Keep the Blood Pumping

Let’s revisit our discussion on dermatitis. So far, the forms of dermatitis that we have discussed had to do with a substance irritating the surface of the skin. But it is important to remember that there are internal factors that can cause dermatitis.

Stasis dermatitis is a form of skin irritation that results from problems with blood flow, especially on the lower leg. Under normal circumstances, blood flows away from the heart in arteries, unloads the oxygen it carries to body organs and tissues, then ending its journey by flowing back to the heart in veins. In order to prevent backflow of blood, veins have valves that make sure to keep blood flowing in the correct direction.

With stasis dermatitis, the valves in veins can malfunction and lose their ability to direct blood flow. Instead of being directed back to the heart, the blood pools and sits in the veins in the foot and lower leg. The veins begin to expand as the volume of blood within them increases. This leads to increased pressure inside the veins, pushing fluid out into the skin, giving the lower leg a swollen appearance. In addition, some of the pooling red blood cells can break down and cause the overlying skin to be discolored. The skin can become itchy, and it may cause people to have night cramping.

Probably the most serious complication of this condition is called a stasis ulcer. Unlike other ulcers, this sore is not due to friction or trauma. It is thought that the overlying skin is starved of adequate oxygen, causing the skin to die and form a very painful ulcer. To make matters worse, the ulcer usually does not heal quickly and can be an entry point for infectious bacteria into the body.

Luckily, podiatrists have become specialists in this arena of medicine. There are many potential treatments available that have shown to be beneficial. We’ll discuss treatment options in our next blog post.

There is a reason why they call it the Achilles

We’ve been talking about skin problems the last couple weeks, and we will return to that subject next week.  But this week something happened that has convinced me to discuss something else.

The Philadelphia Phillies are a baseball team that was expected to reach the World Series this year.  However, they were on the brink of being eliminated from the playoffs by the St. Louis Cardinals this last week.  Ryan Howard, the 1^st baseman for the Phillies was Philadelphia’s last hope.  Unfortunately, he made the last out to end the game.  To make matters worse, as Howard tried to run to first base, he fell to the ground in pain.  Once evaluated, it was apparent that he had ruptured his Achilles tendon.

Achilles tendon ruptures are common and often happen with abrupt pivoting movements or when someone starts exercising after a long period of inactivity.  When it happens, the person describes the event as if they were hit in the back of their heel with a bat and they hear an audible pop.  Incredibly, they will still be able to walk, but with dramatic difficulty.  If you run your finger up the back of the heel, you’ll feel a depression or soft spot instead of the normal tense tendon inserting into the heel.  Some ruptures are partial while others may be complete.  If the rupture is bad enough, the tendon can recoil on itself like a fruit rollup.

If you try to treat a rupture conservatively, the recovery time is longer and the risk for re-rupture is very high.  For that reason, ruptures are most effectively treated with surgical repair.  Although you take on the risks of surgery, surgical repairs allow for better results long term.  You often can resume exercise sooner, the motion in the ankle is better, and overall the patients have fewer complaints.  Your podiatrist is a skilled surgeon that can perform this surgery and help you along your road to recovery.

Psoriasis Made Simple

Another dermatological term loosely thrown around is psoriasis.  Let’s discuss in more detail what this term really means.

The cells in our skin are known as keratinocytes.  These cells evolve from the basement part of our skin, but then proceed to migrate to our outer layers and die.  This process allows for continuous renewal of our skin.  Once a cell is “born,” it takes about 28 days or 4 weeks for it reach our skin’s surface and fall off.

Now, imagine instead of a month, this process took place in just 24 hours.  Such is the case with psoriasis.  Too many keratinocytes are produced in a very short amount of time.  The outer cells are pushed out faster than they can fall off.  This causes the skin to become very thick and elevated, especially on the elbows, knees, top of the feet, back, and scalp.  The elevated plaques are salmon colored and become shiny, like the skin of a fish.    Depending on circumstances, these plaques will go into remission but reoccur many times through a person’s life.

What causes psoriasis you ask? Psoriasis is usually something that runs in the family, and the first outbreak may be preceded by strep throat or a viral infection, or some other stressful event.  However, the exact causes are until unclear.  In more severe cases, psoriasis can spread into the joints and cause psoriatic arthritis.
How can you know if you have psoriasis?  If you’ve ever cut yourself where the skin was previously normal, but afterward had an elevated plaque show up on that spot similar to the plaques you have on your elbows and tops of your feet, check with your doctor to rule out this condition.

Fortunately, psoriasis does not shorten a person’s lifespan or lead to skin cancer.  Nonetheless, it can become a cosmetic nuisance depending on its location.  Thankfully, there are many treatments available including UV light, topical corticosteroids, and special wound dressings that can keep outbreaks in check.  More aggressive treatments are available if necessary.  Your podiatrist can help manage psoriasis that presents on the feet and toes.

Eczema Revealed!

Eczema… It’s a word we have all heard before, and a word we’ve probably used when describing someone’s skin. But what does it really mean?

Eczema is an “umbrella” term or “catch-all” phrase. It encompasses a wide variety of skin conditions that really have little or no relation to each other. In truth, eczema is a non-specific word whose definition is not clearly defined. Even among medical professionals, there is confusion on the true definition of the word.
For that reason, instead of eczema, we will use the word dermatitis, meaning inflamed skin. There are many causes of dermatitis, and we will discuss a couple here.

Contact Dermatitis is a skin reaction to something that comes into contact with our skin. This category can be further broken down into two categories: Irritation Contact Dermatitis, and Allergic Contact Dermatitis.
Irritation Contact Dermatitis is a skin reaction to a substance that most everyone would react to if they were exposed. Examples include exposure to harmful chemicals, harsh cleaning products, highly concentrated detergents, and strong solvents. This also includes diaper rash in babies when their skin is exposed to urine or stool for a prolonged period. Non-prescription lotions and creams may help to decrease itchiness and soothe the rash. On the foot, this condition may present after buying new shoes which use cement or other manufacturing agent that irritates your skin.

Allergic Contact Dermatitis is a skin reaction that only occurs if you are particularly sensitive to a specific substance. This is the proverbial “allergic reaction” people can have to different plants, fragrances, nickel or other metals, latex, or medications. Even if you aren’t originally allergic to one of these agents, with repeated exposure, you can develop them.

How can you tell if it’s allergic or irritation dermatitis? If it is irritation, the rash shows up the first time you are exposed to the agent, and the rash comes immediately after exposure. If it is an allergy, you will not develop a rash the first or even second time you are exposed. It is only after you have been exposed a couple of times that you develop a rash, and after exposure, the rash does not show up for a day or two. Your podiatrist can help recognize these types of reactions on the feet and give appropriate treatment.

Your Epidermis is showing!

We probably all fell for that joke as kids, but all joking aside, some of the terms used in medicine can be tricky to understand. Medicine is a foreign language that must be learned as if you were learning Spanish or French. Dermatology seems to be a branch of medicine that has unfamiliar or confusing terminology. I would like to address different skin conditions that can manifest in the feet and how they vary. But before we discuss them, I think it would be beneficial to review the components of skin.

The outermost layer of the skin is called the epidermis (0.04 mm thick). There is no blood supply to it and there are no nerves within it. This layer protects your muscles and internal organs from the external environment, and can be considered part of the immune system. The epidermis can be broken down into 5 different layers. One of these layers is responsible for cell division, which replaces the dead skin that falls off.

A different layer contains melanocytes which are responsible for skin color. Another layer contains cells that are “sown” tightly together to prevent passage of foreign elements. Yet another layer secretes a fatty substance that acts a barrier to water and other harmful substances. This is a very robust barrier that is tough to cross, which is why you don’t do not swell up with water when you go swimming!

Maybe you have heard that anything you put on your skin (lotions, make-up, etc.) gets into your blood. But when we remember that there are no arteries in the epidermis, that a layer of cells are tightly packed together, and that a substance must pass the fatty barrier to reach our blood, you can be assured that almost nothing gets across. Only harsh chemicals in highly concentrated amounts should cause you to worry.

The middle layer of the skin is called the dermis (0.5 mm thick). This layer contains blood vessels, nerves, glands, and hair follicles. Collagen and elastin give structural strength to the dermis. Depending on the area of the body, the skin will have different glands that secrete either a smelly substance (armpits, groin), a watery substance (palms of hands, soles of feet), or an oily substance (causes acne).

The last layer of the skin is called the hypodermis or subcutaneous tissue. This layer is made up of fat cells and allows the skin to slide without friction over the underlying muscle and bone.
Each of these layers (or structures within a layer) can be struck with disease. We will discuss common foot dermatologic conditions in our next series of posts.

Give Me the Antibiotics and No One Gets Hurt

Historically, the first antibiotic discovered was penicillin. Although it was discovered several years before World War II, it was not widely manufactured and distributed until the war. This antibiotic has advanced into an entire family of antibiotic drugs to treat different types of bacteria. Previously untreatable staph and strep bacterial infections have become manageable conditions. The discovery and use of antibiotics has without a doubt saved millions of lives. Amoxicillin and Erythromycin are examples of antibiotics currently in use.

So, if antibiotics are so great, why is it that doctors often send people away without them? What purpose would it serve to keep them from their patients?

Just as the name infers, antibiotics are anti-bacterial. However, a sore throat or stomach sickness is often caused by a virus. A runny nose or sinus congestion can be caused by an allergic reaction. Foot infections are commonly caused by fungus. In these situations, what purpose would it serve to give an antibiotic? I hope it is clear that giving an antibiotic to kill a virus, fungus, or solve allergies is similar to using weed killer to kill cockroaches.

To make matters worse, misusing antibiotics can actually cause them to lose effectiveness when they are really needed. Bacteria are very smart little organisms. They are constantly changing so that they can better survive. We all have “normal flora,” otherwise known as bacteria that live in our intestines, on our skin, and in our mouth. However, these bacteria are kept in check by our immune system and by our protective layers of mucous and skin. By taking antibiotics when not indicated, we expose these bacteria to antibiotics. Instead of fighting the source of infection, some bacteria die but others are allowed the opportunity to develop protection against the antibiotics. So when you get a deep cut on your foot and those same bacteria are allowed to penetrate your body, the antibiotics may not be effective. For this reason, it is important to save the antibiotics we currently have for when they are truly needed. Your doctor is your best resource for knowing when they are to be used.

Nerves do pain, and more…

Ok, I know I said last week that we’re going to talk about a devastating foot condition caused by peripheral neuropathy this week, but I wanted to touch on another aspect of nerve dysfunction before we delve into it. So stay tuned….

We talked last week about high blood sugar in association with diabetes and how it damages the function of nerves. Specifically, we focused on how nerves lose the ability to sense pain. But nerves do a lot more than just sense pain.

Nerves are so smart that many of them function without us even knowing. Do you have to remember to keep your heart beating, or to keep your lungs breathing when you are asleep? Of course not! That is because nerves have an “autonomic” function (think of it as a nerve working automatically, without you needing to tell it to work). That is why you do not need to think about your heart beating or your lungs inflating. For this same reason, we do not have to think about digesting the food we eat, or moving the food through our digestive tract. It just happens.
Another important autonomic function of a nerve is its ability to control where the majority of our blood flows. During a marathon, blood is most needed in the muscles, heart and lungs. After a meal, blood is needed in the digestive tract to absorb essential nutrients. During an academic exam, the brain needs blood more than anywhere else. When you’re about to have sex… well… you get the picture. Depending on current needs, our body can shift blood flow so that it is used more efficiently. Just like losing pain sensation, high blood sugar can damage nerves so that they can’t perform their “autonomic” tasks.

Instead of food slowly but surely travelling through the intestines, it sits motionless in the stomach. Instead of bones getting the correct amount of blood flow, they are flooded with blood, making them soft and unable to handle the normal stresses of our weight. As nerve function continues to decrease, symptoms become worse and worse.
With that introduction, next week’s blog will focus on Charcot foot, a condition being seen more and more as diabetes spreads.