Clavus Treatment & Management

Updated: Aug 22, 2016
  • Author: Nanette B Silverberg, MD; Chief Editor: William D James, MD  more...
  • Print
Treatment

Medical Care

Treatment of a clavus 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). [36] Garlic extracts have also been described as being helpful. [37]

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. [38] Intralesional triamcinolone and topical vitamin A acid compounds also may reduce localized hyperkeratosis. Triamcinolone can lead to localized hypopigmentation. [39]

A carbon dioxide laser can be used to pare deep lesions. [40]

A combination product to be applied by physicians consisting of 1% cantharidin, a vesicant, mixed with 30% salicylic acid and 5% podophyllin has been described as effective for most people after just one session. In a study looking at 72 patients, 90.3% with callosities on the feet demonstrated that application of this agent after paring with a 15 blade effected clearance in 79.2%, 12.5%, 6.9%, and 1.4% after 1, 2, 3, and 4 sessions, respectively, with only one recurrence at 1 year follow-up. [41]

Injection of botulinum toxin into the plantar area of two patients with pachyonychia congenita has been described as beneficial for the reduction of clavus formation and blisters. [42]

Reduced friction may be accomplished with the use of silicone-lined sleeves on the toes, padding, and, in select cases, silicone [43] or collagen injections [3] 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. [44]

Vacuum orthoses have been described to aid in lesional clearance for diabetic patients with plantar callosities. [45]

Further inpatient care

Further inpatient care is not required unless surgical adjustments are needed.

A patient with diabetes who has neuropathic ulcers and overlying clavus formation may require further care.

Rheumatoid arthritis patients may benefit more from surgical interventions than callous debridement. Forefoot arthroplasty and first metatarsophalangeal joint implants may improve clavus formation and rheumatoid foot pain long-term.

Measurement of the foot for orthoses is beneficial in the case of multiple clavi.

Next:

Surgical Care

Surgical options for clavus should be used when only conservative measures fail.

Chronic foot pain despite conservative therapy is the number one indication for surgery.

Hallux valgus correction may aid in reduction of painful callosities over the long term. [45]

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. [46]

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. [47]

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.

Description of excision followed by either grafting, use of flaps, or grafting using split-thickness graft with or without a collagen/elastin matrix graft has been described as effective in a single resistant case. [47]

Previous
Next:

Consultations

An orthopedist and a podiatrist can be helpful in adjusting abnormalities of gait or pressure distribution.

In cases of suspected arthritis, a rheumatologist can be consulted.

Dermatologists are best consulted to assess for the possibility of other disorders in the differential diagnosis, especially warts and keratoderma.

Previous
Next:

Diet

No special diet is required; however, weight loss relieves some of the foot pressures involved.

Previous
Next:

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.

Previous
Next:

Prevention

Clavus formation is a common painful frictional disorder that results in hyperkeratosis. Multiple methods to reduce friction and thus prevent recurrences are described in Medical Care and Long-Term Monitoring.

Previous
Next:

Long-Term Monitoring

Numerous contributory factors may result in thickened skin on the feet. Factors such as occupation, athletic pursuits, footwear, underlying bony abnormalities, and problems with general health may contribute to clavus formation.

Etiologic factors must be carefully assessed before treatment can be given.

Symptomatic relief can be achieved by thinning the hyperkeratotic lesions and by using cushions or insoles, which reduce pressure on the affected areas.

Surgery can be an adjunctive treatment in those patients with intractable clavus formation and chronic foot pain.

Using a combination of modalities and reducing the pressure of footwear ultimately reduces the appearance and discomfort of the clavus.

Previous