The feet and scleroderma

How can systemic sclerosis affect the feet?

Most people tend to give their feet little consideration until they develop problems. Systemic sclerosis (systemic scleroderma) can affect the feet in many ways including the circulation, nails and skin.

Circulation and Raynaud’s phenomenon

We know that systemic sclerosis can be associated with problems with the blood vessels that can lead to poor circulation. In some circumstances, this can lead to difficulties such as breaks in the skin known as ulcers which can be painful and take a long time to heal. Raynaud’s is the abnormal response of blood vessels, commonly occurring in response to a change in temperature. Raynaud’s is frequently seen in the fingers but is also common in the feet; however we notice it less as we can’t see the colour changes because our feet are usually covered up! Prolonged or very frequent Raynaud’s spasms can damage areas of tissue leading to ulcers. These can be painful and prone to infection, therefore if you suspect you have an ulcer you should keep it protected and seek medical advice.

Nails
The nails can be affected in several ways. We know from looking after many patients with systemic sclerosis that the bones at the end of toes may alter their shape (be re-absorbed), which in turn alters the shape of the nail. This may lead to an increased incidence of in-growing toes nails, which can be both painful and prone to infection.

Skin
Many patients with systemic sclerosis experience patches of thickened skin, and these patches may be found on the feet, commonly on the dorsum (top) of the foot. You may also notice that your skin generally becomes dry and itchy. Some people may experience calcinosis where bumps of calcium form under the skin and can be painful. Sometimes the calcium breaks through the surface of the skin and a soft chalky substance is released which often eases the discomfort. It is very important not to attempt to treat these yourself but to observe the calcinosis for signs of infection, which will require assessment by your doctor for antibiotics, and to seek medical advice if the calcinosis is a problem to you.Some people with systemic sclerosis experience a feeling of 'walking on pebbles', particularly when walking on uneven surfaces. This may be due to changes in the fibro-fatty pad which normally protects the ball of the foot. This discomfort can be helped by podiatric input to provide appropriate padding or the use of footwear with a thick sole which will add a layer of protection to the ball of the foot.

Some practical information to help keep your feet healthy

Infections

Some people with systemic sclerosis may find that they are more prone to developing infections, or that infections take a long while to get rid of, even with prompt use of antibiotics. The reason for this may be related to the underlying affect of systemic sclerosis itself, or indeed from some of the treatments associated with systemic sclerosis such as immunosuppression.

It is very important that people with systemic sclerosis visit their GP promptly if they notice any sign of infection. Signs of infection include heat, swelling, pain and redness.

How should I look after my feet?
Well, the good news is there are many things you can do to look after your feet. Here are a few pointers:

Moisturise your feet as often as you can, ideally three or four times a day, being careful not to leave any cream between your toes. People tend to find their own choice of moisturising cream which suits them but something quite simple such as aqueous cream or E45® are popular choices (these may be bought at the chemist or may be available on prescription).
Inspect your feet daily – As you moisturise or put on your footwear, take a note of any changes in the skin. If you are concerned seek medical advice.
Choose footwear which does not rub and allows plenty of room for adequate socks/tights. A thick sole may help protect against the cold, and the use of a thermal insole is recommended if your footwear can accommodate one.
Ask to be referred to NHS podiatry services for a full podiatric assessment.

How should I cut my nails?
Ideally cut your nails in a line straight across the free edge of the nail. Nails may become thicker or you may experience difficulty managing to physically reach down and manipulate clippers, in this case you may seek help from professional services such as chiropody or podiatry.

What about chiropody/podiatry?
This service is available both privately and on the NHS although service provision may differ regionally. The podiatrist will be able to assess your underlying circulation and the mechanics of your feet and provide a wide range of treatment and advice. Podiatry is the modern term for chiropody but with extra skills to assess and diagnose conditions as well as to treat their symptoms. There are different types of training and qualifications in foot care but the qualification required by the NHS is that of "State Registration" which currently involves a three year degree in podiatric medicine.

What else can I do to help myself?

As systemic sclerosis and Raynaud’s can affect the blood vessels, any further damage such as that caused by smoking can be detrimental. Therefore it is strongly advised that smokers stop smoking. Smoking cessation advice is available through the NHS, so it is a good idea to speak with your GP or practice nurse about the support available in your area.

Naomi Reay MA, DN, RGN, SRCh

Scleroderma Nurse/Researcher