Marc A. Brenner, DPM, FASPD Past President of the American Society of Podiatric Dermatology Medical Staff, North Shore LI Jewish Hospital, Manhasset, NY Private Practice and CEO of the Institute of Diabetic Foot Research, Glendale, NY

Dr. Brenner is the Editor of the textbook Management of the Diabetic Foot, Williams & Wilkins Publisher. He is a member of the American Podiatric Medical Association, is an author and editor of numerous publications, and has over 250 lectures, videos and nationwide radio/television tours to his credit. He's Board Certified in podiatric medicine and presently on the medical staff of North Shore Hospital and Long Island Jewish Hospital.

Dr. Brenner lectures nationally on practice management, podiatric dermatology, and diabetic foot pathology. His more than 30 years of clinical experience includes treating many VIPs, professional and college athletes, as well as numerous professional musicians. His outward and dynamic personality makes him a demanded speaker on podiatric dermatology and diabetic limb salvage techniques and other podiatric pathological conditions.

Treatment of Hyperkeratosis Traumatica Marginalis Calcis
Using Salicylic Acid and Urea Combination (Kerasal®)

by Dr. Marc A. Brenner

Hyperkeratosis Marginalis is frequently seen in post menopausal women, and it is clinically demonstrated through cracking, scaling and/or redness of the heels on both feet. It was initially described by a Hungarian dermatologist named Haxthausen in 1934. It is occasionally referred to as keratoderma climactericum. It is a form of xerosis or xeroderma, which is the mildest form of Ichthyosis and is defined as a dehydration of the skin – with the fine cracks resembling the cracking of porcelain. In severely neglected cases (figure 1), these fine cracks become enlarged, painful, deep fissures, which in time can become infected with secondary bacteria. This condition (which is less common) simulates ichthyosis vulgaris or even Unna-Thost disease, which is resistant to therapy.

Figure 1: Serve Hyperkeratosis Marginalis with deep fissuring, which is termed Ichthyosis Vulgaris

CASE STUDY

The more common Hyperkeratosis Marginalis is shown here in a sixty one year old, slightly obese, hypertensive Caucasian female. This patient came to our office with the chief complaint of cracking of the skin and pain, upon weight bearing, of both of her heels. (figure 2).

Figure 2: Initial view of Patient’s Condition

The initial onset of this problem was approximately two months ago. This patient frequently wears backless shoes throughout the day without orthotics. After a complete podiatric and lower extremity examination, she was advised to always wear socks and shoes with a back counter and laces. A regiment of daily Kerasal ointment, morning and evening, was recommended. After ten days of this regiment, she was seen again in our office (figure 3).

Figure 3: Ten days after Kerasal Treatment

There was significant improvement in both discomfort and cosmetic appearance for this patient. Kerasal Ointment, in conjunction with positive foot hygiene, showed improvement in this specific case. Basic xeroderma will likewise benefit by this combination product. Obviously, larger, more scientific studies should be initiated.

The treatment of xerosis has three aspects: Controlling keratinization to reduce scaling, replacing water content and maintaining hydration, and alleviating the symptomatology. Salicylic Acid and Urea have been widely used in the topical treatment of xerosis for three decades. Salicylic Acid has been a widely used keratolytic agent in the treatment of hyperkeratoic conditions such as seborrhoeic eczema, pityriasis rubra pilaris, psoriasis, neurodermatitis, and verracae. Urea has been used for the past fifty years for hyperkeratoic conditions including xerosis, alligator or fish skin, and even avulsion of toenails when used under occlusion. It is known that urea increases water uptake in the stratum corneuem. Urea is also thought to exert its keratolytic effect through the process of unfolding proteins. It is also, antifungal, antibacterial, antiodor, and has antiyeast properties. Urea is naturally found in the skin and is an important part of the skin’s natural moisturizing system. Salicylic Acid is a keratolytic agent that breaks up into the intracellular matrix and thus softens the stratum corneuem. Both of these processes will increase skin desquamation; thus enhancing the shedding of scales, which will result in the softening appearance of the skin. The combination of 10% urea and 5% salicylic acid in Kerasal Ointment might exert a strong peeling effect through a greater release of the acid or by synergistic pharmacological effect of the two substances.¹

In conclusion, Kerasal is the first product in the United States to include both of these agents and is manufactured using a patented process. It is the only Salicylic Acid product that is water soluble and highly occlusive. With this in mind, Podiatric physicians should definitely consider Kerasal Ointment in their armamentarium for xerotic conditions of the lower extremity, especially Hyperkeratosis Traumatica Marginalis Calcis.

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References:

T.H. Nook discusses this in his study on “In Vivo measurement of the Keratolytic Effect of Salicylic Acid in Three Ointment Formulations” published in the British Journal of Dermatology 1987, Vol 117, pages 234-245.

Kerasal brand site for Professionals

Kerasal offers a full line of over-the-counter (OTC) therapeutic foot care products used to treat xerotic foot conditions, repair cracked heels, exfoliate dry skin and soften calluses. Kerasal products comes in convenient forms to encourage compliance and offer safe and effective solutions for diabetic foot care.

Kerasal’s history is deeply routed in the podiatric community – in fact, it was originally a product available only through the podiatrist’s office, beginning in 1996. Today we offer products for direct dispensing as well as products for purchase in retail stores.

Kerasal has long been trusted by podiatrists, pharmacists and other professionals as an effective and safe method to smooth and soften feet without a prescription. www.kerasalpro.com