eMedicine Specialties > Dermatology > Environmental
Clavus: Treatment & Medication
Updated: Jun 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Treatment should be aimed at reducing symptoms such as pain and discomfort with walking. Paring of the lesions immediately reduces pain. Once the etiology of the foot pressure irregularity is determined, attempts at pressure redistribution should be made. The use of orthotics and conservative footwear with extra toe space are often beneficial. When all else fails, surgery may be performed.- If abnormal dermatoglyphics or pinpoint bleeding is seen, wart therapy is initiated. If normal dermatoglyphics are noted, salicylic acid compounds and orthotics may be beneficial.
- Relief of symptoms may be achieved by thinning and cushioning of the involved lesions.
- Paring of the lesions immediately relieves pain, especially with helomas. Lesions may be maintained in this state if the patient uses short soaks and pumice stone debridement at home. Debridement may be enhanced with the use of keratolytic agents, such as ureas, alpha-hydroxy acid (eg, glycolic, malic, or lactic acid), or beta-hydroxy acid (eg, salicylic acid).31
- Self-adhesive pads are most effective for reducing thick lesions, whereas lotions, creams, and medicaments in petrolatum are best for maintenance. Most salicylic acid compounds are 10-17%. High concentrations of salicylic acid (eg, 40%) may lead to severe maceration, and in patients with diabetes, it may lead to frank foot ulcerations.32 Intralesional triamcinolone and topical vitamin A acid compounds also may reduce localized hyperkeratosis. Triamcinolone can lead to localized hypopigmentation.33
- A carbon dioxide laser can be used to pare deep lesions.34
- Reduced friction may be accomplished with the use of silicone-lined sleeves on the toes, padding, and, in select cases, silicone35 or collagen injections3 over the bony prominence in question.
- Lamb's wool may be beneficial in interdigital corns. Pads or permanent insoles, which place pressure proximal to the metatarsal head, relieve stress on the region. Insoles may be made of silicone or soft plastics.
- Shoes with extra length are required for toe deformity, and shoes with extra width are required for lateral toe callosities. Shoes should be soft inside without seams that rub or press. Orthotics can be placed in the shoe for patients with abnormalities of the foot, such as cavovarus. Orthotics can be created by using insoles made to correct deformities noted on dynamic pressure molds. Reduction of heel height may be helpful for patients with metacarpal head callosities.36
Surgical Care
Surgical options should be used when only conservative measures fail.
- Chronic foot pain despite conservative therapy is the number one indication for surgery.
- Surgical corrections for claw, hammer, and mallet toes are simple procedures.
- Shaving of prominent condyles of bony prominences may be beneficial particularly on the fifth digit.
- Arthroplasty of the fifth toe interphalangeal joint also may be performed.
- Metatarsal condylectomy or chevron osteotomy may be performed to relieve metatarsal head pressure.37
- These procedures generally are performed on multiple joints simultaneously to prevent imbalances, which may be induced by single condylectomy.
- Induced imbalance causes transfer lesions, ie, clavus formation of a new site on the foot.
- Mann and DuVries described the use of a combination of arthroplasty and condylectomy. This combination results in 95% clearance, with only a 13% occurrence of transfer lesions.38
- When thinning of the plantar fat pads is contributory to the formations of callosities, injectable silicone can be used on the soles underneath the callosities and corns to reduce pressure related callous formation.
Consultations
- An orthopedist and a podiatrist can be helpful in adjusting abnormalities of gait or pressure distribution.
- Dermatologists are best consulted to assess for the possibility of other disorders in the differential diagnosis, especially warts and keratoderma.
Diet
No special diet is required; however, weight loss relieves some of the foot pressures involved.
Activity
Adjustment of the footwear and the use of special insoles aid in the maintenance of full mobility and eliminate the need for activity limitation.
Medication
Debridement may be enhanced with the use of keratolytic agents, such as ureas, alpha-hydroxy acid (eg, glycolic, malic, or lactic acid), or beta-hydroxy acid (eg, salicylic acid). The use of these agents is not recommended in pregnant women and young children. Most salicylic acid compounds are 10-17%. High concentrations of salicylic acid (eg, 40%) may lead to severe maceration and frank foot ulcerations in patients with diabetes. Self-adhesive pads are most effective for reducing thick lesions, whereas lotions, creams, and medicaments in petrolatum are best for maintenance. Intralesional Kenalog and topical vitamin A acid compounds also may reduce localized hyperkeratosis. Kenalog may be injected during pregnancy because of its limited absorption; however, it can lead to localized hypopigmentation. Topical vitamin A derivatives are not intended for use in women who are pregnant or intending to become pregnant because their safety ranges from category C to category X.
Keratolytics
These agents cause cornified epithelium to swell, soften, macerate, and then desquamate. Commonly used agents include urea, alpha-hydroxy acids (eg, lactic acid, glycolic acid), and beta-hydroxy acids (eg, salicylic acid).
Lactic acid 10-12% (Lac-Hydrin)
May loosen the adhesion of the keratinocytes in the stratum corneum, thereby thinning the skin.
Adult
Apply topical qd/bid
Pediatric
Not established
None reported
Documented hypersensitivity; lactic acidosis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause stinging and burning at the site of application; irritation; blistering
Salicylic acid (Compound W, Panscol, Sal-Plant)
May be compounded in petrolatum at any percentage, usually is used at 5-20%, beginning with lower percentage. Can be purchased over the counter as a liquid or pad preparation, ranging from 17-40% (multiple companies make these). Can be irritating or cause blistering.
Adult
Apply bid to qwk
Pediatric
Apply as in adults (high risk of blistering)
Enhanced blistering possible with other keratolytic agents
Documented hypersensitivity; moles, birthmarks, or warts with hair growing from them; genital or facial warts or warts on mucous membranes; irritated skin or any infected or reddened area
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Irritation and blistering (limit use); prolonged use in infants, patients with diabetes, and patients with impaired circulation not recommended
Urea (Ureacin-40, Aquacare)
Promotes the hydration and removal of excess keratin in conditions of hyperkeratosis.
Adult
Apply to affected area prn
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; viral skin disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use near eyes; caution if applied to broken or swollen skin
Intralesional corticosteroids
These drugs have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Triamcinolone (Kenalog, Amcort)
Injectable version of triamcinolone is available in concentrations of 3-40 mg/mL. Generally, this compound is diluted to 1-4% for injection into lesions, such as a clavus.
Corticosteroids cause the skin to thin, and this beneficial side effect can be used to reduce the thickness of a clavus. However, overusage also can lighten the skin and cause atrophy.
Adult
Inject into lesion every month (has prolonged activity of 3-4 wk)
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; atrophy of the skin; excess corticosteroid syndromes; hypersensitivity to class B or D corticosteroid compounds
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
With chronic systemic exposure to the drug, it may reduce local immune system activity required to destroy dermatophytes and other microbes; caution in children (reduced skin thickness and intolerance for painful procedures); severe infections; hyperglycemia; edema; osteonecrosis; myopathy; peptic ulcer disease; hypokalemia; osteoporosis; euphoria; psychosis; myasthenia gravis; growth suppression
Retinoids
Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes, and they may reduce the potential for malignant degeneration. Retinoids modulate keratinocyte differentiation.
These agents are not specifically approved for use in clavus therapy. Only tretinoin has been shown to be useful for clavus therapy in the topically applied form. These agents cause the skin to peel by loosening of keratinocyte adhesion. Irritation and discomfort are limiting adverse effects.
Tretinoin (Retin-A, Avita)
Inhibits microcomedo formation and eliminates lesions present. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Also available as 0.01% and 0.025% gels.
Adult
Apply topically qhs to qwk
Pediatric
Not recommended except in unusual circumstances
Increased toxicity with coadministration of benzoyl peroxide, salicylic acid, and resorcinol; avoid topical sulfur, resorcinol, salicylic acid, other keratolytics, abrasives, astringents, spices, and lime
Documented hypersensitivity; photosensitivity; pregnancy; localized disease (eg, dermatitis) at the intended site of application
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Photosensitivity with excessive sunlight exposure; caution in eczema; do not apply to mucous membranes, mouth, and angles of nose; caution in pregnancy (oral isotretinoin associated with major neural-tube birth defects)
More on Clavus |
| Overview: Clavus |
| Differential Diagnoses & Workup: Clavus |
 Treatment & Medication: Clavus |
| Follow-up: Clavus |
| Multimedia: Clavus |
| References |
| Further Reading |
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References
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Further Reading
Clinical guidelines
Dermatologic manifestations.
New York State Department of Health - State/Local Government Agency [U.S.]. 2004. 15 pages. NGC:003931
Guidelines for the management of actinic keratoses.
British Association of Dermatologists - Medical Specialty Society. 2007 Feb. 9 pages. NGC:005656
Clinical trials
Potential Research Study Participant Registry
Study to Compare Different Light Therapies (Narrowband Ultraviolet B Vs PUVA) for Hand and Foot Skin Diseases.
Related eMedicine topics
Corns (Dermatology)
Arsenical Keratosis
Warts, Nongenital Warts, Plantar
Keywords
callosity, corn, heloma, heloma durum, heloma molle, callous, callus, plantar callus, heloma, tyloma, keratoma, plantar corn, plantar callus, intractable plantar keratoses, jeweler's callus, cherry pitter's thumb, cameo engraver's corn, weight lifter's callus, prayer callus, cigarette lighter thumb, knuckle pads, Russell's sign, Russell sign, screwdriver operator's clavus, spine bumps, hairdresser's hand, sucking callus, Vamp disease, mousing callus
