Ulcerations are a result of a break down of the skin. Ulcerations are classified based upon their depth and their cause. Common ulcerations are due to diabetes, ischemia (poor circulation), and venous stasis (varicose veins).

Diabetic ulcerations are by far the most common form of ulceration of the feet. These ulcerations occur in areas of the foot that are exposed to excessive pressure or irritation from the rubbing of the shoes on the skin. corns and calluses develop as a result of excessive pressure over bony areas of the foot. Over time the thickened callus that forms can act as an irritant that breaks down the skin under the callus, forming an ulceration. This is more likely to occur if the person with diabetes also suffers from diabetic neuropathy. Diabetic neuropathy is a condition that most commonly affects the nerves of the hands and feet. Diabetic neuropathy causes a loss or alteration in the ability to perceive pain associated with excessive pressure, heat or cold, sharp and dull, vibration and position sense. As a consequence, corns and calluses which would normally be painful do not cause pain and over time, breaks down the skin causing ulceration. Quite often, an infection will also occur which can result in bone infection (osteomyelitis) or deep tissue infection. If the person also has poor circulation, gangrene can develop.

Treatment is geared toward prevention. People with diabetes must learn to inspect their feet daily and obtain medical attention as soon as they notice anything suspicious or an ulceration forming. Calluses which have a black or blue appearance are in the early stages of ulceration. Corns and calluses should be treated regularly by a podiatrist. These areas should be protected from pressure by using pads and/or cushions. Over-the-counter corns removers must be avoided. These home treatments have acid in them, which can burn the skin and cause infection. Once an ulceration has started, every effort must be made to reduce the pressure to the area or it will not heal. Special shoe inserts, called orthotics, are useful in reducing abnormal pressure on the bottom of the foot in areas of calluses or ulcerations. There are also several different topical medications that are used for the treatment of ulcerations. Treatment should be guided and supervised by a physician.

Ischemic ulcerations occur in areas of poor circulation. Commonly they form on the feet, ankles and lower legs. As the circulation gets worse, the skin begins to thin and is less resistant to pressure and friction forces. Spontaneous break down of the skin can occur. These ulcerations tend to be painful, with a whitish or light-pinkish base. Treatment is focused on keeping the ulceration clean and free from infection. By-pass surgery may be indicated to improve the circulation to the area. Hyperbaric oxygen treatments may also be useful. It is important not to use bandages that can cut off the circulation, or adhesive tape, which can tear the skin when removed.

Venous stasis ulcerations occur in areas where the venous circulation is poor. Venous circulation is the blood flow that returns to the heart in the veins. Varicose veins are abnormal veins that do not allow normal blood flow back to the heart. As the veins become more and more damaged, there is a pooling of fluid that accumulates in the feet and ankle. This swelling of the tissue, over time will cause damage to the skin, and can result in open sores or ulceration. These ulcerations tend to weep a clear fluid, have a reddish base and become infected easily.

Treatment is geared toward prevention by reducing the swelling in the legs with the use of support stockings, medications to reduce the swelling, and elevation of the legs. Once ulcerations have developed, treatment consists of keeping the ulcerations clean and free from infection. This often requires the long-term use of oral antibiotics. A common form of treatment consists of wrapping the legs with a dressing called an unna boot. This dressing is a gauze wrap which has xinc oxide impregnated in it. This dressing helps to keep the bacteria that is in the ulceration from growing and also adds compression to help reduce swelling.

Hyperhidrosis, or excessive sweating, can be localized to one area or it may be generalized. In the localized type, the most common sites are the palms and soles of the feet. The cause of the excessive sweating is not well understood. There is an emotional component to it in some but not all cases. The excessive moisture contributes to athlete's foot and plantar wart infections. There are no good oral medications for the control of hyperhidrosis. Topical anti-persperants are of little value. A prescription topical medication called "Dry sol" is of some value. This medication works best if applied to the feet before going bed, then wrapping the feet in plastic wrap and wearing socks. This should be done three to four nights in a row. Although this is not a cure for the problem, it does provide temporary relief and is useful as part of the treatment plan for athlete's foot and plantar warts in patients who suffer from hyperhidrosis.

Psoriasis is a common, chronic, and recurrent inflammatory disease of the skin. It is characterized by round, reddish, dry scaling patches covered by grayish white or silvery white scales. The lesions have a predilection for the nails, scalp, elbows, shins and feet. On the feet, it can be difficult to distinguish it from athlete's foot, and the nail appearance may be confused with fungal infections of the toenails. The nail appearance does have a unique characteristic; it may have a pitting appearance. A characteristic feature of the condition is pinpoint bleeding when the scaled areas are brushed off. A variant of psoriasis is called pustular psoriasis. This form of the disease is characterized by small pustules or blisters filled with clear or cloudy fluid. This can mimic acute athlete's foot. It characteristically does not itch or burn. It is distinguished from athlete's foot by negative fungal cultures. The picture can become confusing because a secondary fungal infection is possible. In this instance both conditions are present at the same time.

Psoriasis can also affect the joints of the feet and lower extremities causing a painful arthritis. X-rays will show characteristic erosions of the bones in the toes. Treatment consists of anti-inflammatory medications, steroids, and other medications specific for the treatment of psoriasis.

Pigmented lesions should always be inspected and observed. Most pigmented areas are nothing but freckles and moles. However a potentially deadly pigmented lesion that can occur on the foot and lower extremity is Malignant Melanoma. A physician should evaluate any pigmented lesion that suddenly occurs or a pigmented lesion that starts to change its appearance. These changes are usually subtle and may consist of increased size and depth of color, onset of bleeding, seepage of clear fluid, tumor formation, ulceration and formation of satellite pigmented lesions. The color is usually not uniform but is likely to be scattered irregularity, being brown, bluish black or black. An increase in pigmentation may precede enlargement of the lesion by several months. Although any part of the body may be affected, the most frequent site is the foot, then in order of frequency, the remainder of the lower extremity, head and neck, abdomen, arms and back. Malignant melanoma may also form under the nails of the feet and hands. The thumb and big toe are more commonly affected than the other nails. Quite often the adjacent skin to the nail is ulcerated. Usually a fungal infection is suspected and antifungal treatment may be administered for months before the true nature of the lesion is discovered. A black malignant melanoma of the toe can also be mistaken for gangrene. Overall, the incidence of malignant melanoma is quite low.

Actinic Keratosis

Another cancer causing lesion that can occur on the feet are called Actinic Keratosis. Although most commonly found in sun-exposed areas of the body such as the face, ears, and back of the hands, these lesion can also occur on the foot. They are characterized as either flat or elevated with a scaly surface. They can either be reddish or skin colored. On the foot they are frequently mistaken for plantars warts. These lesions are the precursor of epidermoid carcinoma. Treatment for these lesions should be through as they are definitely precancerious. Treatment consists of freezing the lesions with liquid nitrogen or sharp excision.

Kaposi's Sarcoma

Yet another cancerous lesion that can occur on the foot is called Kaposi's Sarcoma. These lesions occur most commonly on the soles of the feet They are irregular in shape and have a purplish, reddish or bluish black appearance. They tend to spread and form large plaques or become nodular. The nodular lesions have a firm rubbery appearance. The appearance of these lesions is an ominous sign. In the late 1970's and early 1980's an outbreak of Kaposi's sarcoma occurred in San Francisco, California. It was later learned that the disease was associated with AIDS infection. It can occur without the concurrent AIDS infection but this is very rare.

Chronic athlete's foot can cause an increased pigmentation to the bottom of the foot. It is associated with dry scaling skin and may have a reddish appearance.

Venous Stasis

Generalized increased pigmentation occurs for a variety of other reasons. Dark patches of skin occur about the ankles and lower legs in persons who suffer from Venous Stasis. Venous stasis is caused by an accumulation of fluid in the lower extremities. This is due to poor venous return of blood to the heart. Venous blood flow back to the heart occurs by way of the veins in the feet and legs. Venous stasis is associated with varicose veins that do a poor job of returning blood to the heart. As a result the blood flow is slowed, becomes stagnant, and fluid accumulates in the ankles and lower legs. As the fluid accumulates in the lower legs, the small and medium-sized veins break or leak fluid into the tissues. As blood cells break up in the tissue, they deposit the iron that is part of hemoglobin in the blood cell. The iron stains the skin causing a light to dark brownish appearance. With time, the skin and subcutaneous fat becomes thinned and will break down creating weeping venous stasis ulcerations. At times, blistering will form with a clear, watery fluid weeping from the skin. This condition requires professional attention by a physician.

Diabetic Dermopathy

Another cause of generalized increased pigmentation is diabetes. The condition termedDiabetic Dermopathy occurs most frequently on the shins and lower legs. They may have the appearance of small scars. Their appearance may precede the diagnosis of diabetes by several years. The actual cause of diabetic dermopathy is not well understood, but it does not cause any particular problem or pose any particular health threat.

Small, spider-like areas of increased pigmentation on the ankles are caused by the break down of small veins in the area and are called Spider Veins; they also pose no health risks.

Infection can be caused by a number of different agents. Athlete's foot is an infection of the skin caused by a fungus. Warts are caused by a viral infection of the skin. When most people think about infections they are thinking about infection caused by bacteria. There are numerous types of bacterial infection. Infection generally requires a break in the skin from a cut, abrasion, puncture wound or ulceration. The most common infection is caused two bacteria, Staphylococcus and Streptococcus. Both of these infections cause progressive tissue damage of varying degrees. People with diabetes can develop infections by several bacteria at the same time.

Infection that occurs in the skin is called cellulitis. Deep infections that develop puss pockets are called abscesses. The most common bacterium that causes cellulitis is Streptococcus. These infections can become very serious and even life threatening. Cellulitis is characterized by spreading redness in the area with an increase in the temperature of the skin, often accompanied by fever and chills. People who suffer from venous stasis, chronic swelling in the legs, are prone to these infections. Cellulitis is also commonly seen in associated with athlete foot conditions. The athlete's foot causes small breaks in the skin, which can become infected, by the Streptococcus bacteria. Soft corns, particularly between the fourth and fifth toes can also become infected and cause cellulitis and or an abscess. Puncture wounds are very likely to become infected. This can result in a very dangerous deep abscess that can also infect the bone. A doctor should evaluate all deep puncture wounds as soon as possible. Simply cleaning the outside of the puncture wound is not enough to prevent infection. Oral antibiotics should be prescribed and the wound watched carefully. If there is any sign of infection, surgical cleaning of the wound should be preformed.

People with diabetes are at particular risk of infection. In fact, people with diabetes spend more time in the hospital for foot infections than for any other reason. Corns and calluses on the feet of people with diabetes can break down and allow bacterial invasion of the tissue. In people with long standing open ulceration the underlying bone can become infected. Bone infections, called osteomyelitis, generally require surgery to remove the infected bone. These infections are very difficult to cure with oral or intra-venous antibiotics without also removing the infected bone. The presence of bone infection can be diagnosed with special tests such as bone scans and MRI. These test are not 100% accurate however and the experience of the treating doctor becomes very important in making the correct determination as to the presence of bone infection.

Gout, which is caused by an elevated blood uric acid level, can be confused with infection. This condition can cause sudden onset of pain, redness, and swelling of a joint or in the soft tissues. It is important to rule out an infection, particularly if it is in a joint. Rare instances of infection can occur without evidence of a break in the skin. The infection is carried to the site by the blood stream. Close examination of the patient may reveal an abscessed tooth that likely is the source of the infection. In other instances no source of the infection can be found.

People who have joint replacements, heart valve replacements or who have a pacemaker must be very cautious regarding infections. They are at risk of an infection spreading from another site to the area of their joint replacement, heart valve replacement or pacemaker. Also, people who have mitral valve prolapsed must be cautious if they have infections because the infection can spread to the heart.

Pigmented lesions should always be inspected and observed. Most pigmented areas are nothing but freckles and moles. However a potentially deadly pigmented lesion that can occur on the foot and lower extremity is Malignant Melanoma. A physician should evaluate any pigmented lesion that suddenly occurs or a pigmented lesion that starts to change its appearance. These changes are usually subtle and may consist of increased size and depth of color, onset of bleeding, seepage of clear fluid, tumor formation, ulceration and formation of satellite pigmented lesions. The color is usually not uniform but is likely to be scattered irregularity, being brown, bluish black or black. An increase in pigmentation may precede enlargement of the lesion by several months. Although any part of the body may be affected, the most frequent site is the foot, then in order of frequency, the remainder of the lower extremity, head and neck, abdomen, arms and back. Malignant melanoma may also form under the nails of the feet and hands. The thumb and big toe are more commonly affected than the other nails. Quite often the adjacent skin to the nail is ulcerated. Usually a fungal infection is suspected and antifungal treatment may be administered for months before the true nature of the lesion is discovered. A black malignant melanoma of the toe can also be mistaken for gangrene. Overall, the incidence of malignant melanoma is quite low.

Kaposi's Sarcoma lesions occur most commonly on the soles of the feet They are irregular in shape and have a purplish, reddish or bluish black appearance. They tend to spread and form large plaques or become nodular. The nodular lesions have a firm rubbery appearance. The appearance of these lesions is an ominous sign. In the late 1970's and early 1980's an outbreak of Kaposi's sarcoma occurred in San Francisco, California. It was later learned that the disease was associated with AIDS infection. It can occur without the concurrent AIDS infection but this is very rare.

Chronic athlete's foot can cause an increased pigmentation to the bottom of the foot. It is associated with dry scaling skin and may have a reddish appearance.

Fissuring or cracking of the skin of the heels can be a painful and annoying condition. The fissures can become deep enough to cause bleeding. Thick callusing and fissuring of the skin is a result of excessive and abnormal friction on the heel while walking. Frequently this occurs in people who wear open-backed sandals or shoes, as these shoes allow more slippage around the heel while walking. The skin thickens as a result of the friction. Skin lotions can help with reducing the dryness associated with the condition. Avoiding open-backed shoes is also helpful. There is a very good prescription medication for reducing the callused area called Whitfields Ointment. This is an old time remedy that many pharmacies no longer carry. With a prescription, some pharmacists will make up the medication for you. The medication contains mild acid compounds that reduce the thick callus. Care should be used with this medication and it should only be used under the supervision of a doctor.

Gangrene of the skin is associated with the loss of blood supply of a particular area. In some instances, it is caused by bacterial infection of an open sore or ulceration. The most common form of gangrene develops in the feet of people with diabetes who also have associated loss of circulation in the feet and toes. Any person with poor circulation can develop gangrene. A sudden onset of pain in the feet or legs associated with a decrease in skin temperature, and color changes to the skin of the feet is a strong indication that there has been a sudden blockage of blood flow to the legs. This condition needs immediate medical attention. People who have diabetes may not experience pain associated with such an event because of a condition called diabetic neuropathy. Diabetic neuropathy affects the nerves of the feet and legs causing a diminished ability to perceive pain, excessive heat, cold, vibration, or excessive pressure. This condition places people who have diabetes at greater risk of injury from any source without their being aware of it. For instance, a patient with diabetes can develop an ingrown toenail, and if they also have diabetic neuropathy, they may not experience the same level of pain as someone without the neuropathy. As a consequence the ingrown toenail can worsen, and become infected without providing the warning signs of pain. If the person with diabetes also has poor circulation, the infection can lead to gangrene of the toe. This situation can ultimately lead to the amputation of the toe, foot, or leg, depending upon how bad the circulation is in the leg.

Treatment

Treatment consists of surgical removal of the gangrene, surgery to improve the circulation (by-pass surgery), hyperbaric oxygen treatment and IV antibiotics.

Severe infections can also cause gangrene. The flesh-eating bacterium called Hemolytic Streptococcus is a rapidly spreading infection. Intense local heat, redness, swelling, fever, and weakness characterize this rapidly developing infection. The infection can start with a small abrasion or injury. This condition requires immediate medical treatment. It can result in amputation and/or death. Treatment consists of surgical removal of the infected tissue and IV antibiotics and supportive care as needed for any failing body functions.

Dry scaling skin on the feet is most commonly due to chronic athlete's foot. This is caused by a fungal infection of the skin and is often associated with a fungal infection of the toenails. Frequently, the skin has a dull, reddish appearance and is an "moccasin" like distribution on the bottom of the foot.

Psoriasis also causes dry scaling of the skin. It presents itself as small, white flaky patches. When these scales are scrapped off it will cause pinpoint bleeding. Psoriasis can also present as pustules or small blisters.

Neurodermatitis often presents itself as a solitary patch of dry, scaling skin that itches constantly. Commonly, it occurs on the ankle. Its cause is unknown. Treatment consists of using topical steroid compounds. Injecting the area with a cortisone compound will also often cure the condition. Allergic dermatitis and contact dermatitis also cause skin rashes but tend to be more acute.