The approach of summer signals an increase in customer queries about foot and leg health. With people now more used to visiting pharmacy first for minor ailments, it’s important that team knowledge is up to date, including understanding when to refer potentially serious symptoms. 

Diabetes is the cause of one amputation every hour in the UK, and a person with diabetes is 20 times more likely to need an amputation, says Diabetes UK. 

For people with diabetes, foot problems are more common and potentially more serious than they might be for others. This is because raised blood sugar, raised cholesterol and high blood pressure can affect sensation in the feet. Known as peripheral neuropathy, this can cause problems with blood flow to the feet, meaning that cuts, sores and blisters don’t heal as quickly.

“Pharmacy staff are importantly placed to advise people with diabetes about their foot health,” says Michael Ratcliffe, podiatrist and sales training manager at Cuxson Gerrard. “If a person with diabetes collects their medication or reports a problem with their feet, staff can ask the person about their foot health and foot checking regime. If the person does not have a checking regime, then they can be advised how to do this.”

People with diabetes should have an annual foot check, usually as part of their diabetes health check with their GP. It’s a good idea to ask customers if they’ve had one in the last year. In addition, Diabetes UK recommends a daily foot check:

• Remove shoes and socks
• Touch both feet and check the temperature – they should feel the same and not hot or cold
• Check feet for calluses, blisters, scabs and any changes in shape or colour 
• Look between toes for dry/flaky skin
• Check toenails are not too long or digging into skin.

For additional advice, signpost to the Diabetes UK helpline (0345 1232399) or website.

Self care advice

“Basic footcare, such as filing toenails, using a pumice stone or emery style foot file and applying moisturising cream regularly, is generally safe. Acid-based treatments such as corn plasters should only be used with the advice of a podiatrist as they can quickly create a wound in the healthiest of people,” says Emma McConnachie, podiatrist and spokesperson for the Royal College of Podiatry. “Blades, sharp implements and cheese grater style devices are best avoided for any person, especially those with diabetes. Any issue which has caused a wound, such as an ingrown toenail, or an open wound of more than one week duration should be seen by a podiatrist.”

Mr Ratcliffe adds that people with diabetes should be referred to an expert if they are unsure about anything on their feet, including corns and toenail problems. “Corns and calluses are increasingly being seen as evidence of pathological pressure and therefore in the diabetic foot, a point of concern,” he says. “A recommendation should be offered that the customer should seek the opinion of their GP or podiatrist. The importance of good skincare in diabetes cannot be overstated. Damage to skin from pressure and dry skin can quickly lead to ulceration, infection and amputation in poorly controlled diabetes.”

At Numark, Sue Swift says: “The best advice pharmacy staff can give to customers with diabetes is to ensure they check their feet daily and to make sure they are clean before putting socks on. They should be reminded to have their feet checked at their annual diabetes care review.”

The foot sensation test

Diabetes UK recommends that people with diabetes carry out a foot sensitivity test (the Ipswich touch test) regularly. Pharmacy teams can signpost customers to an explanatory video.

The customer will need a helper to conduct the test. It consists of the helper touching six toes (three on each foot) and recording how many touches the patient feels. Touch should be very light and for no more than a few seconds.

If the patient does not feel two or more touches, it’s likely they have reduced sensation and should contact their GP.

Charcot foot

This is a serious complication associated with diabetes. It is important to recognise the signs, as there is a risk of amputation if it’s not treated:

• Swelling of foot
• Warmth (affected foot feels warmer than the other)
• Change in foot colour
• Change in foot shape.

If a customer notices any of these signs, they should take the weight off their foot and contact their GP or footcare team. Treatment includes keeping the foot as still as possible, in a plaster cast or boot, for the bone to heal and prevent a foot ulcer. Surgery is sometimes needed to reshape the damaged foot.

Standing issues

A recent survey for the Royal College of Podiatry found that 79 per cent of retail workers are on their feet for four to 10 hours during their working day. Of these, 30 per cent felt that their mental wellbeing and quality of work was affected after just four hours, rising to 41 per cent by hour eight. A further 35 per cent didn’t seek a solution to their issues or know what solutions were available.

Chartered physiotherapist Ben Lombard says Plantar fasciitis and bursitis in the feet are common, as are hip and knee pain from lack of strength and stability in the hip stabiliser muscles. “I would suggest these customers work on muscles to strengthen the core and lower back, such as deadlifts, planks and back extensions,” he says. “For the legs, squats and lunges are helpful. For sore and aching feet, calf raises are good. They need to strengthen the muscles in their hips and core. Other advice to pass on includes wearing decent, supportive footwear and to take regular breaks to stretch and get off their feet.”

The Royal College of Podiatry suggests these simple steps to pass on to your customers to help them to avoid foot problems:

1. Wash feet daily in warm, soapy water to help prevent infections
2. Keep feet moisturised to avoid dry, cracked skin. Rub dry areas with a pumice or foot file in the bath or shower
3. Wear well-fitting shoes. Try on new footwear in the afternoon when feet are at their largest
4. Check feet weekly to spot any problems early
5. Change socks daily to avoid sweaty feet and Athlete’s Foot
6. Trim toenails straight across, never down the corners, to avoid ingrown nails. Leave corners of nails visible above skin
7. Try not to wear the same shoes two days in a row to reduce chances of fungal infection
8. Do calf stretches daily to keep feet supple
9. Keep high heels for special occasions only. 

Compression hosiery 

Compression hosiery is recommended for conditions including venous ulcers, varicose veins, lymphoedema and post-thrombotic syndrome. It provides graduated pressure and increases venous blood flow and is available in three compression types: light (class 1), medium (class 2) and high (class 3). The condition of the customer’s skin should be checked before recommending compression hosiery and, ideally, venous ulcers should be healed first.

“Pharmacists can recommend compression hosiery for their customers if they have varicose veins and have a family history of venous disease,” says Ms Swift. “If the patient has swollen ankles, they must be assessed by their GP first before compression hosiery can be prescribed and provided by pharmacy staff. Open toe stockings are an alternative option which are easier to apply and are cooler in hot weather. However, they can ride up the foot more easily and can exacerbate joint pain in the feet.”

DVT warning signs

Although half of people with a DVT have no symptoms, it’s important to be aware of the possible signs:

• Leg or calf may be swollen or painful
• Skin may look red and feel warm or tender to touch.

If a clot travels to the lungs, it can cause a pulmonary embolism. Warning signs are shortness of breath, chest pain and a weak, dizzy feeling. With any of these signs, the patient should see a doctor immediately.

Category management

Cathy Crossthwaite, Numark OTC business development executive, has the following tips for category success: “Simple navigation with clear signposting and positioning by condition can help customers to locate and browse the category. The three core subcategories are athlete’s foot, verrucae, and nail care, so pharmacy teams should use these as beacons to help customers locate the category, with key brands blocked together on the fixture to create impact. Many products within the category are often displayed on hanging units. If this is the case, pharmacists should ensure that all footcare products are positioned close together to save customers traveling to different ends of the pharmacy to locate required products.”

Mr Ratcliffe adds that clear labelling is paramount, to help with questions such as ‘I have a corn… what do I buy? My skin is dry, there are cracks in my heels… what do you suggest?’ He says: “These kinds of daily questions should be answered clearly with product category labels. The difference between what each product offers, particularly what each brand can and can’t do, should be known to pharmacy staff.”

Product news

Dermatonics has launched the Sensi-Pedi foot range. Products include Sensory Foot Soak with lime essential oil; Sensory Foot Scrub with lime and coconut shell to exfoliate; Hard Skin Removing Balm with shea butter and oat lipid oil; Heel Balm, enriched with Manuka honey, and Deodorizing Fuzzy Foot Foam, with honey and menthol. The company also offers a Diabetic Pre-Ulcerative Callus Risk Assessment tool.

Cuxson Gerrard is the representative for Gerlach products in the UK and is launching a selection of products to care for normal, dry, sensitive and diabetic skin. These include Gehwol Medical Care Concept’s Lipidro Cream, a dry skin moisturiser with 10 per cent urea, glycerin and sea minerals.

Views of the P3pharmacy category panel

“This is a relatively small area, but our most popular products are for cracked heels and for blisters, which both sell consistently all year round. Most of the queries we get from customers relate to how to treat and prevent cracked heels. Best sellers are Flexitol for cracked heels and Compeed blister plasters. It’s important to stock a variety of sizes for both conditions. They’re often an impulse buy, so it’s a good idea to keep stock on the counter as well as on your foot care stand. We don’t get too many asks for compression hosiery, though we do keep flight socks in stock.”

Sarina Mughal, Day Lewis, Knightsbridge

Anxiety resulting from the pandemic means customers don’t want to see the doctor for health issues they perceive as less serious. Foot care is one of them, so there’s a responsibility on pharmacists to diagnose serious problems and signpost patients if needed. Fungal infections, such as athlete’s foot, are common in older people and 15-20 per cent people with diabetes could develop them as well. An effective anti-fungal treatment containing terbinafine, miconazole or clotrimazole, with good hygiene advice from a pharmacist, could be very valuable.”

Hardik Desai, Ticehurst Pharmacy, Kent

“This is a fairly important category for us – we promote using our digital displays – with the main concern being how to treat hard skin, though other main concerns are tired feet and legs, and varicose veins. We have a chiropodist running a foot clinic, which is popular with our customers. Top sellers include Vogel’s Venogel for tired legs and Flexitol for hard skin. For athlete’s foot, we sell a tea tree powder which can be used after treatment to help prevent recurrence. We don’t sell many compression stockings – probably about five pairs a month. The Activa range does well.” 

Deepak Bilakhia, Carrington Pharmacy, Nottingham