's pathological and requires treatment.

What other factors, apart from pain, do you use to decide whether callus is 'physiological' or 'pathological?

This is a different question than, what factors do you take into account when deciding whether or not to treat a callus, although there is likely to be a degree of overlap?

I lately saw the term 'physiological corn', which seems to be an extension of the idea of physiological callus, and was defined as a pain free corn and therefore did not require treatment. If this definition of 'physiological', as painfree, continues to evolve will we soon have apparently absurd conditions such as: a physiological cancer or a physiological CVA?

Bill Donaldson

 

Hi Bill,

Can I ask where you are hearing this? At which point does physiological become pathological, and who determines this? If pain is the decisive factor, then I suppose patients with peripheral neuropathy won`t need treatment any more :wacko: I agree, no treatment plan can be formulated upon a single factor.

Cheers,
Bel

 

I'd say that pathological is implied in the definition of Callus. The thickening of skin one finds, for EG under the heel as opposed to on the dorsum of the toes is a different thing.

I read somewhere that Callus is caused by the premature cornification of skin cells, causing the cornified layer to behave abnormally. But I'm no dermatologist. Ask Holly.

 

Define `abnormally`

 

Ummmm

Pathologically.

And before you ask, I define pathologically as abnormally.

You know, all like sticky and stuff. Because of the level of keratin in it?

I'll get me coat.

 

Ok, so you reckon we should be striving to make skin `normal`, then? Thus, any pathology can be rectified by normalising the foot?

Just joshing ya :drinks

 

bully

What actually is the variation in thickness in the cornifed layer between plantar weight bearing and non plantar weight bearing skin?

Average I mean .

 

Touche.`Tis thicker. I`ll give you that. You really want an average, I`ll have to get back to you.

 

Why I´m doing this Ive no idea -

Tissue stress.

in an none neuropathic/diabetic ( I´m sure there is more ) Patient

Callous is Physiological unless painful - is is a sign and symptom of increased friction and shear forces at that point, but if not painful leave it.

In a neuropathic/diabetic ( I´m sure there is more ) Patient it is a sign and symptom of increased friction and shear forces at that point and in most cases be treated due to increased likely hood of breakdown.

I´m sure I´m about to be schooled :drinks

 

a somewhat similar theme to this thread - Validity of comparing plantar pressures before and after callus reduction?

 

Thats what we're all here for ;-)

I'd say tissue stress probably does hold the answers. But I'm not happy with pain as the deciding factor. Apart from neuropathy it just seems wrong.

I suspect it is affected by a number of factors. Thickness can't be it cos you'd not expect baby soft skin on a 39 stone docker or a marathon runner. The viability of the subcutaneous tissue must be an issue as well, as must location. Callus limits the flexibility of the skin (increased stiffness?) which has to demand more flexibilty around the borders.

I suspect this is a job for ZOOSS, (a close relative of zools).

 

Sure, tissue stress is a factor, but would you make the call not to treat a non-painful corn/callus on a pt with reduced vascular supply or is immuno-compromised? What if the callus although not painful, is pruritic?

OK, I`m nit-picking. IMO, you hit the nail on the head when you said `likely hood of breakdown`. It`s about establishing risk by assessment of all contributing factors. Not simply labelling callus as either physiological or pathological.

My point exactly (although it`s not tissue stress in isolation). Hyperkaratosis/callus/corns, call it what you like, is a pathology (skin disorder). Histologically, changes occur including increased local fibroblast activity, elongation of the rete pegs and thickening of the stratum spinosum. Causes can be due many reasons including congenital and hereditary disorders, mechanical forces, acquired disease and infections, etc. But you know all that, already.

In my world, any dermatological treatment (which includes no treatment) is percursed by thorough assessment of med hx, physical exam, assessment of foot function and, if required, further investigation. Only then can an effective treatment plan, according to the individual patient, be formulated. It`s plain lazy and dangerous to base clinical decisions on labelling a lesion as either `a` or `b`without considering all factors. Akin to foot typing. Only worse

 

PS what is/are ZOOSS`S?

EDIT: Is it Zones Of Optimal Skin Stiffness?

 

Hi Bel,

I have taken two quote from the web.

Neale's Common Foot Disorders Ch 12 p408

"Some practitioners are of the opinion that callus which produces no discomfort and functionally is of a protective nature should not be removed. This may be referred to as 'physiological callus'."

Journal of Foot and Ankle Research 2009 2:8

Distributiion and Correlates of Plantar Hyperkeratotic Lesions
by Martin J spink, Hylton B Menz and Stephen B Lord

"This natural process of symptom free hyperkeratosis (physiological hyperkeratosis)............ Hyperkeratosis becomes pathological when the keratinised material builds up sufficiently to cause tissue damage and pain."

I am sure that if I had access to a data base that I could find a considerable number of other references to 'physiolgical callus', eg Kate Springett and Julia Potter.

These ideas from the literature are to be found on a number of practitioners' web sites.

Bill

 

Thanks for that Bill. Still don`t like the terminology though. "Symptom free hyperkeratosis" is an oxymoron. Hyperkeratosis is a symptom.

I suspect that a few practitioners have picked up on the terminology `cos it`s catchy. Like `overpronation`. I know Julia Potter has undertaken much research in this area and I have discussed `pathological callus` with her. Just annoying that some of her work has been taken out of context.

Just my view, of course.

Bel

 

Hyperkeratosis is a sign as well as symptom

If you reduce unpainful callous when the body repairs itself is it more likely to be painful ?

 

Exactly.

Is the body `repairing` itself after we enucleate a corn or reduce callus? I would say it is just as, if not more, likely to become painful if it is not reduced and biomechanical and/or systemic issues addressed. Don`t get me wrong, I`m not suggesting that we reduce every bit of callus regardless. The point I am trying to make is the principle involved in clinical decision making is the same as any other pathological complaint that we are presented with. It depends.

 

Nice :drinks

 

That's my phrase remember. I patented it.

Cost you 0.02p each time you use it.

 

`Got a dermy problem? Ask blinda, the ten-year old agony aunt.`

Ok, cannot work out how to start a new thread but this is my question.

Why do some people get Athletes foot (Onycosomething) and other people do not?

 

Hello Joe, been a while?

It`s mainly down to the individuals anti-microbial peptides, ie their immune system. Some fight the infection effectively, others don`t. Of course, other factors such as reducing the odds of reinfection post treatment play a part. I recommend pts with a histroy of recurrent TP apply Lamisil Once approx 3 or 4 times a year to `keep on top` of it. IMO, it`s a matter of maintaining those pesky dermatophytes, you`ll never completely eradicate them, but you can keep `em under control!

Mind you, some of the tinea treatments around are jolly expensive. We're all feeling the pinch, and none more than me since my pocket money was reduced to just £2 a week. It's all the more humiliating because Cindy Spencer told us she gets £5 a week plus all the sweets she can stuff in her gob, so she doesn't even have to budget for confectionary! You can imagine my angst when the new Justin Bieber lunchbox came out priced at £5.99. My mummy said something preposterous about saving for a few weeks so I went and asked my granny to give me some cash but she started ranting about how her generation had to work down the mines and were happy with belly button fluff for dinner, and my sister punched me and told me to get a paper round. So there was nothing for it, I had to subsidise my wage by 'borrowing' from mummy's purse. I felt guilty for a bit, but there's nothing like the sensation of munching on Space Raiders whilst staring into Justin's eyes to make any residual guilt go away.

Hope that helps!

Bel


http://www.thedailymash.co.uk/

 

Bel thanks.

Sorry about the onyco stuff, late night.

http://en.wikipedia.org/wiki/Antimicrobial_peptides

This suggests an activity against bacteria, not fungi?

When I was 'schooled' we were told that our 'immune system', I think they meant the blood cell response was not triggered by fungi, but clearly we must have some defense or we would all be walking around like mushroom farms?

A notable Pod/dermo suggested the epidermis produced some proteins against dermatophytes, but early research.

I think much of what is taught turns out to be 'compromised' in practice, nail growth being one of my pets.

I think dermatology is a cool discipline and as yet the organ skin has lots of secrets to reveal.

Callus on a brides foot is definitely pathological, what do you think of the 'fish' treatment, do they get a smoother finish than the scalpel?

 

No problem, If I didn’t know better I would have thought you were being a tinker and pulling my leg

Not sure why you would think that. To quote from your own source;

"Antimicrobial peptides (also called host defence peptides) are an evolutionarily conserved component of the innate immune response and are found among all classes of life. Fundamental differences exist between prokaryotic and eukaryotic cells that may represent targets for antimicrobial peptides. These peptides are potent, broad spectrum antibiotics which demonstrate potential as novel therapeutic agents. Antimicrobial peptides have been demonstrated to kill Gram negative and Gram positive bacteria (including strains that are resistant to conventional antibiotics), mycobacteria (including Mycobacterium tuberculosis), enveloped viruses, fungi and even transformed or cancerous cells [1] Unlike the majority of conventional antibiotics it appears as though antimicrobial peptides may also have the ability to enhance immunity by functioning as immunomodulators."

Indeed.

Yep, said `notable pod` and I have discussed this. Bet he talked about alligators. The protein molecules in question consist of one or more polypeptides....but as you say, early days.

Too true. On both counts.

Having been a bride twice, I`ll take heed of your advice and remember that next time. Never tried the Garra rufa myself, I`d rather have fish on the braai than at my toes.

Cheers,
Bel

 

I participated in Julia Potter's study to evaluate and quantify callus but heard nothing after sending in our results.
Is there a paper yet on the outcomes, do you know, please.
It would be interesting to see what sub-categories and respective treatments have been suggested.
Also I think we should throw into the do we/don't we remove callus debate the third factor of psychological benefits. Especially for our female patients. And if we don't treat them then they will resort to all manner of self-treatment and/or the infamous Garra rufa fish, which as we all know is very hygienic with no risks of cross-contamination!

 

Hiya Nan

The study that you helped with was an undergrad dissertation in 2006 and was supervised by Julia. The author is a friend of mine, but I can`t remember where it was published. I`ll put out my `feelers` and get back to you.

Cheers,
Bel

 

Um...

I suspect Bel will be along in a mo. I'll leave this one to her.

 

Chicken.

Hi Mr/Ms Peezy,

I think I get what you`re saying....same principle in that a stone in your shoe or a needle isn`t painful either, as the discomfort is felt in the nociceptor not the inanimate object? But, you`ll agree that callus CAN, not always, produce pain?

Sure, if the causative factor(s) are not addressed, then pain will recur in an area of high stress and force, before the hyperkeratosis has developed. The callus is a symptom of such, which in itself, CAN induce further pain. Mother Natures` way of letting us know that we need to intervene

Cheers,
Bel

 

If callus is the body's natural "response" to increased pressure (barr dermatological pathologies), then deflection + debridement is definitely the way to go.
I think most podiatrists (waiting for the objections), would debride callus anyway without hesitation.

 

Yup no sense leaving something to get thicker and harder then spliting and get infected. Oi Vey ! Whats with all this debate ....usually the Patient asks you to reduce the callus, customer always right. Callus is (if left thick) always pathological in origin and end results. When I was windsurfing we would deliberately create callus on our hands to "Harden them up" only problem was when too thick it would blister to back to square one. Reducing the callus would have left the underlying skin tough enough for the job yet supple enough to stand the shear involved.

 

exactly Jbwheele !
same deal with guitarists etc.
Heck , I get patients asking me to debride their PHYSIOLOGICAL callus . Comes as a second nature almost.
CALLUS? DEBRIDE!!

 

Hey I am enjoying this Debate about callus I was going to say something about palm callus and dare I say it Mass Debates on the subject but I wont, you know dont want to offend anyone. Yep I play guitar as well and the same goes for callusing up your tips (Fingers that is). On a more serious note, sometimes as we are all aware a benign plantar callus on a long term diabetic can cover up a huge undermined aseptic ulcer..........

 

I was not 100 percent sure where to put this but I was hoping to ask blinda for her expertise.

I have seen two people this week that have small (1-3mm) whitish green spots on the dorsum of the foot that at appearance look a lot like mold? The doc here seems to have no answer and it appears fungal but I'm at a bit of a loss to explain it. The same appearance and random patterning was present in both individuals. Both are osteo arthritic as well and both are believed to have gout. Is there a connection? They are not related or live near each other.

Blinda do you know what this might be?

Thanks

 

(Thanks for the nudge, Dave. Whassat? I`m not p***ed y`know http://www.youtube.com/watch?v=KF8U_v6S120)

Hi Todd,

Excuse my tardiness in replying. Any chance of a pic? Really difficult to discuss a dermy case without visual aid.

Are the lesions macules (flat), papules (elevated), pustules (blisters containing pus) or ulcerative erosions (crusts of skin resulting from loss of the epidermis, sometimes associated with inflammatory or infectious skin diseases)?

Initial thoughts; if it looks like mould, then it probably is. Skin scrapings sent for culture would confirm this.

That said, tophi gout can manifest as yellow/grey-ish/white, chalky nodules on any peripheral joint, including dorsal, but these are usually ulcerative and quite painful.
The OA could precursor a reactive arthritis, which can mimic pustular psoriasis (although usually seen on the palmer/plantar surfaces)....see here;
http://www.clevelandclinicmeded.com...ology/dermatologic-signs-of-systemic-disease/

Colourful Differential Diagnosis;

• Pseudomonas infection (green subungual/interdigital tissue)
• Bleeding diathesis (red sweat)
• Copper exposure (blue sweat)
• Contamination from corynebacteria, paint, chemicals or clothing dye
• Hyperbilirubinemia (yellow/green skin - My son, Jack, had this congenitally. Nuffin` a bit of sunshine couldn`t cure)

http://www.annals.org/content/145/9/710.2.extract
http://scienceroll.com/2007/12/13/green-sweat-possible-explanations/

Cheers,
Bel

 

Tardiness?...heck, no worries. We all just come here when we can. (at least me anyway) I just really appreciate your response!

Regretfully I have no pic at this time but am due to follow up with them in the new year so I'll do my best to remember to take pics to share at that time..

The lesions are definetely macules and are greenish white. Randomly sized and spaced all over the dorsum and sides of the foot . There are none on the soles at all or interdigitally or in the nail areas. They are dry and non painful in both individuals as well.

Odd thing is that in the one case her doc took a sample and sent it away (I do not know where) and apparently the results came back as unknown.

I best get a picture. Sorry about that. I suppose it is like finding a needle in a stack of needles without a pic!

Thanks Blinda for the references as well.

Todd

 

Just thinking out loud an not my area of expertise but would this macule outburst be related to a somewhat supressed immune system?

 

its good for the kwonledge but in reality how can I tell the patients that they dont need any treatment becoz its physiological in nature and btw it doesnt hurt, i bet they will say ok then go to someone else......

 

@ Blinda
.... regarding my post on the macules and needing pics:

dorsum:



Does this help you close in on what it might be Blilda?

I really appreciate your time on this and I'm sorry it took so long to get the pics. He cancelled his follow up due to icy roads and was only able to see him again recently.

 

Agree with the last few posts, my patients would be very underwhelmed if I left callus alone. With right shoe advice , regular treatment and daily Urea based cream, almost all feet will substantially improve over a couple of years.

 

Hi Todd,

Thanks for obtaining the pic. Helps enormously. Few more questions; How old are the patients? Do the lesions itch? Do they scrape off? You say the lesions are macule, but are they palpable, ie very slightly raised? Some of them do appear to be plaques.

With the pic and info thus far, I`m inclined to think the OA/gout is a red herring and more likely to be Stucco Keratoses (age spots);http://www.dermnet.com/images/Stucco-Keratoses http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=-1354487226. These relatively common benign lesions are usually found on the lower limb and predominantly occur in elderly men. They can be removed with cryotherapy and/or curettage.

Or, Idiopathic guttate hypomelanosis/leukoderma;http://dermatologyforyou.com/conditions/guttate_hypomelanosis.asp. http://www.dermnet.com/images/Idiopathic-Guttate-Hypomelanosis/photos/2These are also benign lesions of unknown aetiology, as the name suggests. They are reportedly related to the effect of the sun on melanocytes, which makes them degenerate and are most commonly seen in middle-aged, light-skinned women. However, with increasing age and sun exposure, it is found almost equally in elderly men and women. These can be treated with topical steroids, topical retinoids, dermabrasion and cryotherapy.

However, I`m intrigued by your description of `whitish green spots`. Whilst the scrapings taken by the doc may not have revealed infection, samples taken by non-dermatologists (I know that`s not a word) are often not taken from where the tinea is active, so a false negative result will come back from the path lab. Therefore, don`t rule out yeast/tinea infection just yet. Pityriasis/tinea versicolor is realtively common;http://www.adultandpediatricdermatology.com/tineaversicolor.php. This is caused by the fungus Pityrosporum ovale, a type of yeast found on human skin. But, it is mainly seen in sweaty, adolescent and young adult males and the most common sites are the back, underarms, upper arms, chest, and neck so IMO unlikely to be this. Topical anti-fungal meds, eg the `azole family, will certainly clear this up.

Hope that helps!

Cheers,
Bel