Warts
Treatment and Prevention of these "dirty little secrets
By Evan A. Vieira, DPM, AACFAS
Warts on your feet are one of those very common problems that affect a huge portion of the population. Even with how common they are, they still remain a "dirty little secret." Having warts carries with it a sense of shame. People often assume that it's a hygiene issue and usually immediately begin speculating on who, what, where, and when; looking for a cause. Well, let's start by saying that in the vast majority of cases, it has nothing to do with how well we take care of ourselves, and even more noteworthy is that we are ALL at risk of contracting them. So what are they? What causes them? How do you get rid of them? And how do you prevent them?
What are warts? One of the main types of warts is a Plantar wart, or more accurately, Verruca Plantaris, which refers to warts located on the feet. Each strain can have certain nuances of lesions; overall they will all produce a small cauliflower-like lesion on the foot. They are usually located on the bottom of the foot, but sometimes on the toes as well. They can be painful, cause bleeding and are highly contagious. Often times, self inoculation will cause a cluster of warts or a mosaic type pattern that can become quite extensive without proper treatment. Each one may have small dark pinpoint-like dots in them, which are little blood vessels immersed in the lesion. These small dots are usually pretty accurate markers for identifying them.
What causes them? Warts as a whole are caused by a virus called the Human Papilloma Virus (HPV). These viruses are everywhere, and we are especially vulnerable to them while barefoot in public places, i.e., pools, and locker rooms. For reasons unknown, HPV seems to have a longer period of survival outside of a human being than some other viruses, making it even easier to catch and spread from person to person, or even from pool deck to person! Since this is a virus that stays dormant in your body, any stresses on your immune system or other types of trauma can cause an outbreak. Many times they are seen in pregnancy and treatment during this period should be as conservative as possible due to some potential risks associated with the chemicals used to destroy them. I would recommend consultation with your obstetrician before having anything done, and if possible have your doctors communicate with each other prior to starting any treatment plans. Children are very susceptible to warts as well, usually associated with running around barefoot in school gyms or camp pools. Again, if your child has any other medical conditions or allergies, always ask your podiatrist and pediatrician to discuss which plan might best suit that particular patient.
How to get rid of them The good news about this condition is that the symptoms are treatable. Once you are infected with the virus, it will remain in your body for life, but the warts themselves can be removed. These are a vast array of methods for controlling and removing them. Based on severity, size, duration, quantity, age, activity level, and degree of pain your doctor can pick a procedure and/or treatment plan that will allow you the best chance for recovery over the shortest time possible. For smaller, more localized cases a regime of debridements in the doctor's office and the application of special topical medications that can destroy the wart are used. In more severe cases, one may consider freezing or heating the warts to destroy the lesions. Surgical excision is usually reserved for those with long-standing cases who have failed more conservative methods. Removing warts surgically can get complicated and require skin flaps and/or grafts to help expedite the healing process. In the majority of cases we deal with, simple conservative methods are effective. However, you must be patient! Warts can be pretty stubborn and require quite a few treatments before they are completely eradicated.
Prevention So, let's say you've never had a wart, or you just recently got rid of one-how can you prevent them in the future? Wear shoes! Don't walk around barefoot at your gym, in the school locker room, or in a public bathroom. In the short time it takes to throw on a pair of shoes, it can save you endless hours of multiple trips to your doctor's office. We are commonly asked if it is okay to walk on the beach barefoot. The answer is yes. Contracting a virus like HPV from the sand at the beach is unlikely and really not of concern. That is not to say that broken glass and sharp shells can't provide other obstacles to a nice day by the water, so we always recommend shoe gear.¨Remember, if you are not sure if what you have is a wart, have it evaluated by a doctor. You are always better off erring on the side of caution than risking more extensive infection.
Pedicures¨ by Evan A. Vieira, DPM, AACFAS
These days, pedicures are among the most popular indulgences women allow themselves. In fact, many get a pedicure multiple times a month, usually without incident.
Infections: ¨ Salons may have dozens upon dozens of customers in any given day, each one being treated with the same instruments, soaking in the same baths and painted with the same polishes. The highest quality salons use sterile instruments, cleaned in a special machine, and packaged separately for each use. However, many establishments use the same instruments repeatedly throughout the course of the day. A nail file, for example, has pores that can collect debris from everyone it has touched. This can spread all sorts of germs that can lead to skin and nail infections. With the spread of more dangerous forms of bacteria, it is extremely important to be aware of each individual salon's practices. If you aren't sure, then ask!
Cuticles/Shaving: Many women have their cuticles cut or removed from their nail plates to allow for even distribution of polish and general aesthetics. However, you have cuticles for a reason. They serve as a barrier at your nail fold, and keep out germs. Once the seal is broken, you open up your toes to all sorts of problems. Another common source of infection are freshly shaved legs. When you shave, you may create small nicks or cuts in your skin which also provide an opening for germs.
Calluses: A lot of pedicurists use actual blades to remove dead skin. Do not let anyone other than your doctor touch you with a blade. The risks here are obvious, and in some states, this practice is even illegal. If you do want them to remove a callus, it should be done with nothing more than a pumice stone.
Ingrown Nails: When your nails are trimmed by the pedicurist, be sure that they are not cut round, but rather left with a square edge. This can help prevent ingrown nails, which can be painful and can result in infections too. If you start to feel pain, contact your doctor as soon as possible. It is a lot easier to deal with an ingrown nail earlier on, before infection and other issues set in.
Toxic Chemicals/UV Light: The newer gel coatings that are applied to nails require that the nails set under UV light for extended periods of time. This carries inherent risks, and over a period of time can have effects similar to overexposure from the sun. Another problem with gel coatings is that they last longer and can conceal nail infections or more serious conditions from both patients and doctors. The gel also requires thorough scrubbing with acetone, which can also cause skin irritation. Be sure to use gel sparingly and keep it on the nail itself.
So, having an occasional pedicure is generally harmless and can be a very enjoyable experience. However, be aware of the risks, ask the right questions and go to the right salons to avoid problems.There is no substitute for regular follow-ups with your podiatrist though. Problems such as infections, nail diseases and even more serious conditions should be screened by a doctor, on a regular basis, to avoid problems down the line. If you have any questions or need a recommendation of a quality, licensed pedicurist, please contact us for a visit.
Osteoarthritis/Hallux Rigidus
 by Evan A. Vieira, DPM, AACFAS
Osteoarthritis or just, arthritis for short, is a degenerative condition that affects joints. Our joints are supported in part by the firm rubbery buffern known as cartilage, which provides the smooth glide mechanism when we move.
 However, over time, wear and tear on our joints can cause degeneration of our cartilage and leave our bones rubbing close together. From this can come pain, osteophytes or loose bone fragments, swelling and loss of motion. Arthritis can affect us all regardless of gender or age. Obviously, as we age, our cumulative use increases, but patients of all ages can be affected.
Hip and knee replacements are now common place in the United States, but arthritis is not exclusive to those joints. The foot and ankle are susceptible to the same type of wear and tear as any other join, and can suffer from the same ailments. Total ankle replacement is emerging as a remedy for those with ankle arthritis, but has not achieved the same type of main stream success as hip and knee replacements to date.
One of the more common problems that presents to the doctor's office these days is pain and limited motion at the great toe joint. This condition called "Hallux Rigidus" is very simply, arthritis of the great toe joint. Even though your great toe joint or, 1st metatarsophalangeal joint, is a fraction of the size of your knee, it can be equally painful and cause just as much limitation of daily activities. Your great toe plays a key role in propulsion during your gait or walking cycle, and takes a brunt of the forces placed on your body during walking, jogging and running.
Over time, the joint can begin to break down and develop stiffness, pain and swelling. The exact etiology of the hallux rigidus beyond just normal wear and tear is a highly debated topic, and much more complex than we will get into here. Our goal in this article is to provide a basic understanding of the disease and the most current treatments for it. Treatments vary greatly depending on the stage of the disease. If we are able to diagnose the symptoms early on, we can try to limit damage with orthotic and shoe modifications as well as control pain with cortisone injections or antiinflammatory medications. Generally, these treatments are productive for a while, but as the disease continues to progress, it becomes more and more difficult to manage the symptoms.
Over time, some patients will develop a bump on the top of the joint called an exostosis. This can cause increased pain and decrease in motion. Once we see changes like this, surgery becomes a significantly viable option. In some patients, we can perform a cheilectomy or more simply, remove the bump from the top of the joint and clean up some of the debris we might find there. This procedure is often times quite effective and successful, however, as with any surgery, proper assessment and patient selection is key.
Once the disease progresses beyond this stage and more significant erosion of the cartilage cap becomes evident, more extensive surgeries come into play. Just like hips and knees, foot and ankle surgeons replace the great toe joint. These implants are similar in structure in function, to other implants and often borrow much of the technology that has been developed from large joint replacement. The procedure is performed as an out patient and patients are encouraged to weight bear and resume activity as soon as they can to gain as much range of motion as possible. Physical therapy and home exercises can increase success rates and aid in regaining function post operatively.
If the disease advances to its final stages and the cartilage erosion is so significant that the bones become flattened and there is basically no motion, then the previous procedures are usually no longer options. Once we get this far along, we generally recommend fusion of the joint. Patients compensate for the loss of motion at that joint and are able to function quite well, however there are limitations. Firstly, for women who still want to squeeze their feet into high heels and suffer the pain, this is not an option. Also, in very physically active athletic people, we try to avoid fusing the joint and find other options.
Hallux rigidus can profoundly affect a person's life, their activities and overall well-being. We are constantly trying to advance our therapies and treatments to improve outcomes and patient satisfaction. Still, this remains a very difficult condition to treat. 
 As we always discuss, proper evaluation and patient selection are key to any successful surgical procedure so do your research and ask the doctor questions!
My Aching Feet
 By Evan A. Vieira, DPM, AACFAS
We have all seen those commercials on television for "custom" orthotics, quickly measured and fitted while you wait at the drug store. Just a stroll through a chain drug store will reveal an entire aisle dedicated to just your feet. So why is there so much advertising, research and merchandise dedicated to the health of our feet?
Quite simply, our feet take a beating all day every day. We take somewhere in the range of 5,000 to 10,000 steps in a single day. Moreover, some of the most common reasons patients visit doctors or emergency rooms in this country are related to sprains, strains and other foot and ankle trauma. That said, many people with general aches and pains in their feet assume there is nothing really to be done for them. They don't mention their feet when talking with their primary care doctor during a routine physical, nor do they call a podiatrist. Instead, they might go to the drug store and try some over-the-counter padding or insert, or ignore their problem all together and just suffer with it.
A doctor, when taking a basic medical history, may uncover that the problem has existed for months or years. When asked why the patient waited so long, the most common response is, "I thought it was normal for my feet to hurt." This could not be further from the truth. Our feet are complex structures with many small bones, muscles and tendons organized to comfortably and effectively support and move us. Deviations in alignment, general wear-and-tear, as well as infections and even more complex orthopedic deformities and may impede their function and leave us ailing.
However, years of research have afforded us a plethora of both diagnostic tools and treatments to restore alignment, regain function and prevent future problems. If you have pain in your heels when you get up in the morning, aches in your joints when you exercise or even nails that grow into your skin, these are all both treatable and preventable. Seeing a podiatrist as soon as a problem arises can increase the chances of a full recovery, decrease healing times and help to develop long term solutions.
If you are suffering with foot and ankle problems, a generic foot scan in a drug store will give you an idea of the pressure points on the bottom of your feet. However, the scan cannot talk to you about your activities, medical history and expectations. It can't examine you and formulate a specific and detailed treatment plan. Don't leave any aspect of your health solely on the expertise of a computer. Seeing your podiatrist will allow you to be treated as the unique patient you are, not just another pair of feet.
Melanoma
 By Evan A. Vieira, DPM, AACFAS
Summer is over, tans are fading, and skin spots are rearing their ugly heads. Usually, we think of these problem areas showing up on the face, chest, back and shoulders. However, they can be found anywhere on our bodies-regardless of sun exposure.
Our arms, hands, legs and feet should not be ignored during exams. In some cases, it's not a matter of forgetfulness but a physical inability that prevents patients from adequately inspecting their feet. Some people just can't get a proper view, either because of their back pain, lack of mobility, or poor eyesight.
Melanoma is the most dangerous type of skin canser, and is caused by changes in melanocytes, which produce a skin pigment called melanin. The rate of melanoma is steadily increasing, and your risk also increases with age. However, it can be found in young people, especially those with multiple risk factors. These include, but are not limited to, fair skin, light eyes, red or blonde hair, people who live in sunny climates, work outside for prolonged periods, have had one or more blistering sunburns during childhood, and those who use tanning devices. Patients with a family history of melanoma, certain types of moles or multiple birthmarks or a weakened immune system, also have higher risk.
One of the most common requests patients have for doctors is an evaluation of skin spots, moles, bumps, sores and so on. So, how do we differentiate what is dangerous and what isn't?
When we examine your feet, there are a few key things that we look for to spot any problem areas. Becoming familiar with the ABCDE system is important for all patients. This system is a simple way to perform important self-exams on a regular basis to keep an eye out for early signs of disease. A symmetry: one half of the lesion is different from other half. B orders: The edges of the lesion are irregular. C olor: Changes from one area to another with shades of tan, brown, black, blue, red or white. There may be a mixture of many colors within one lesion and a breakage in skin may be present. D iameter: The spot is usually larger than 6mm in diameter, but can be smaller. E volution: The lesion keeps changing in appearance.
These basic criteria are crucial to the early identification of melanoma when treatment is most successful. Remember, early detection is facilitated by regular check ups and a basic awareness of what to look for. For example, many patients come in for evaluation of discoloration in dark in color, has progressed rapidly, and has become painful, these could be signs of a far more serious condition like melanoma.
Too often patients neglect to check in between their toes, on their nail beds and on the soles of their feet. Regular visits with your podiatrist are the best way to avoid missing discrete lesions that might otherwise be inaccessible to you.
Xerosis
 By Evan A. Vieira, DPM, AACFAS
Now that flip flops are a distant memory and next summer feels like light years away, we all tend to neglect our feet. We tuck them away in big fluffy boots to hibernate all winter long. This time of year, as the temperatures drop and the air dries out, so does our skin.
We will see many patients start coming in complaining about dry, flaking skin that just won't go away. People try lotion after lotion, some even quite expensive, to try and alleviate the problem unsuccessfully. What people don't realize is that sometimes it's not just a simply a case of dry skin.
Xerosis is the medical term for dry skin and can be very itchy, irritating, painful and unsightly. Many times it will not respond to over-the-counter lotions and might require more involved treatment. Severe and chronically dry feet can be linked to a more serious underlying condition or disease. Evaluation by a podiatrist can help rule out these type of conditions and, if necessary, guide you towards appropriate testing or specialists. However, in most cases, xerosis is a localized and self-limiting condition that is very successfully treated with prescription medications that actually chemically remove the dry skin.
In some cases, patients can also develop cracks or fissures in the skin which can be extremely painful and can lead to more serious issues like bleeding and infection. If you notice these, you should call a podiatrist and be evaluated as soon as possible. When this occurs, intervention is required to remove the dead callused skin and medications may be required to prevent infection and help the skin heal. If you notice redness, swelling, drainage or pus, this can be serious and should be treated as an emergency.
Please call our office to make an appointment with Dr. Vieira or one of our other doctors.
