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Programme no. 5 - Feet
RADIO 4
THURSDAY 10TH JULY 2008 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: EMMA SUPPLE
PRODUCER: PAULA MCGRATH
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MYERS
Hello. The vast array of foot preparations on sale in any chemist shop or supermarket for that matter gives some indication of just what a foot sore nation we are. But are corn plasters, arch supports and heel cups too little, too later? Is there much more we could do to prevent athletes and verrucas? Or more radical solutions for bunions, hammer toes and other mechanical problems that cause some people real pain and disability.
Well If you've got poor aching feet, especially if you have other medical problems such as diabetes or arthritis you've come to the right place for advice and for information today from our expert, she's podiatrist Emma Supple.
We've got a lot of callers waiting. Susan Zatland is first, she's in Gerrards Cross and wanting to tell us about her son who's got a very large verruca and has had it for some time I think Susan, tell us a little bit more - causing a lot of trouble?
ZATLAND
Hello. We all picked one up about six years ago from the same place and all managed to get rid of it but nothing will get rid of his.
MYERS
How old is he?
ZATLAND
He's 13. And we've tried everything. He's seen the nurse at the surgery and had it frozen. I've used the freezing spray that you can buy over-the-counter and all the drops and I've dug at it until it hurts him and it just won't go.
MYERS
Well my guest today, podiatrist Emma Supple, has slightly raised her eyebrows when you talked about digging away at it. Was that possibly the wrong thing to do?
SUPPLE
No it was a very good idea. At the end of the day the verruca is a virus that sits like a wart into the skin and gets pressed in. It goes no further than the dermis in the epidermis and dermis and it needs to be got rid of. And any treatment that you do - a topical treatment with salicylic acid preparations or freezing it or electrosurgery are all to get that wound response going and the healing response. So the old fashioned lighting a needle and sterilising it and poking it works very well because you're just irritating it, getting the body's healing and bringing it in, so actually that was a good idea. And it's a shame it hasn't worked.
MYERS
Well it is a shame and it's interesting that for once these old wives tales do seem to work in this case although you also hear about wart charmers, I don't know whether they work in this case because it is a wart virus isn't it.
SUPPLE
It is a virus, so the good news is it's a virus and the bad news is it's a virus because they can be quite stubborn to get rid off. Could you just tell me where it is on his foot please?
ZATLAND
It's on the ball - is it the ball of the foot?
SUPPLE
The ball of the foot, so is it sore?
ZATLAND
No, in fact it's become so hard it's quite protected now.
SUPPLE
Yes well that's one of the clever things that verrucas do - they throw up a wall of keratin - hard skin - to protect themselves and sort of seal themselves in - that's the thing that does need to be paired down by a podiatrist and sort of making the verruca a bit more vulnerable. But really it will go - all the evidence shows that these verrucas do go on their own in children. And the only things I would suggest if you get some selenium and some zinc supplements just to boost his immune system and that can help them go. But I'm sorry it's taken so long, they are stubborn but it will go.
MYERS
Thanks for that. Chris Evans is on the line, he's in London, also got a verruca and has been told to leave it alone, is that the right advice, again Chris I think you've had it for some length of time, tell us a bit more about it, is it causing you a lot of pain?
EVANS
No it's not really causing pain, it has been around for an awful long time and I went to see someone about it about three years ago, two years ago, and he said if it wasn't hurting just leave it alone and it will go away on its own eventually but you know I wondered how long that would take.
SUPPLE
Well thank you for your call but grown up verrucas are a lot more difficult to treat than children's verruca. So the rule is for children we do leave them alone, they will go naturally and for adults then I'm afraid that we do have to sort of attack them a little bit more. But clearly if it's not hurting you then why would you go in and hurt it with some agents? And I would certainly start off with the very gentle salicylic acid preparations you can get from your pharmacist just to gently break down that bit of keratin. And then if you want it removed effectively then electrosurgery, where we numb up the area, scoop it out, you've got a little bit of healing to do but that is the definitive answer. And the vitamin A, selenium and zinc would be very useful as well just to take orally.
EVANS
So where would I go for that treatment then?
SUPPLE
The electrosurgery treatment?
EVANS
Yes.
SUPPLE
You can get it via your GP, you can get it in private practice or you can get it in NHS podiatry units.
MYERS
And interesting though, just back to that point, why would you want to get rid of it - I suppose, I don't know for you Chris, but I suppose it can look ugly even if it's not actually painful, some people will find it painful.
EVANS
I wondered if, as it's a virus, whether it sort of affects your body as a whole in some small way?
SUPPLE
No it literally just sits - as I said - in the derma epidermal junction so it can't go any deeper, it doesn't matter how long you've had it, it's not going to go any further. It can obviously multiply and go elsewhere and you don't want to spread it and you don't want to give it to other people but it also quite self contained, so you don't need to worry about it too much.
EVANS
Is that something, as well, because they used to say verrucas were dreadful things to have in swimming pools and stuff, then I got the impression that that wasn't the case anymore so they don't actually spread it?
SUPPLE
Ah well, thank you - thank you for that comment because I feel very strongly that children should not be excluded from swimming pools just because they've got a verruca, especially when it's almost universal, it's so commonplace, and to keep a child off swimming for two years just because they've got a verruca is something I get quite cross about. So I always say paint it with nail varnish, just to seal it in, blue for the boys, pink for the girls and just - yes it's a verruca, yes you would like it to be got rid of but they will go.
MYERS
Thank you very much. We'll go to another caller in Crowthorne, Marjorie Trindle is waiting to speak to us about toenails, what's the problem with your toenails?
TRINDLE
Well I noticed about 18 months ago that my nails - my two big toenails - were coming away from the toes and the GP said it was some sort of fungal infection and he prescribed Trosyd nail solution. And he said it will take a long time. Well I used it twice a day for seven months and it had absolutely no effect. So I stopped using it. They haven't got any worse but they haven't got any better and now I've noticed my fingernails are going to same way - they're coming away from the fingers - and it's more difficult to apply obviously - to apply this Trosyd nail solution to my fingers because one is using fingers all the time.
MYERS
Sure, that sounds ...
TRINDLE
... you can't leave it to dry sort of thing.
MYERS
And Marjorie just to be clear then - when you say your nails are coming away, are they flaking off or are they lifting?
TRINDLE
No there's a gap forming between the nail and the finger and it looks ...
MYERS
Is that as painful as it sounds?
TRINDLE
No it's not painful really, no, no. It's difficult to clean them though because the - what's normally just the little bit at the top is going right down - halfway down the fingernail sort of thing.
MYERS
Okay, well let's see if we can get some advice on these fingernails and starting in toenails and going to fingernails.
SUPPLE
Thank you Marjorie. The all important thing is that the nail is subject to a nail seal and if you break that all important seal between the nail and the flesh then you'll introduce an infection and of course over time a fungal infection, which is very common, affects one in three of us, will start to grow, if you like. And the topical treatments that you just pain on the nails themselves are, in my opinion, not very useful, I recommend creams that you rub into the base of the nail and then as the nail grows up but all the agents that you use topically take months, they do take application and diligence. And that's fine because you usually do see a good improvement. The oral treatment - the terbinafin drug that you need to get from your GP on prescription - is the definitive way to clear up a fungal infection in your fingernails and your toenails.
TRINDLE
Oh I see, so I can get something I can take right.
MYERS
Okay, so that's, as you say, is a drug treatment you get from your GP and perhaps we can spell it out for people, so they're clear - t e r b i n a f i n - I think I've written it down here.
TRINDLE
T e r ...
MYERS
B i n...
SUPPLE
Terbinafin ...
MYERS
Yeah Terbinafin.
SUPPLE
Speak to your GP about that.
MYERS
Okay well that should sort the problem out and I'm not sure what Marjorie did to break the seal, I mean is this something you see a lot in the surgery?
TRINDLE
Yeah I just wondered about that.
SUPPLE
Well I mean it can do - the nail itself can be weakened by washing up liquid, by anybody who immerses their hands in water, I mean that's where the idea of wearing your yellow gloves comes from. So anything that makes the nail more permeable to infection or damage. And then of course if you're touching your feet, touching your fingers and vice versa it's a fungus, it can come from the soil, it can come from yourself, whatever, just get it sorted.
MYERS
And would this in fact be the same fungal infection that people have when they talk about athletes foot but in this case it's in the nail, is it the same thing?
SUPPLE
Yes it's still a tinea infection but she needs to have it checked out to have a proper diagnosis.
MYERS
Thank you very much. Okay, we'll go to Richard in Bradford and Richard - someone had to phone in with this problem, thank you, you're the guy with the sweaty feet I think, you and a lot of other people. So - and with problems with the skin though as well on your feet, is that right, give us a little bit of a description of this if you will.
RICHARD
Yeah they've been sweaty for many a year now really. The skin gets very soft and white and sort of slightly swollen I suppose and it's also very cratered, so I've got these pits in my feet. And occasionally it gets quite painful.
MYERS
And have you had treatment for this before, have you tried to do anything?
RICHARD
Well I sort of mentioned it to the doctor and he just said I needed to keep changing my socks. I've mentioned it to a podiatrist and he sort of said something similar and he also said spray deodorant on them. But it just doesn't really do anything. I'm stuck with the problem. And I was just wondering if - what actually causes the excessive sweating, so if I understood more about it could I actually nip it in the bud and allow my skin to heal up?
MYERS
Okay well Emma what's your take on this?
SUPPLE
Well sweaty feet, really sweaty feet is the condition called hyperhidrosis which means that the normal ways of keeping control of your sweat don't work and deodorants are a very useful or antiperspirants crucially, because the deodorant just covers up the smell, and antiperspirant stops the perspiration, so there's a difference between the two products, they can be very useful. And the foot has a lot of sweat glands and there is a lot of sweat coming out. So if it's really bad then we need to have a look and see what's going on but what you're describing Richard is a condition that sounds like pitted keratolysis, which is a bacterial infection and the skin becomes wet and lacerated, the bacteria sits on the skin and creates these little craters that is often mistaken as a fungal infection and actually needs bacterial treatment. Often simply using the antibacterial soap, use that on it, and sometimes a topical antibacteria cream will solve the problem and then you get the sweaty feet addressed and even we're using botox now which can be a very useful way to get rid of very sweaty feet.
MYERS
Well you mentioned pits, so maybe that's exactly the right diagnosis in that case Richard, not a phrase that's been used to you in the past - pitted keratolysis.
RICHARD
No that's a new one.
MYERS
Well it might be - it might be the answer. So what are we saying to Richard - to the GP with that as a possibility, to look into whether it might be this pitted keratolysis?
SUPPLE
Definitely and start using antibacterial on it, if you use it for a week and it hasn't improved then see a dermatologist but I - from listening to it, it sounds like that.
MYERS
Hope that helps. I mean this business of whether things are fungal, whether they're bacterial, whether they're viral - is there sometimes confusion, do you see people being given the wrong treatments for their foot condition when it comes to the skin condition?
SUPPLE
Well they're all very common, a bacterial condition is the least common, viruses are obviously hugely universal. But there can be a bacterial infection infecting a fungal infection and a corn or callus can be invaded by a verruca. So it's always important to get a professional opinion and I would always say go and see a podiatrist, putting up with foot pain or foot conditions is not normal and needs to be looked at.
MYERS
In fact it's one of the pleasures, I think you were saying earlier, of your work, that you go - you do actually have satisfied customers 9 times out of 10 actually get quite a lot of instant relief for their problems.
SUPPLE
Yes we're very effective at delivering almost instant results which as a profession is really quite unusual I guess, we're used to it.
MYERS
Let's go to June now who's concerned about her big toenail which is growing in on itself - curling around, is the description I've got here. Can you be nice and graphic and tell us what's going on for those who can bear - it's a bit of a squeamish thing for a lot of people I know but what's actually happening June?
JUNE
Well it's only on one toe, the other toe seems to be perfectly normal - the toenail. I should tell you that I've had rheumatoid arthritis for about 50 years because you did mention it at the beginning of the programme, although whether that has any bearing on it I don't know. Yes, going back about 10 years it was fashionable I think to cut V notches in your toenails, so I used to do that in the hope that that would remedy it but it hasn't and it's getting progressively worse. I mean it does literally - it's curling back into the toe but only on the right foot. So what I now do I get pair of clipper and I cut it very, very short and perhaps the squeamish people had better put their hands over their ears, because I cut about three quarters of it and then I catch hold of the piece of toenail and I pull, so that the toenail comes out from the corner and out from the part where it's grown back into itself, I don't know if that's ...
MYERS
I think that's quite enough information, thank you.
JUNE
But it can be very, very painful.
MYERS
Yes of course, absolutely. Let me put you over to Emma and see what advice she's got for you.
SUPPLE
Well it sounds like your toenail's giving you a lot of trouble. Have you ever dropped anything on to it in the past?
JUNE
Well no not that I'm aware of.
SUPPLE
And it's not thicker than it used to be?
JUNE
No but I have just thought of something, you saying that. I was a dancer, I was trained as a dancer and of course it's your right foot that takes all the stress and strain.
SUPPLE
It sounds like you've damaged the growing part of the nail many a year ago and the nail now grows up damaged and you've beautifully described having to manage it. I mean clearly a podiatrist can help you out doing that, if it's getting difficult - thinning down the nail and surgery to stop the problem coming back, either taking away the offending portion of the nail that's digging in or removing the whole nail in its entirety can often be cosmetically acceptable and clinically relevant course of treatment.
JUNE
Would it grow again?
SUPPLE
Not if we didn't want it to.
JUNE
Well if we did want it to, which I would?
SUPPLE
Well the idea of removing it permanently is you'd be left with the indentation where the nail used to be and that actually can be cosmetically really rather good, you can find that it won't dig in and it won't be an area that's giving you problems, especially in the nature of your rheumatoid arthritis it's important to have things that don't take you - later on that give you trouble.
JUNE
I have had a number of operations on my toes but not on the big toe strangely enough, on the other toes. So they haven't - the joints have been removed so there's no pliability. So for that reason and the reason of my bad toe - toenail - over the years I've invested in shoes that have the toes cut out, what we used to call peep toes so that's to prevent the pressure so I can walk in comfort. I get teased quite a lot but people don't understand why I'm really doing it.
MYERS
So I mean I hope that's been a little bit useful to you June, what's been said today and I wonder in general - I mean obviously June's got particular complications with her rheumatoid arthritis and the fact that she's been a dancer and so on and so forth and has had operations. Generally speaking in growing toenails - is there a simple way of either preventing them or looking after them - June did say she cut a V into them and have heard people say that's a way of stopping the pressure of the side of the nail digging into the side of the toe, but is that a good idea do you think?
SUPPLE
We would rather you didn't, a V cut into the centre of the nail is something that, as you say, is an old wives tale and the idea was that as the nail grew the V would fill in and the side of the nail would no longer be pressing against the flesh and irritating and causing in growing toenail. You get an in growing toenail if you do what we used to refer to as bathroom chiropody, so you dig down the side too much, break that all important seal or you get an in growing really through no fault of your own and it's the shape of the nail that you've inherited - so it can be too broad, or it can be too curly - either way there's an irritation of the nail as it rubs against the side of the flesh and that's what causes an in growing toenail. So generally speaking local anaesthetic, remove the portion of the nail, put some phenyl down the side so it doesn't grow back up again, you're left with a nice straight nail and it grows beautifully.
MYERS
So it's a visit to the podiatrist.
SUPPLE
A visit to the podiatrist.
MYERS
Thank you very much. Let's go to Harrow and Hanna. Hanna's waiting to talk to us about corns which I think you've got and have tried to get rid of but without a lot of success. What's happening there Hanna?
HANNA
These are in fact inter digital corns.
MYERS
Between the toes?
HANNA
Between my big toe and the second toe. There's - I've had them for about four years now I suppose, worse on one side than the other and I've been to see a chiropodist on an annual basis but I think I'll have to go more often now. I've tried everything to stop these toes rubbing together because apparently that's what causes the problem, I've tried silicone toe dividers, foam, strips of foam, I wear I think sensible shoes and the situation just seems to be getting worse so that it's painful to walk and I'm a keen walker and I really don't quite know what to do next.
MYERS
Let's see if Emma's got any further suggestions, it does sound as though you've tried a number of obvious things to do, is there anything else that Hanna might be able to have a go at?
SUPPLE
Well inter digital corns are very painful because they literally are often in the cleft of the toes and it's where the toes are pressing on each other and they get quite sweaty down the side there. So they're difficult to remove by a chiropodist/podiatrist and they come back straight away really because the toes don't stop pressing each other. And clearly deeper shoes, any form of spacer will help. But it sounds like you're at the stage where you need to see a podiatric surgeon and have a look and see if the toes can be straightened out or if you've got a little piece of bone deep there that's irritating the corn and is giving you pain at every step and that might just need burring down. It really depends on what you're presenting with but I would certainly get some intervention now because you've tried conservative treatment and surgical might be the most helpful for you now.
HANNA
So that would be a case of referral by the GP would it?
MYERS
Yeah that sounds like the case. Hanna give it a go and thanks for calling us today, I hope that works out for you. Let's take us on into the podiatry - surgical podiatry - which is Emma's specialty anyway, we've got Diane Jones who has bunions and is interested as to whether surgery might be the answer. You've been looking into this I think Diane but are not sure whether it's going to be for you, what are your issues around this?
JONES
Yes that's right. I've got two moderate to severe bunions and I was referred to a surgical podiatrist who suggested scarf osteotomies. And I asked him about patient feedback and he said I haven't had any complaints. I'm a researcher so I know how to access evidence but really all I can find is the clinical views of outcomes, apart from one study by Dawson et al. But I'm interested really in the patient experience of this type of operation and its outcomes, whether people are pleased basically that they had the surgery.
MYERS
And if you - if you get the sort of evidence then perhaps it will help you make the decision is that the point?
JONES
Well absolutely it feels much too risky to undergo the surgery without feeling confident that a majority of people are happy with the outcome. And I know there is anecdotal information that some people aren't but I don't know how typical that is.
MYERS
Well let's see. Emma are your patients happy with the bunionectomies that you do for them, whether it's this scarf osteotomy, I think that's one procedure, I don't know if that's one that you do and whether you recommend it?
SUPPLE
I do recommend it and scarf osteotomy was originally designed by Dr Lowell Weil who I actually worked with in America so I know a lot about the procedure. The great thing that you're looking for is patient satisfaction and actually as podiatric surgeons across the country we've come together in a national audit called PASCOM and part of that is called the PATSAT [phon.], which essentially means that at six months post surgery every patient, regardless of the procedure, is asked what their satisfaction rate is with their surgery and the question that's the most important is would you have the surgery again and I'm very pleased to say we actually have some very robust data to support that and the fact that the scarf osteotomy is mainly the procedure that's used for mild to moderate bunions, not necessary severe bunions, so you'd need to speak that over with your clinician. It's a very well tested tried out procedure with quite a lot of data behind it.
JONES
Is that data now published because I did contact the Society of Chiropodists and Podiatrists and I was told that PASCOM isn't publicly available, I'd be really interested to have a look at it?
SUPPLE
Well certainly if you leave your contact details I can pass you on the relevant information about that.
MYERS
Could I just throw in as a bit of a googly though at the end here an e-mail from Greta who said that she had a bunionectomy at the end of February and her foot is painful and still has some swelling, she's finding it difficult to walk, is this normal, is that what you have to expect if you have this procedure?
SUPPLE
Yes, I mean the - it takes six weeks for bone to heal and the scarf osteotomy has great benefits because it's a stable osteotomy with internal fixations so you can walk on it. But clearly some people do very well in that timescale and other people take longer. Now clearly if that lady's having ongoing problems she needs to speak to her surgeon and use it and get some more advice and find out if there's any particular problem appertaining to her. We expect a normal return to full activity six to three months, some people can take six months if not longer.
MYERS
Okay thank you very much. There we will have to stop. Thanks very much to everyone who has phoned and the many people who have e-mailed with their questions on this very popular topic. Thanks Emma for your answers.
If you missed anything in today's programme you can listen again to the whole programme, you simply go to the 91Èȱ¬ website that's bbc.co.uk, you follow the prompts to Check Up. You can, if you wish, download this programme as a podcast. If you prefer to speak to a real person about further sources of information then you can call this number: 0800 044 044.
And next Thursday please join us for what will be the last Check Up, thank you.
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