Cancer and your feet

We see a variety of patients from all sorts of community and word of mouth referral systems. Ultimately, patients often have far more medical issues than their feet and ankles alone. I will see various patients in different stages of oncologic management, either post chemo into radiation therapy for various malignancies, and even patients post Moh's surgery and are here for skin care of the legs and feet.  Either way, various conditions may arise post chemotherapy to manage these various cancers, and often the feet and legs can have the brunt of the side effects manifesting in various ways.  We will see patients with numbness, tingling, and even swelling in the legs after these treatments. We are called to manage these secondary conditions and have a multitude of protocols in place to achieve high levels of excellent outcomes in relief of these symptoms. Here is an overall synopsis of management of swelling of the ankles and legs:

Dr Brian Timm, DPM, FACFAS

Diplomate: American Board of Podiatric Surgery 

(Soon to be named American Board of Foot and Ankle Surgery)

Swelling

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What is swelling?

Swelling, otherwise known as edema, is a build up of fluid in the body.  Swelling most often affects the dependent extremities (like the feet, ankles and hands) but swelling can also affect other parts of the body, such as the abdomen.  Causes of swelling include:

• Fluid retention, including salt and water related to medication, heart disease, liver disease, or kidney failure.
• Blockage of veins or lymph system.
• Malnutrition.

Chemotherapy-related, or cancer swelling:

• Some chemotherapy drugs can cause fluid retention in the body.  This form of cancer swelling is most noticable in the feet, ankles, hands, and face.
• Swelling or angioedema may also occur with hives as part of an allergic reaction.  It is a vascular reaction that causes an increased ability for fluid in the cells to "leak" into the layers of the skin, resulting in swelling.  This happens much less often than hives alone.  The fluid retention causes swelling generally in the tongue, lips, or eyelids. Swelling of the airways can result in difficulty breathing, closing off of the airway and death.  If swelling is happening along with signs of breathing difficulty seek help immediately.

What are some symptoms of swelling to look for?

• Feet and lower legs get larger when you sit or walk.
• Take a look at your feet, ankles and hands.  Are they swollen?  When you press on the skin with your finger, is there an indentation that stays for a few seconds?  If so, you may have "pitting edema."
• Hands feel tight when you make a fist
• Rings are too tight
• Abdomen appears to be swelling or distended
• Shortness of breath (especially when lying down)

Things you can do to manage swelling:

• Elevate your feet as often as possible. (Either sitting in a chair with your feet on a stool with a pillow or in the bed or couch with feet up on two pillows)
• Do not stand for long periods of time.
• Avoid tight clothing (shoes, girdles, etc).
• Do not cross your legs.
• Reduce your salt intake if swelling is present. Avoid foods such as bouillon, potato chips, tomato juice, bacon, ham, canned soups, soy sauce, and table salt, for example.
• Try to eat a balanced diet (see eating well section).
• If your swelling is severe, consider wearing Jobst stockings or TED hose.
• Weigh yourself daily. Notify your doctor or health care provider if you have gained 5 pounds or more in a week.
• Take your medications exactly as prescribed.

Drugs or recommendations that may be prescribed by your doctor or health care provider for symptoms of swelling:

• Depending upon the causes of your swelling, your doctor or health care provider may prescribe a diuretic.  Diuretics - may be known as "water pills" as they work by making you urinate out extra fluid. Some examples of this medication may include furosemide (Lasix), and Hydrochlorthiazide. You may receive this medication alone or in combination with other medications.
• Your doctor or health care provider may recommend that you see a registered dietitian to help plan a diet tailored to your condition.

When to call your doctor or health care provider about swelling:

Call your doctor or health care provider immediately: 

• If you are short of breath.

Call your doctor or health care provider within 24 hours:

• If you have gained 5 pounds or more in one week.
• If you develop sudden and severe fluid retention.
• Your feet or hands feel cold to the touch.
• If you are unable to eat for more than a day.
• If you have urinated only a little bit or not at all.
• If the swelling appears to move up your arms or legs.

Call your doctor for concerns after surgery: Morbilliform drug reaction

Morbilliform drug reaction

What is morbilliform drug reaction?

Morbilliform drug eruption is the most common drug hypersensitivity reaction. Many drugs can trigger this allergic reaction, but antibiotics are the most common group. The eruption may resemble rashes or exanthems caused by viral and bacterial infections.

It is also called maculopapular drug eruption, morbilliform exanthem and maculopapular exanthem.

Who gets it?

Morbilliform drug eruptions are very common, comprising 95% of all drug-induced skin reactions. Beta-lactam antibiotics (penicillins, cephalosporins), antibiotic sulfonamides, allopurinol, anti-epileptic drugs and nonsteroidal anti-inflammatory drugs (NSAID) are the most common drugs to cause this. However the list is very long and includes herbal and natural therapies.

On the first occasion, the skin rash usually appears 1-2 weeks after starting the drug, but sometimes may occur up to 1 week after ceasing the medication. However on re-exposure to the causative (or related) drug, skin lesions appear within 1-3 days.

In general, a morbilliform skin rash in an adult is usually due to a drug, but in a child is more likely to be viral.

The development of a morbilliform eruption after starting amoxicillin for sore throat and fever is almost diagnostic for glandular fever (infectious mononucleosis), occurring in almost 100%.

Clinical features

Morbilliform drug eruption usually first appears on the trunk and then spreads to the limbs and neck in a symmetrical pattern. Mucous membranes are not affected.

The exanthem consists of widespread pink-to-red flat spots (macules) or raised bumps (papules) that blanch with pressure. It may resemble the rash of measles, rubella or scarlet fever, thus mimicking viral and bacterial exanthems. The spots may cluster and merge to form sheets over several days, sometimes involving the entire skin surface. On the lower legs the spots may appear purple and non-blanchable (purpura), especially if the patient has a low platelet count. On the extremities the spots may appear ring-shaped (annular) or hive-like (urticaria-like), giving a polymorphous (mixed) appearance, a clue that this is a drug reaction and not due to infection.

The rash may be associated with a mild fever and itch.

Treatment

Often times patients can develop this presentation with use of prophylactic antibiotics, and the best course of action is to discontinue the medication if possible immediately. Other times ancillary treatment may also be useful such as prednisone, cremes, diphenhydramine, and referral to allergist for severe cases.  

Pickle-Ball tips for Seniors

1. Don’t red line your heart by working out to exhaustion.
   
2. Use lower intensity, endurance-type exercise such as bicycling, swimming and jogging slowly as cross training.  Cross training is what makes you stronger and more fit.   More pickleball just gives you overuse syndrome.
   
3. Drill on the pickleball court part of the time and play part of the time.
   
4. Sit down and rest when you get tired.
   
5. Nap if possible.
   
6. Eat healthy foods like green leafy vegetables, fresh veggies, fresh fruit not juice.  Leave out carbs with white sugar.  A banana, low fat yogurt and a bagel for breakfast is not a balanced healthy way to hit the pickleball court.  Why not? Any low fat product has more sugar in it (not more calories, but more sugar).  A banana converts to sugar and a bagel is starch (which converts to sugar).   Put a little almond butter and banana on the bagel or tuna on the bagel for some added protein.
7. Stretch after you exercise.  Stretch all the time.   Stretching even a little goes a long way for your health.
   

Hope this helps,

Dr Timm

Blister Protocols

Blisters are caused by skin friction. Your foot is sliding or shifting in your shoe during running and other activities. Fluid collects between the irritated layers of skin tissue and swells. Blister treatment should help to avoid infection, minimize pain and discomfort, stop swelling and maximize recovery.  

Most of the time patients are not presenting in the office with this as a chief complaint unless it is infected or not healing readily, but patients often ask me how to treat them. Here is a good guide in general for you to follow, keep in mind this does not include DIABETICS, as you all should not treat your own wounds without my help.

Brian Timm, DPM, FACFAS

Diplomate American Board of Podiatric Surgery 

For an​​ intact blister:

• Apply a piece of moleskin, adhesive felt or tape that is 1.5 to 3.25 inches larger than the blister, with a central hole slightly larger than the blister
• .Apply antibiotic ointment.
• Place a piece of gauze over the moleskin, felt or tape and add a piece of adhesive tape to hold the gauze in place.

Over-the-counter products such as Mueller® More Skin or Spenco® 2nd Skin® work well for blister relief and protection.

If you are going to continue running, drain blisters in weight-bearing areas that are greater than 0.8-inch in diameter. Follow these steps:

1. ​​Clean the site with an alcohol wipe or hydrogen peroxide.
2. Use a flame sterilized needle to lance two to four holes in the side of the blister.
3. Apply pressure to push out the fluid. Clean and dry the skin.
4. Apply benzoin around the blister. 
5. Apply a thin layer of antibiotic ointment at the puncture sites. Do not remove the outer layer of dead skin.
6. Apply a blister care product. 
7. Check the site daily.

If the fluid appears hazy or cloudy in the blister, drain it. Apply antibiotic ointment and a protective covering. Check the site frequently.

For a r​uptured blister:

1. Treat with antibiotic ointment over the blister and use a protective covering. 
2. If the outer layer is torn off or only a flap is left, carefully cut off the loose skin, clean the area and cover the new skin with antibiotic ointment. Use a protective covering such as Tegaderm, or some other variant over the counter. 
3. If infection is present, clean the site frequently, apply antibiotic ointment and see your health care provider for more treatment options.