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Feet first

By Sasa Jankovic

Foot infections can be painful and unsightly so the sooner they are treated, the better.

Your customers may present with a variety of infections, from verrucas to athlete’s foot and fungal nail infections, and it is particularly important to act quickly if patients have an illness affecting their immune or circulatory systems, or if they have diabetes.


Verrucas are warts on the soles of the feet. They usually have a black dot in the centre — which is the blood supply to the verruca — surrounded by a harder, white area. Because they are underneath the foot they grow up into the skin and can get more painful over time.

It is common to have several verrucas at once. Up to 80 per cent resolve spontaneously within about two years, but over the counter (OTC) treatments can treat them much faster.

However, such treatments must be used with care, as Michael Abrahams, podiatrist at The London Nail Laser Clinic, explains. “OTC treatments are generally tissue destructive. Many contain salicylic acid at 15–26 per cent (eg, Salactol, Bazuka Extra Strength Gel) or up to 50 per cent (eg, Verrugon). [These products are] applied nightly in many cases, and the acid breaks down the skin.

“Because the acid may spread to healthy skin you should advise customers to protect the treated area with tape or spread petroleum jelly around it,” he advises.

Cryotherapy treatments (such as Wartner), which freeze the affected tissue, have also become available over the counter. Again, there are risks with such products, says Dr Abrahams: “There are instances where the liquid has dripped causing burns, and if good tissue freeze is not achieved [the products] are less effective.

“Prior to freezing, the skin should be debrided, and care should be taken to ensure the freeze is centred on the verruca.”

If your customer cannot face treating their own verrucas you could recommend they see a podiatrist, who can apply stronger treatments such as 70 per cent salicylic acid.

Athlete’s foot (tinea pedis)

The itchy, scaly, cracked skin of athlete’s foot will affect around a quarter of all adults at some time in their lives. Caused by a combination of bacteria and fungus, it creates dry and cracked skin — usually between the toes — as well as blisters.

Athlete’s foot is commonly caught in shared swimming pools and showers. One way to try to prevent it is to wear flip-flops in wet, communal areas and avoid walking around with bare feet or sharing towels or footwear with anyone with the condition.

If you have a customer with athlete’s foot, advise them to treat the infection immediately to prevent it spreading and causing other problems such as fungal nail infections, and make sure they understand the importance of good foot hygiene.

Again, there are OTC products that can help. “Athlete’s foot responds well to topical antifungal treatments,” says Dr Abrahams.

“Lamisil is fungicidal and works after a seven-day period, and Daktarin, Canesten, Mycil and so on are fungistatic and require about a three-week period of daily treatment.”

Remember that some creams contain steroids, which should be avoided for the treatment of young children and women who are pregnant or breast-feeding without prior consultation with their GP.

Fungal nail infections

Toenail infections are often linked to athlete’s foot and are very common. Infected nails become thick, discoloured and malformed, and can be slow to respond to treatment. If the infection has taken hold then OTC nail paints and prescription tablets can help, although they cannnot always completely cure the nail so that it looks normal.

“Topical treatments such as Clearzal contain antifungal and antibacterial agents, which may help reduce the spread or severity of the nail infection,” says Dr Abrahams, “but they do not usually help when the entire nail plate is involved or many nails are affected.

“It depends on the depth that the liquid is able to penetrate. If caught early, Curanail may be beneficial for one or two nails with only minor involvement.

“Terbinafine and itraconazole are the two common systemic drugs, which need to be taken orally for [between six weeks and] six months.

“However, these can affect the liver so blood tests to monitor liver function are often advised, and some primary care trusts do not advocate GPs prescribing these. Some patients are understandably reluctant to take these, so you should be prepared to give advice regarding their potential side effects.”

For customers wanting to try a herbal approach, some people find that tea tree oil can help treat fungal skin infections, but it must be used with care as some users report an irritated reaction on healthy skin.

Whatever route your customer chooses, it can take up to 18 months for infected toenails to look normal again, and fungal nail infections recur in about 25 per cent of people who get the condition.

Diabetic patients

People with diabetes have to take extra care of their feet because they are at risk of a decrease or lack of sensation in their lower limbs due to neuropathy. This means that unless they check their feet regularly they can miss small wounds, blisters or the beginnings of foot infections, which can quickly worsen or turn into ulcers.

Christina Wright, service development manager at Numark, advises: “By developing a relationship with diabetic patients, pharmacists can promote themselves as the first port of call for checking feet and legs and help educate people about footcare.”

It is also very important to advise any customers with diabetes to remember to keep their blood sugar under control, as elevated blood glucose reduces their body’s ability to fight infection and slows down wound healing.

 Extra training

  • Patient leaflets and posters are available from The Society of Chiropodists and Podiatrists.
  • Numark is developing a diabetes support service for its members, tocomplement its diabetes toolkit. The service, due to be launched in October 2010, will include a footcare module containing marketing materials, patient leaflets and staff training information. Further information, including the cost of the service, will be available in duecourse from Christina Wright on 01827 841269 (e-mail
  • The National Pharmacy Association’s “Pharmacy interact” training course includes a module on skin and feet. Designed for pharmacy counterassistants, the course is accredited by the Royal Pharmaceutical Society and costs £79 (plus VAT). An “Interact plus” course with a skin learning module is also available for £30 (plus VAT). Further information is available from the NPA website or on 01727 800402 (

When to refer

If a customer is experiencing pain or a wound does not appear to be healing, you should refer them to see their GP or a podiatrist.

By law, podiatrists and chiropodists must be registered with the Health Professions Council. To help customers find a registered podiatrist you can direct them to the Society of Chiropodists and Podiatrists’ website.

Market data

Data from the SymphonyIRI Group show that the retail sales market for OTC products to treat athlete’s foot has risen 0.4 per cent (in the year ending 15 May 2010) to just under £20m, with Lamisil, Daktarin, Scholl, Mycil and Daktacort the five top-selling brands.

However, while overall OTC sales in the sector are up 3.5 per cent for most major multiples, they are down 0.9 per cent for other multiples, including Boots and Superdrug, and down by around 3.1 per cent at all other pharmacies.

When it comes to OTC products to combat verrucas, sales fell 7.5 per cent to £17,712,386 in the same period — which represents a fall of between 5.8 and 9.2 per cent for major multiples but an increase in sales at all other pharmacies. The top five OTC brands in the period were Bazuka, Scholl, Wartner, Peditech and Aqua Rapid.

So how can pharmacies get these sales levels back up and encourage customers to buy? “Lack of consumer education about the condition and how best to treat it leaves consumers unsure about what to buy,” says Scholl’s brand manager for athlete’s foot and verrucas.

“Additionally, there are often a number of products available to treat the same condition, leaving consumers feeling confused. The pharmacist should therefore aim to be the source of information for the consumer and should provide objective advice on how to diagnose and treat the condition, recommending the right product for the customer’s situation.

“Providing the consumer with advice will help them to feel reassured and more comfortable with what to buy.”

Citation: The Pharmaceutical Journal URI: 11015754

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Supplementary images

  • Pair of feet (Milosluz/

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