Articles

Debridement of Calluses
To the Editor:

A recent review article1 stated that for diabetic patients "debridement of calluses … should be routinely provided by trained personnel". My experience suggests otherwise.

For more than twenty years, I have served in a clinic responsible for the healing of wounds in the feet of diabetics. From time to time we see a patient who has lost all or part of one leg and presents with a new ulcer on the contralateral foot. I have asked all of these individuals about the cause of the wound that led to the amputation. The answer has always been the same -- an attempt to debride a callus, usually by a podiatrist and usually by abrasive filing or by the use of a blade. Sometimes the debridement was performed by the patient.

In my private practice, devoted to the treatment of diabetes, we will occasionally see a new patient who comes for treatment of a foot ulcer. With one exception (tight ski boots) the wound has been caused by debridement of a callus, usually by a podiatrist but sometimes by a pedicurist. In one such case, a podiatrist debrided a callus on the great toe of one of my patients on a Friday evening. On Monday morning, I removed 5 ml of pus from that toe. It is unfortunate that I never bothered to tabulate the many instances of infected ulcers secondary to callus debridement that I've seen over the years. The likely reason for such damage is that even professionals don't always know how much dead epidermis can be removed before the underlying living tissue is traumatized. In diabetics, of course, the risk of infection is especially great.



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Our technique for dealing with calluses is to eliminate the pressure or shear that caused them so that they can regress. On plantar surfaces this usually involves addition of material to the underside of an orthotic shoe insert to transfer pressure to another site, such as the arch. This technique is known as "posting" in the pedorthics trade.

I can only recall one instance where debridement of callus was likely beneficial. A homeless gentleman appeared in clinic with calluses one inch thick. I cut them down to about 1/8 inch with a nail clipper.

I hope that this letter will persuade your readers that debridement of calluses is more likely to cause foot ulcers than to prevent them.

 

Richard K. Bernstein, M.D., F.A.C.E., F.A.C.N., C.W.S.

Diplomate, American Academy of Wound Management

diabetes@scientist.com

Director, Peripheral Vascular Disease Clinic

North Bronx Health Care Network

In affiliation with The Albert Einstein College of Medicine

Bronx, NY.