The toe box of the shoe is the semi-circle that covers and protects the toes. Remember those cute little red and white sneakers that your mom got you when you just started to walk? Remember how they had that white rubber toe? That’s the toe box. But consider what a rubber toe box like that can do to your skin. The rubber toe box prevents the release of perspiration. The rubber toe box also contributes to an increase of the temperature inside the shoe.  This contributes to excessive perspiration and creates a terrible environment for the skin. So we grew up and grew out of the rubber sneakers, but guess what? Most shoes have a toe box to stiffen the shoe and promote the durability of the shoes. As a result we see toe box problems in a host of other shoes including work boots (especially safety shoes), clogs, oxfords and others. Simply reach into the shoe and feel for the materials that make up the toe box.

Dermatitis is a generic term used to describe any condition that exhibits inflammation of the skin. The environment in a shoe is pretty harsh, but when you manufacture the shoe with materials that can’t vent moisture, dermatitis is bound to occur. Toe box dermatitis is the term usde to describe the skin reaction that takes place as a result of an enclosed or rubber toe box.  But toe box dermatitis can occur at any age. Toe box dermatitis is simply the result of the contrast found when wearing a shoe (sweaty and hot) compared to being barefoot (cool and dry). As a result we see peeling and redness in the skin or what we call dermatitis.

Treatment of toe box dermatitis

The most important aspect of treating toe box dermatitis is prevention. Avoid shoes with synthetic materials that trap moisture. Wear canvas or leather materials that will breath and accept moisture. Consider rotating shoes, wearing them only once every other day. And don't forget open toe sandals.  Drying agents like Onox can help to inhibit moisture. And lastly, frequent changes of socks will always help to wick away moisture, keeping the feet cool and dry.

Most cases of toe box dermatitis clear with these simple methods of care.  Occasionally we will see an opportunistic fungal infection of the foot that can be controlled with antifungal soap or antifungal cream.

In adult foot care, the most common source of dermatitis is a chronic fungal infection of the skin called dermatophytosis. The appearance of dermatophytosis resembles dry skin. Dermatophytosis is found on the sides and soles of the feet. The border of a dermatophytic infection is often quite distinct showing peeling skin and inflammation. The fungal organism responsible for dermatophytosis burrows into the skin causing the red appearance (erythema) we call inflammation. The cause of this particular form of dermatitis is a fungal organism named tinea rubrum. Dermatophytosis is often treated unsuccessfully as dry skin. This form of dermatitis is best treated by changing the environment within the shoe to be less conducive to the growth of fungus. Fungus thrives in a dark, damp environment. The creation of a dry, cool environment can make a significant first step in treatment. This form of dermatitis is also treated by using a combination of a drying agent, antifungal shoe spray, antifungal soap and a topical antifungal on a daily basis.

Contact dermatitis is another common condition in foot care. Contact allergens can be any number of chemicals or environmental substances. The chemicals used in the processing of leather are a common contributing source of contact dermatitis of the foot. Other direct irritants seen in adult foot care include cement dust, fertilizers and herbicides. A number of direct irritants are activated by light exposure and include sun screening agents, topical antibiotics and aerosol tanning agents. Biological irritants such as poison ivy and poison oak are also common in foot care. One important aspect in treating contact dermatitis is a good patient history that recognizes the patient's occupation and social activities. First and foremost in the treatment of contact dermatitis though is the identification and removal of the contributing irritant. This process may not be easy and may include the discontinuation of any oral medication taken by the patient that may be a source of systemic skin reaction. Avoid direct sun exposure. Use of an oral or topical antihistamine may help control any inflammatory reaction. And lastly, skin softeners need to be used to hydrate the skin.

Atopic and neurotic dermatitis are two forms of dermatitis also found in adult foot care. Atopic dermatitis is a category of dermatitis that is usually associated with allergic disorders such as asthma and hay fever and immune disorders. Neurotic dermatitis is found in patients who experience generalized anxiety that results in focal irritation of the skin of the hand or foot, often both. Atopic dermatitis and neurotic dermatitis are both treated with topical steroid creams and skin softeners.

Dermatitis secondary to circulatory changes of the feet are common. Decreased arterial flow to the feet results in dryness and a brittle appearance of the skin. These findings are common in older adults. In advanced peripheral arterial disease (PAD), crusting of the compromised digits occurs. Crusting is also found in acute cases of circulatory compromise such as frostbite.

Venous stasis dermatitis is common in older adults who have poor venous return of blood from the feet back up the leg to the heart. This condition results in pooling of fluids in the lower 1/3 of the leg. This pooling creates a rough 'orange peel' appearance of the skin of the leg. The skin also becomes flakey and dry. Ulcerations of the medial ankle are common. Treatment for arterial and venous forms of dermatitis focus on the return of normal blood flow to and from the extremity. For arterial forms of dermatitis, skin softeners should be used on a daily basis. For venous dermatitis, elevation of the legs and compression hose are used to control swelling of the legs. Topical skin softeners are also helpful.

Dermatitis of the feet in children should also be noted. Toe box dermatitis is a common condition seen in young children, To treat toe box dermatitis, first take a careful look at the materials that are used to manufacture the shoe. Avoid shoes that contain non-breathable rubber components. Consider rotating shoes, wearing then only once every other day. Powders and sprays can help to wick away moisture from the foot. And lastly, frequent changes of socks will always help.

Left untreated, venous stasis can progress to a venous ulceration.  The most common location for a venous ulceration of the lower extremity is over the medial aspect of the ankle.  Venous ulcerations vary in size and depth.

Treatment of stasis dermatitis and venous stasis ulcers.

Central to the treatment of venous stasis dermatitis and venous stasis ulcers is control of lower extremity edema. Edema can be controlled by elevating the legs above the level of the heart, use of diuretics and the use of compression hose. It's important to realize that when using compression hose, the hose need to be put on first thing in the morning in advance of any swelling. If swelling is allowed to occur before applying the support hose, that swelling will likely be there the rest of the day.

Eczematous changes (peeling and flaking) and lichenification (hardening of the epidermis) can be treated with skin softening agents. Inflammatory changes of the skin are common and can be treated with topical or oral steroids. Discoloration of the skin is difficult to treat. Discoloration or darkening of the skin is often due to the deposition of hemosiderin (the iron component of red blood cells). Once hemosiderin is deposited in the skin, is is much like a tattoo that stains the skin from within.

Ulceration of the skin is common, particularly at the medial (inside) ankle. The area superficial to the origin of the great saphenous vein is the most common site of ulceration. Ulcerations should be cultured and treated for infection if necessary. Dome paste boots, also called an Unna boots are the gold standard for treating venous stasis ulcerations. Dome paste boot are saturated with zinc oxide that will moisturize the skin. Dome past boots are applied on a one weekly basis to control lower extremity edema. Treatment can take from one to many weeks to see complete closure of the venous ulcer.  Negative pressure treatment of the wound along with skin grafting may be necessary in severe, non-healing ulcers.

It is essential to realize that control of edema is necessary following successful treatment of a venous stasis ulcer. Compression hose should be worn daily to prevent reoccurrence of ulcerations.