Treatment management of a patient with heloma durum: a case study

Patient Management -- Heloma Durum

Presentation and Management

The patient suffering from heloma durum typically presents with complaints of discomfort from the formation of hardened tissue in localized areas of the foot such as the on the dorsolateral aspect of the fifth toe or the dorsum of the interphalangeal joints of the lesser toes (Dunn, Link, Felson, et al., 2004; Taylor, Lillis, & LeMone, 2008). While the condition is normally benign (Dunn, Link, Felson, et al., 2004; Freeman, 2002), it can also be the source of physical discomfort that causes patients to alter their choice of footwear and activities, and in extreme cases, it can cause changes in their gait which can also precipitate other physiological problems such as of the knees, hips, and spine (Dunn, Link, Felson, et al., 2004; Taylor, Lillis, & LeMone, 2008). The condition is normally managed through the most conservative means possible (Hamric, Spross, & Hanson, 2009).

Heloma durum is caused by hyperkeratosis, which is an increase in the keratinocyte activity whereby persistent external pressure such as that associated with friction from footwear stimulates the protective formation of thicker skin layers (Dunn, Link, Felson, et al., 2004; Taylor, Lillis, & LeMone, 2008). Therefore, in most cases, management of heloma durum requires little more than changing footwear to eliminate the source or irritation either alone or in conjunction with supplementary padding in between the affected toes, intended to separate them or between the toes and the footwear to eliminate excess friction (Dunn, Link, Felson, et al., 2004; Freeman, 2002). If conservative treatment does not resolve the problem, removal by sharp debridement is often used. In extreme cases, surgery may be required, particularly where the underlying source of the condition is structural because even removal of the heloma durum through sharp debridement does not prevent its subsequent recurrence (Dunn, Link, Felson, et al., 2004; Freeman, 2002; Sage, Webster, & Fisher, 2001).