List of Abbreviations
No.
Terms and Definitions
Corns and calluses are focal frictional hyperkeratoses developing as a normal physiological reaction of the skin in response to chronic excessive pressure or friction.
A corn is a circumscribed, painful area of hyperkeratosis arising as a result of prolonged mechanical action.
A callus is a skin reaction in the form of hyperkeratosis in response to prolonged mechanical irritation, often of an occupational nature.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Corns and calluses are focal frictional hyperkeratoses developing as a normal physiological reaction of the skin in response to chronic excessive pressure or friction.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The formation of calluses and corns is caused by locally acting excessive mechanical loads.
Corns and calluses arise as a result of hyperkeratosis caused by increased keratinocyte activity associated with epidermal stimulation by chronic skin pressure or friction.
Abnormal mechanical impacts on the skin lead to epidermal stimulation, increased keratinocyte activity, and the formation of an accumulation of several layers of the stratum corneum of the epithelium (hyperkeratosis). Abnormal mechanical loads can be the result of numerous internal factors (bony prominences/exostoses or hammertoes, clubfoot, flat feet, etc.) or external factors (ill-fitting footwear, surface irregularities inside the shoes, obesity, high physical activity, trauma by various objects, including during occupational activities). As mechanical stress on the skin increases, the body attempts to protect irritated areas by forming a hyperkeratotic lesion such as a corn or callus; however, in tight shoes, this damage will lead to increased pressure, thereby creating a vicious cycle. Impaired blood circulation and innervation in various parts of the body (most commonly in the lower extremities), including varicose veins, obliterating atherosclerosis, and polyneuropathy, intensify the rate of formation and severity of corns and calluses, and contribute to the formation of complications such as fistulas and malignancy [1-8].
1.3 Epidemiology of the Disease or Condition
In the Russian Federation, statistical accounting of patients with calluses and corns is not maintained. The prevalence is unknown. It is estimated that the incidence of foot corns ranges from 14% to 48% of the population. They are reported to affect mainly older age groups with a slight female predominance due to the wearing of narrow shoes. Elderly people are also prone to the loss of protective fat pad cushioning, known as fat pad atrophy, which may increase the incidence of painful corns [1,9-11].
1.4 Features of Coding the Disease or Condition
L84 - Corns and callosities
1.5 Classification of the disease or condition
There is no universally accepted classification, however, the following main clinical varieties (types) can be distinguished [1,12-13].
1. Corn.
a) hard (heloma durum);
b) soft (heloma molle).
2. Callus.
a) diffuse-sliding;
b) discrete-nuclear.
1.6 Clinical presentation of the disease or condition
A corn is a circumscribed hyperkeratotic skin lesion with a central conical thickening (core) of keratin, with its base on the surface and apex directed inward, penetrating deeply into underlying tissues and structures, causing pain and inflammation. Corns typically present as dry, hard, rough, skin-colored papules with a whitish center (the so-called core), located over a bony prominence, painful upon pressure, walking, and standing, but asymptomatic to the touch. As the keratin masses grow and thicken, corns can enlarge and cause severe pain during ambulation. Long-standing corns may be complicated by penetration into nerve fibers and blood vessels (neurovascular corns) and can become dense and fibrous (neurofibrotic corns), causing inflammation and/or severe pain that significantly impacts the patient's daily activities. The pain may be dull, boring, or sharp and shooting. The conical core of the corn, which represents a thickening of the stratum corneum, is a protective response to mechanical trauma. This central core distinguishes a corn from a callus. Corns are divided into two subtypes: hard (heloma durum) and soft (heloma molle).
A hard corn ("heloma durum"), which is the most common type, appears as a dry, hyperkeratotic horny mass with a hard central core. Hard corns most frequently occur on the dorsolateral aspect of the fifth toe or on the dorsal aspect of the interphalangeal joints of the lesser toes.
A soft corn or interdigital corn ("heloma molle") results from the absorption of a large amount of moisture from sweat, appears whitish, and is characterized by a macerated appearance. A soft corn is an extremely painful skin lesion that can develop between any toes, but most commonly between the fourth and fifth toes due to pressure from an exostosis at the metatarsophalangeal joint pressing on the toe. This location often leads to maceration, and sometimes to secondary bacterial and/or fungal infection, or ulceration.
Corns may have a round, ellipsoidal, or conical shape, and can be single or multiple, uncomplicated or complicated by secondary bacterial and/or fungal infection, sinus tract formation, or malignant transformation.
A callus represents a broad or diffuse hyperkeratotic lesion of relatively uniform thickness, commonly found beneath the metatarsal heads in areas of friction, irritation, and pressure. Clinically, a callus presents as a large hyperkeratotic plaque of relatively uniform thickness with poorly defined borders, unlike a corns, and a smooth or rough surface, yellowish-brown in color, and painless upon palpation. The two main types of calluses are diffuse-sliding and discrete-nuclear.
The localization of calluses is not restricted to the feet; they occur wherever the skin experiences increased mechanical stress (palms in laborers, chin in violinists, etc.). Individuals engaged in various sports, certain professions, or other repetitive mechanical activities develop calluses of various sizes and locations as stigmata. Examples include "surfer's knots", boxer's knuckles, "runner's toe", rower's calluses, "milker's nodule", "tennis player's toe", "jogger's nipple", "prayer callus", "yoga mark", and neck or chin calluses in violinists. They resolve spontaneously after the cessation of the mechanical irritant.
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis is established based on the analysis of complaints, medical history, physical examination, and assessment of the clinical picture of the disease [1,12-13].
2.1 Complaints and Anamnesis
Complaints and anamnesis are described in section 1.6. "Clinical picture".
2.2 Physical Examination
Physical examination data are described in section 1.6. "Clinical picture".
2.3 Laboratory Diagnostics
Laboratory diagnostics are performed to rule out secondary pathogenic flora.
It is recommended for patients with corns and calluses in the presence of diabetes mellitus to undergo microbiological (culture) examination of the discharge from skin eruption elements for sensitivity to antibacterial and antifungal drugs when secondary infection is suspected [16-19].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: given the proven association between corns and neuropathic ulcers in diabetes mellitus, along with a high risk of infection upon loss of skin integrity, and to prevent severe complications, it is indicated to perform a microbiological (culture) examination of the discharge from skin eruption elements for sensitivity to antibacterial and antifungal drugs, which allows for the prescription of effective antibacterial and antimycotic therapy.
2.4 Instrumental Diagnostics
Not applicable.
2.5 Other Procedures
It is recommended that patients with corns and calluses undergo consultations with specialist physicians: an initial examination (inspection, consultation) by a dermatovenereologist for the diagnosis and treatment of the disease; an initial examination (inspection, consultation) by an orthopedic traumatologist for the diagnosis and correction of identified musculoskeletal disorders; an initial examination (inspection, consultation) by a surgeon/pediatric surgeon for the diagnosis and treatment of long-standing, painful corns refractory to topical conservative therapy, including those complicated by sinus tract formation or necrosis, especially in diabetic-neuropathic limb tissue damage, to determine the surgical treatment strategy, including sharp debridement [1,6,20-22].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Achieving effective therapy for corns and calluses requires a comprehensive and interdisciplinary approach.
3.1 Conservative Treatment
Any biomechanical abnormalities and/or foot deformities should be managed with appropriate conservative treatment. This involves wearing properly fitted footwear, using custom orthotic insoles or soft padding (e.g., silicone cushions), and foot-correcting devices (special orthopedic prostheses and correctors) that reduce friction and enhance comfort. Corns develop in areas of friction or pressure and spontaneously disappear when these causative factors are eliminated. Frequently, a bone spur or exostosis is present beneath both long-standing hard and soft corns, and unless this exostosis is removed, cure is unlikely.
Topical therapy.
It is recommended to prescribe topical preparations with a keratolytic effect to areas of hyperkeratosis in patients with corns and calluses to improve keratinization and exfoliation (D11A Other dermatological preparations, Cosmetics (V07AT) [22-31].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended for the restoration of the epidermal barrier and to improve keratinization to prescribe topical cosmetic products: emollients (creams containing petrolatum, paraffin, silicone, mineral and vegetable oils) and moisturizers (creams and ointments containing sodium chloride, urea, glycerin, ceramides, and physiological lipids) 2–5 times a day [32-39].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
3.2 Surgical Treatment
Surgical treatment is performed in adult patients only in cases of conservative therapy failure while simultaneously eliminating provoking factors. Surgical treatment includes excision and/or destruction of corns using various methods: sharp debridement, electrosurgery, ablative laser therapy, etc. [39-44].
It is recommended for adult patients with corns and calluses to undergo physical methods of destructive therapy with prior local infiltrative skin anesthesia for the removal of the corn [45-52]:
electrosurgery,
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
or
laser destruction (laser therapy) of skin tissues.
GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).
Comments: ablative laser therapy may be used. An erbium-doped yttrium aluminum garnet (Er:YAG) laser with a wavelength of 2940 nm has been used for the treatment of corns with minimal thermal tissue damage [52]. However, it must be remembered that some patients may experience a recurrence of lesions, especially if the provoking factor persists.
3.3 Other Treatment
Not applicable.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable.
5. Prevention and Dispensary Observation
It is recommended for all patients to avoid wearing ill-fitting footwear and mechanical trauma to the affected skin area for the prevention of the disease [1-3,12-13,15].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
6. Organization of Medical Care
Treatment is mainly carried out on an outpatient basis in dermatovenereological and surgical medical facilities.
7. Additional Information
None.
Criteria for Evaluating the Quality of Medical Care
№ | Quality assessment criteria | Performance evaluation |
|---|---|---|
1. | Initial appointment (examination, consultation) by a dermatovenerologist | Yes/No |
2. | Topical therapy with keratolytic agents was performed (D11A Other dermatological preparations, Cosmetics (V07AT) (in the absence of medical contraindications) | Yes/No |
References
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Appendix A1. Working Group Composition
1. Potekaev Nikolay Nikolaevich – Doctor of Medical Sciences, Professor, President of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Union against STIs (IUSTI/WHO), Honorary President of the Euro-Asiatic Association of Dermatovenereologists (EAAD), Board Member of the European Academy of Dermatology and Venereology (EADV), Corresponding Member of the German Dermatological Society (DDG), Honored Doctor of the Russian Federation, Chief freelance specialist in dermatovenereology and cosmetology of the Russian Ministry of Health, Chief freelance specialist in dermatovenereology and cosmetology of the Moscow Department of Health, Director of the Moscow Center for Dermatovenereology and Cosmetology, Head of the Department of Skin Diseases and Cosmetology at the Faculty of Continuing Medical Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health.
2. Dolya Olga Valentinovna – Doctor of Medical Sciences, Member of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Union against STIs (IUSTI/WHO), Member of the European Academy of Dermatology and Venereology (EADV), Member of the Guild of Sexually Transmitted Infection Specialists "USTI RU", Deputy Director for Research at the Moscow Center for Dermatovenereology and Cosmetology.
3. Zhukova Olga Valentinovna – Doctor of Medical Sciences, Professor, Executive Director of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Union against STIs (IUSTI/WHO), Member of the Guild of Sexually Transmitted Infection Specialists "USTI RU", Chief freelance specialist in dermatovenereology and cosmetology of the Central Federal District of the Russian Ministry of Health, Chief Physician of the Moscow Center for Dermatovenereology and Cosmetology, Head of the Department of Dermatovenereology and Allergology with a Course of Immunology at the Medical Institute, Peoples' Friendship University of Russia.
4. Gadjigoroeva Aida Guseykhanovna – Doctor of Medical Sciences, President of the Interregional Public Organization of Trichologists and Hair Research Specialists "Professional Association of Trichologists", Member of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Hair Research Society (EHRS), Head of the Department of Clinical Dermatovenereology and Cosmetology at the Moscow Center for Dermatovenereology and Cosmetology.
5. Zavarina Irina Vladislavovna – Candidate of Medical Sciences, Member of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Academy of Dermatology and Venereology (EADV), Senior Researcher at the Department of Clinical Dermatovenereology and Cosmetology at the Moscow Center for Dermatovenereology and Cosmetology.
6. Baranov Aleksandr Aleksandrovich – Doctor of Medical Sciences, Professor, Academician of the RAS, Chief freelance specialist in pediatrics of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia.
7. Namazova-Baranova Leila Seymurovna – Doctor of Medical Sciences, Professor, Academician of the RAS, President of the Union of Pediatricians of Russia; Past President of EPA/UNEPSA; Head of the Research Institute of Pediatrics and Child Health at National Medical Research Center No. 2 of the Petrovsky National Research Centre of Surgery, Head of the Department of Faculty Pediatrics at the Pediatric Faculty, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Chief freelance pediatric specialist in preventive medicine of the Russian Ministry of Health.
8. Ambarchyan Eduard Tigranovich – Candidate of Medical Sciences, Leading Researcher, Head of the Pediatric Dermatology Department at the Research Institute of Pediatrics and Child Health, National Medical Research Center No. 2 of the Petrovsky National Research Centre of Surgery of the Ministry of Science and Higher Education of the Russian Federation, Member of the Union of Pediatricians of Russia.
Conflict of interest: the authors declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Dermatovenereologists.
Residents and trainees of continuing professional education cycles in the specialty "Dermatovenereology".
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Levels of Evidence (LE) rating scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | There is only a rationale for the mechanism of action of the intervention (preclinical studies) or expert opinion |
Table 3. Scale for grading grades of recommendation (GoR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Not used.
Appendix B. Physician Action Algorithms
Flowchart 1. Management algorithm for an adult patient with suspected corn and callus.
Appendix C. Patient Information
All patients are advised to avoid wearing ill-fitting shoes and mechanical trauma to the affected skin area for disease prevention. Any biomechanical abnormalities and/or deformities should be treated with appropriate conservative management: properly fitted footwear, and when indicated, custom orthotic insoles, special orthopedic pads, and correctors that reduce friction and increase comfort.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not used.