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SEPTEMBER 1, 2001 / VOLUME 64, NUMBER 5 www.a a fp .o r g /a fp AMERICAN FAMILY PHYSICIAN 791

office-based or prescription treatm ents, but

others have yet to be p roven b eneficial. This

article reviews the efficacy of several widely

available over-the-counter foot remedies for

minor foot problems. Foot care for patients

with severe orthopedic or systemic disease,

including the care of the diabetic or vascularly

comprom ised foot, is beyond th e scope of this

article.

Properly Fitted Shoes

Ill-fitting shoes can cont ribute to abn orm alfoot m echanics and areas of excessive pres-

sure. When a patient presents with foot pain,

bun ions, corns or plantar warts, the physician

should instruct them in how to choose prop-

erly fitting shoes. (Althou gh papillomavirus is

the etiologic factor in p lantar warts, they tend

to occur in areas where the foot is subjected to

excess pressure.) An imp ortan t com pon ent in

the treatment of foot problems is finding

properly-fitting shoes, because they con-

tribute to symptom relief and help prevent

recurrences. Table 1 lists instructions for

proper shoe fitting.

Antifungal Agents

Tinea pedis, generally known as athletes

foot, is a fungal infection of the skin of the

foot. Heat and damp ness are predisposing fac-

tors. Diffuse involvement of the entire sole of

the foot an d dorsal surfaces of the foot is called

moccasin-type tinea pedis and often requires

Minor but troubling foot

problems are common

complaints in primary

care.In one series,1 71 per-

cent of elderly patients

reported foot problems that impaired their

function, and 39 percent had consulted their

physician about t he problems. A variety of

products are available over-the-counter for

the treatment of common foot problems,such

as athletes foot, onychom ycosis, foot pain,

corns, warts and bunions. Several of theseproducts are cost-effective alternatives to

Several effective and inexpensive over-the-counter treatments are available for minor

but t roubling foo t problems. In m ost cases, one w eek of therapy w ith topical

terbinaf ine is effective for interdigital tinea pedis. Treatm ent of plant ar w arts w ith

17 p ercent salicylic acid w ith lactic acid in a collodion b ase is as effective a s cryoth er-

apy, but trea tme nt m ust be sustained for several mo nths. Toe sleeves and toe spacers

can relieve p ain from hard o r soft corns. M etata rsal pads can relieve the pressure asso-

ciated w ith plantar k eratoses. Heel cups often can relieve pain caused by a ge-related

thinning of th e heel fa t pad . Plantar fa sciitis is a comm on cause of a nterom edial heel

pain caused by repetitive strain on the plantar fascia. Although the mainstay of ther-

apy is stretching exercises, ready-made arch supports and insoles can be helpful

adjuncts. (Am Fam Physician 2001;64:791-6,803-4.)

Over-the-Counter Foot RemediesJOAN M. BEDINGHAUS, M.D., and MARK W. NIEDFELDT, M.D.

Medical College of Wisconsin, Milwaukee, Wisconsin

O A pa t ien t in fo rma- t ion handou t on remed ies fo r commo nfoo t p rob lems, wr i t t en by the authors of th isart icle, is providedon page 803 .

PRACTICAL THERAPEUTICS

M embers of var ious

fam ily pract ice depar t -

m ents develop ar t ic les

for Practical Therapeu-

t ics. This art icle is one

in a series coordinated

by the Department o f

Family and Community

M ed icine at the M ed-

ical Col lege of W iscon-

sin, M i lwaukee. Guest

editors of the series are

L inda N. M eurer, M .D. ,

M .P.H., and Doug lasBow er, M.D.

TABLE 1

Guidelines for Proper Shoe Fit

Proper ly f i t ted shoes do not need to be broken in, bu t ins tead should be

comfor tab le to w ear righ t ou t o f the box .

Shoes should b e f i t ted on b oth f eet dur ing w eight bear ing, preferably at the

end of the day when the feet are most swol len.

A l low a space of one-half inch betw een the end of the shoe and the longest

toe. In athlet ic shoes, allow up t o on e inch.

Check the width. Adequate room should be al lowed across the bal l of thefoo t . The f i rst m etatarsoph alangeal jo int should b e in the w idest par t of

the shoe.

The heel should fit snugly.

The fit over the instep should be checked. A shoe that laces allows for

adjustmen t o f t his area.

Orthot ics and inserts wi l l change the f i t o f shoes. A pat ient w ho p lans to u se

an or thot ic shou ld f i t the shoes w hi le wear ing the or th ot ic .


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systemic antifungal therap y (Table 22-11) .How-

ever, interdigital tinea pedis, which presents as

cracking and maceration in the interdigital

spaces, respon ds well to topical antifungal

agents (Table 22-11) .

Five an tifungal an tibiotics are wid ely avail-

able in cream form without a prescription:clotrim azole (Lotrimin), miconazole (Mon i-

stat-Derm), terbinafine (Lamisil AT), tolnaf-

tate (Tinactin) and undecylenic acid (Dese-

nex). Results of controlled studies2,3,12,13 have

demonstrated that all of these agents have

high rates of mycologic cure and symptom

relief. All are used on ce or twice daily for fou r

weeks, except terb inafine which is effective

with one week of therapy in 88 to 97 percent

of cases.

Althou gh a 30-g tube of terbinafine cream

costs considerably mo re than any of the other

agents m entioned, a single tube is sufficient

for the recommended treatment duration.

The other agents mention ed often requ ire the

use of mu ltiple tubes, resulting in higher over-

all cost. Topical terbin afine is a logical first-

line choice for the treatment of tinea pedis.

Althou gh n o d irect com parative stud ies have

been performed, terbinafine has a similar

mycologic cure rate to prescription-only topi-cal butenafine 1 p ercent cream (Mentax).

Foot hygiene is an important part of the

treatment of tinea pedis.All studies show cure

rates of 30 to 40 percent in patients using a

placebo, which is m ost likely caused by

hygiene measures (study protocols usually

include twice-daily washing and dr ying of the

feet) and the mild antifungal activity in the

cream vehicle used for the placebo.

The an tifun gals tolnaftate and miconazole

are also marketed in spray form for the pre-

vention of athletes foot. In a 12-week study14

in a prison popu lation, 88 percent of the sub-jects tr eated with tolnaftate spr ay proph ylaxis

were free of tinea pedis compared with 69 per-

cent of subjects treated with un medicated talc

and 50 percent of un treated contro l subjects.

In a primar y care population, there is no evi-

dence that daily prophylaxis with antifungals

is cost-effective compared with treating tinea

pedis as it occurs.

Tea tree oil (an essential oil derived from

the Australian M elaleu ca altern ifolia ) is also

marketed for the treatment of athletes foot.

Results of a study15 found that tea tree oil was

comparable with tolnaftate in reducing thesymp toms of tinea pedis, but no m ore effec-

tive than placebo at achieving mycologic

cure.

Several over-the-counter topical products

are marketed for the treatment of onychomy-

cosis. However, we were un able to find any

stud ies concern ing the effectiveness of topical

agents for th is purpo se.

792 AMERICAN FAMILY PHYSICIAN www.a a fp .o r g /a fp VOLUME 64, NUMBER 5 / SEPTEMBER 1, 2001

Top ical terbin afine is a logical first-line cho ice for t he t reat-

m ent of t inea pedis.

TABLE 2

Remedies for Common Foot Problems

Pro b lem Rem edy

Interdigi tal t inea pedis Topical terbinaf ine (Lamis il AT, $16 for a 30-g tub e)2, 3

M o c c asin ti n ea p ed i s Sy st e m ic a n t if u n g a l t h e ra p y

Simple p lan tar war ts 17 percent sa l icyl ic ac id in f lex ib le co l lod ion (Duof i lm ,C o m p o u n d W ,4, 5 Wart-Off , $9 to $3 0 per oz) daily

fo r six to 1 2 w eeks. Relieve excess pressure w ith

proper shoe f i t and pads, i f indicated.

M osaic plantar w ar ts4 Difficult to cure. Salicylic acid paint is as effective as

other t reatment s.

Co rns Pro p erly f it t in g sh o es

Paring and curettage by physician or podiatr ist

Cushions, toe sleeves ($3 to $5)

Lambs w ool padd ing ($5 per 3/8 oz)

Heel p ain Heel cu p s6 ($3 to $10 per pair )

Plan tar f asciit is St ret ch in g exercises7- 9

Closed-cell foam shoe insert 10 ,11 with arch suppor t

is of ten helpful ($8 to $20 per pair ).

In format ion f rom references 2 through 11.


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W art Treatments

Several bran ds of 17 percent salicylic acid

combined with lactic acid in a base of flexible

collodion are available (e.g., Duofilm, Com -

pound W, Wart-Off) for the treatment of

warts (Table 22-11) . Results of one study4

showed no significant difference in cure rate

of hand warts between the 17 percent salicy-

late paint and cryotherapy with liquid nitro-

gen alone or combined. In the treatment of

simple plantar war ts, 17 percent salicylic acid

paint cured 84 percent of patients in a referralpopulation 4 and 76 percent of patients in a

small primary care case series.5 Patients

should be informed that daily application of

acid paint is required for two to three mon ths

for com plete eradication of warts.

Mosaic plantar warts are clusters of small

plantar warts that are resistant to treatment.

Salicylic acid paint has a similar cure rate for

mo saic plantar warts (45 percent), compared

with more expensive treatments such as

10 percent glutaraldehyde, 40 percent benzal-

konium chloride dibromide and 5 percent flu-

orouracil (Table 22-11) .4 No stud ies were foundthat directly compared acid paint with

cryotherapy in the treatment of mosaic plan-

tar war ts. Salicylic acid is also available in a

40 percent plaster for the treatment of plantar

warts (Sal-Acid, Mediplast), but we were

unable to locate any studies concerning the

efficacy of this form of treatment.

Corn Plasters, Corn Cushions

and M etat arsal Pads

A corn is a hyperkeratotic nodule that is

caused by excessive pressure on the foot . Soft

corns are keratin nodules between the toes

(most often the fourth and fifth toes) that

have become macerated by perspiration and

are extremely tender. Soft corns can be diffi-

cult to distinguish from interdigital tinea

pedis. When hyperkeratotic nodules occur on

the sole of the foot, they are called plantar ker-

atoses or clavi (Figure 1). Corns frequently are

tender and h ave a clear, hard keratin center

when shaved. These features help differentiate

corns from warts, which are not very tender

and bleed from multiple capillary loops when

shaved.

Treatment of corns involves the removal of

excess keratin and the relief of pressure. A

physician or podiatrist may remove hardcorn s by paring with a sterile blade, followed

by curettage of the keratin core (Table 22-11) .

Corn plasters are felt pads that contain 40

percent salicylic acid. Altho ugh salicylate is

keratolytic and may be an effective treatment

for corns, no studies of the effectiveness of

plasters for the treatm ent of corns are avail-

able for review.

Foot Problems


Treatm ent of w arts wit h 17 p ercent salicylate solut ion is as

effective as cryotherapy w ith l iquid n itrogen.

FIGURE 1. The area over the third metatarsalhead (indicated by t he examiners thumb) is acommon site for plantar keratoses. A greasepencil or lipstick mark on this area of the footcan help locate the exact spot in the shoe toplace a metatarsal pad.


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Placing a metatarsal pad (Figure 2) in the

shoe16 will relieve pressure on the plantar

metatarsal heads and m ay help p revent recur-

rence of plantar keratoses. After marking the

nod ule with lipstick or a grease pencil, have

the patient step barefoot into the shoe. The

pad should be placed proximal to the markmade on the insole of the shoe. Metatarsal

pads can also be used to chan ge the alignmen t

of the toes to relieve pressure on soft corns.

Shoes with wide, deep toe boxes help pre-

vent recurrence of hard corns on the dorsal

surfaces of the toes, and wide toe boxes help

relieve soft corns. Pressure on to es may be

relieved with Silipos toe sleeves, polym er gel

(e.g.,Cu shlin Gel),or with padding of foam orlambs wool. Lambs wool is preferred over

cotton padding because it does not retain

mo isture and d oes not com press (Table 22-11) .

Insoles, Ortho tics and Arch Suppo rts

Ready-made insoles are marketed for relief

of heel pain, foot pain and back pain. In a

small crossover study,17 73 percent of subjects

reported d ecreases in back, leg and foot p ain

caused by prolonged standing on the job with

the u se of viscoelastic polyurethane insoles.

There is som e evidence that metatarsal pads18

and closed-cell foam insoles19 are useful in th erelief of metatarsalgia.

Elderly patients may suffer from heel pain

caused by age-related th inning of the heel fat

pad. In cont rast to p lantar fasciitis, age-related

heel pain is greatest in th e center of the heel,

and is usually not present on arising in the

morning (Figure 3). Heel pads or heel cups

(Table 22-11) may help relieve acute symptoms


The Authors

JOA N M . BEDINGHAU S, M .D., is assistant professor of fam ily and com mu nity m edicine

at the M edical Col lege of W isconsin, M i lwaukee. Dr. Bedingh aus received her medicaldegree from Harvard M edical School, Boston, and comp leted a fam ily practice resi-dency at Cleveland M etropol i tan G eneral Hospital .

M ARK W. NIEDFELDT, M .D., is assistant prof essor of f amily and comm unity m edicineand ort hoped ic surgery at th e M edical Col lege of W isconsin. He received his medicaldegree from t he M edical Col lege of W isconsin, wh ere he also com pleted a residencyin fam ily medicine and a fel lowship in pr im ary care sports m edicine. Dr. Niedfeldt ishead of th e Foot Cl in ic at Froedtert M emorial Luth eran Hospital , M i lwauk ee.

Address correspondence to Joan M . Bedinghaus, M .D., Department o f Family and Com -mun ity M edicine, M edical Col lege of W isconsin, 8701 Watertow n Plank Rd., Mi lwauk ee,WI 53 226. Reprints are not avai lable from the auth ors.

FIGURE 2. Two types of commonly availableself -adhesive metatarsal pads are shown. Padsshould be placed proximal to the poin t of con-tact between the plantar keratosis and theshoe.

FIGURE 3. The blue mark indicates the loca-tion of tenderness in heel pain caused by th in-ning of the heel fat pad. The red mark indi-cates the typical point of maximal tendernessin plantar f asciit is.


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in p atients with heel pain (Figure 4) . Heel pads

may also benefit patients who stand on hard

surfaces for extended periods of time.7 Hard

and soft heel cups have been used with suc-

cess. Hard cup s contain th e heel pad beneath

the calcaneus and help to restore some of its

compressibility, while soft cups add cushion-

ing in addition to cont aining the fat pad.6

Patients with plantar fasciitis present with

heel pain, but on examination the anterome-

dial aspect of the heel at the origin of the plan-

tar fascia on th e calcaneus will be mo re tender

than the central area (Figure 3) . Plantar fasci-itis is not limited to the elderly and it fre-

quent ly occurs in ath letes. Patients m ay report

the greatest pain with standing in the morn-

ing, after the plantar fascia has contracted

du ring th e nights rest.

Althou gh stretching of the plantar fascia

and Achilles tendo n is the mainstay of treat-

men t in plantar fasciitis, inserting cushioning

insoles m ay be helpful adjun cts. Because flat-

tening of the foot du ring walking triggers pain

by overstretching th e planter fascia, orth oses

designed to m aintain the m edial longitudinal

arch dur ing ambulation are preferred.8

Orth oses made of cork, viscoelastic poly-

mer or closed-cell foam provide cushioning

by reducing shock during walking by as

much as 42 percent (Figure 5) .9 Results of a

survey10 of run ners using orthotics for plan-

tar fasciitis showed that 74 percent rep ort ed a

significant improvement of symp toms with

the use of ortho tics and 90 percent contin-

ued to use orthotics even after resolution of

symptoms.

In a prospective, random ized trial11 of

patients with plantar fasciitis, rates of pain

relief were higher for patients who u sed ready-

mad e heel cups and insoles com bined with a

stretching program than for patients who

used rigid custom orthotics combined with

stretching or stretching alone. Over-the-

counter foam insoles and arch supports gen-erally cost $8 to $20 per pair, while custom-

mo lded orth otics cost $100 to $300. A trial of

the inexpensive alternative certainly seems

justified befo re refer rin g patien ts to a po dia-

trist or a pedort hist.

Orthotic shoe inserts may be effective for

pain relief in patients with pes planus, hyper-

pronation or a cavus foot.20 Rigid, semi-rigid

and flexible shoe inserts all can be used. It may

also be possible to obtain adequate arch sup-

por t by changing the brand of shoe. Well-fit-

ting shoes are an essential comp onent of any

treatment plan for patients with foot prob-lems. Patients who do not respond to simple

interventions, or those who have orthopedic

or systemic diseases complicating their foot

care may require a referral to a po diatrist, foot

clinic or or thop edist.

The authors indicate that th ey do not have any con-

f l icts of in t erest . Sources of fun ding: no ne repor ted.

Foot Problems


FIGURE 4. Either a hard or soft heel cup maybe helpful in age-related heel pain.

FIGURE 5. Viscoelastic polymer or closed-cellfoam insoles, which have molded support forthe plantar arch.


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Foot Problems

REFERENCES

1. M unro BJ, Steele JR. Foot -care awareness. A surveyof persons aged 65 years and older. J Am PodiatrM ed Assoc 1998;88 :242-8 .

2 . Evan s EG, Do d m a n B , W i l li am so n DM , Bo w e n GJ,Bowen RG. Com par ison o f t e rb inaf ine and c lo t r i -mazole in treating t inea pedis. BM J 199 3;30 7:6 4 5 - 7 .

3. Berman B, El l is C, Leyden J, Lowe N, Savin R, Shu-pack J, et a l . Eff icacy of a 1-w eek, tw ice-daily regi-men o f t e rb ina f ine 1% cream in the t rea tment o finterdigi ta l t inea pedis. Results of p lacebo-con-trol led, double-bl ind multicenter tr ia ls. J Am AcadDermato l 1992;26 :956-60 .

4 . Bunney M H, No lan MW, W i ll iams DA. An assess-

ment o f methods o f t rea t ing v i ra l war ts by com-parative treatment tr ia ls based on a standarddesign. Br J Dermatol 1976;94:667-79.

5 . Romm FJ. Treatm ent and ou tcome o f w ar ts. J FamPract 1986;22 :373-4 .

6. Jorgensen U, Bojsen-M ol ler F. Shock absorbency offactors in the shoe/heel interaction w ith specialfocus on role of the heel pad. Foot Ankle 1989;9 :294-9 .

7. Schepsis A A, Leach RE, Gorzyca J. Plantar fasci it is.Etio logy, treatm ent, surgical results, and review ofthe l i te ratu re . C l in Or th op 1 991;185-96 .

8. Singh D, Ang el J, Bentley G, Trevino SG. Fortn ightlyreview. Plantar fascii t is. BMJ 1997;3 15:17 2-5.

9 . DeMaio M , Pa ine R, M ang ine R, Drez D. Plan ta rfasci i t is. Orthopedics 1993;16:1153-63.

10. Gross M L, Davl in LB, Evanski PM. Effectiveness of

orthotic shoe inserts in the long-distance runner.Am J Spor ts Med 199 1;19 :409-12 .

11. Pfeffer G, Bacchetti P, Deland J, Lewis A, A ndersonR, Davis W, et al. Comparison of custom and pre-fabr icated o rthoses in th e in i t ia l treatm ent o f proxi-mal plantar f asci it is. Foot A nkle Int 19 99;20:214-21 .

12. Fuerst JF, Cox GF, Weaver SM , Duncan W C. Com -parison bet w een undecylenic acid and tolnaft ate inthe t rea tment o f t inea ped is. Cut is 1980;25 :544-6 ,5 4 9 .

13. Gentles JC, Jones GR, Roberts DT. Eff icacy ofmiconazole in the topical treatment of t inea pedisin sportsmen. Br J Dermatol 1975;93:79-84.

14. Charney P, Torres VM , M ayo AW, Smith EB. Tolnaf-tate as a prophylactic agent for t inea pedis. Int JDermato l 1973;12 :179-85 .

15 . Tong M M , Al tman PM , Barne tson RS. Tea t ree o i l inthe treatment of t inea pedis. Australas J Dermatol1992;33 :145-9 .

16 . Sheard C. Simp le management o f p lan ta r c lav i.Cut is 1992;50 :138.

17 . Basfo rd JR, Smi th M A. Shoe inso les in the w ork-place. Orthopedics 1988;11:285-8.

18 . Ho lmes GB, Timm erman L . A quant i ta t i ve assess-ment o f the e f fect o f meta ta rsa l pads on p lan ta rpressures. Foot Ankle 1990;11:141-5.

19 . Ke lly A, W inson I . Use o f ready-made inso les in thetreatment of lesser metatarsalgia: a prospectiverandomized control led tr ia l . Foot Ankle Int 1998;19 :217-20 .

20 . Ryan J. Use o f poste rio r n igh t sp l in ts in the t rea t-ment of p lantar fasci i t is. Am Fam Physician 1995;52 :891-8 , 901-2 .


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