Foot care for individuals needing care: What relatives must know about organisation, prescriptions, and hygiene

What lies behind it

The human ageing process fundamentally alters the entire musculoskeletal system as well as the structure of the skin and nails. In elderly individuals requiring care and chronologically ill patients, physiological ageing processes accumulate alongside pathological changes. The subcutaneous adipose tissue on the sole of the foot, which serves as a natural shock-absorbing system, loses volume and elasticity over the decades. This fat pad atrophy causes the metatarsal heads and calcaneal bones to be exposed to more direct mechanical pressure.

Simultaneously, microcirculation within the cutaneous tissue declines. The capillaries transport less oxygen and nutrients to the periphery. The activity of sweat and sebaceous glands decreases significantly, leading to pronounced xerosis cutis. This extremely dry skin loses its natural barrier function against pathogenic microorganisms. Fine micro-fissures, known as rhagades, develop and serve as portals of entry for bacteria such as Staphylococcus aureus or fungal pathogens.

The structure of the toenails also undergoes marked alteration with advancing age. Nail growth slows from an average of 1.5 millimetres per month in young adults to less than 0.8 millimetres in people over 70 years of age. Keratin synthesis in the nail matrix changes. This frequently leads to onychauxis, an abnormal thickening of the nail plate, or to onychogryphosis, in which the nail thickens into a horn-like texture and curves into a claw-like shape. Such altered nail structures can no longer be shortened safely with conventional household nail scissors or clippers.

A major medical factor is the reduced perception of pain and temperature in the context of sensory polyneuropathy. Many people requiring care no longer feel small cuts, pressure points, or foreign objects in their shoes in time. If such microtrauma remains undetected, ulcerative tissue necrosis rapidly develops in combination with reduced arterial blood flow. Podiatric science makes a clear distinction here between purely cosmetic foot care and medically oriented podiatric treatment.

Typical signs

Relatives should inspect and palpate the feet of family members requiring care at regular intervals. Thickened, yellowish-brown discoloured, or brittle nail plates indicate onychomycosis. Without consistent treatment, this fungal infection of the nail matrix spreads to adjacent toes and permanently destroys the nail structure. Lateral redness and swelling of the nail fold suggests onychocryptosis, an ingrown toenail, which is extremely painful and leads to secondary infections.

On the sole of the foot and on the toe pads, mechanical overload is frequently evidenced by circumscribed hyperkeratoses. These plaques of calloused skin form at sites of increased pressure. Beneath a thick hyperkeratotic layer, a clavus can inadvertently form. Such a corn features a keratin plug extending deep into the dermis, which presses on nearby nerve endings and causes sharp pain.

In contrast to normal hyperkeratosis, vascular and neurological warning signs must be observed. Cool, pale, or lividly discoloured skin on the toes points to advanced peripheral arterial disease. If palpable pedal pulses at the dorsalis pedis artery or posterior tibial artery are absent, arterial blood supply is compromised. Affected individuals often do not complain of pain because concurrent polyneuropathy blocks pain transmission in the spinal cord. Careful differentiation between harmless dryness and incipient trophic disturbances is essential for maintaining foot health.

A further indication of the need for action is a change in gait. If individuals requiring care begin to limp when stepping down, avoid the rolling motion of the foot, or refuse to stand altogether, hidden pressure injuries on the soles of the feet are frequently present. If relatives observe such protective behaviour, an in-depth podiatric or medical assessment must be conducted.

Everyday causes

In everyday care, several contributing factors usually accumulate to cause a deterioration in foot health. A frequently underestimated cause is ill-fitting footwear. Many individuals requiring care wear slippers that are too soft or worn out, or socks that are too tight, compressing the toe area. Slipping inside the shoe generates friction, while socks that are too tight with tight elastic bands hinder venous return and exacerbate ankle oedema.

Foot mechanics represent another problem. With age, the arch structures flatten. Transverse flatfoot, fallen arches, or hallux valgus deformities develop. These malalignments alter the pressure distribution under the sole of the foot. Areas that are not anatomically designed for heavy weight-bearing are subjected to persistent overload. The result is reactive keratinisation, an increased formation of callus as the skin attempts to protect itself.

Underlying conditions such as diabetes mellitus, chronic renal insufficiency, rheumatism, or Parkinson's disease drastically increase the risk of foot complications. In diabetic foot syndrome, microvasculopathy and neuropathy cause even the smallest injuries to remain unnoticed and heal poorly. Parkinsonian symptoms such as rigidity and tremor make independent foot hygiene completely impossible for those affected.

Errors in care committed by well-meaning relatives or trained staff without specialized podiatric qualifications form another cause of complications. Cutting toenails round deep into the lateral sulcus provokes ingrown nail edges. The use of sharp instruments such as callus planes, razor blades, or mechanical rasps regularly leads to deep cuts. Furthermore, over-the-counter corn plasters containing salicylic acid pose a considerable danger to individuals requiring care. The acid not only etches away the calloused tissue, but also damages surrounding healthy tissue when blood flow is reduced, which can lead to deep chemical burn ulcerations.

When medical evaluation is necessary

Relatives must learn to distinguish harmless skin changes from acute medical emergencies. An immediate medical evaluation by a general practitioner, diabetologist, or dermatologist is required if signs of a bacterial infection are present. These include rapidly spreading redness, localized heat, swelling, and the discharge of pus or wound secretions around the nail fold or the sole of the foot.

Particular urgency is required if blisters, erosions, or ulcers form. When areas of skin take on a dark, bluish, or black discolouration, tissue necrosis is present. In this situation, there is a risk of tissue death, which, without prompt interventional vascular medicine or surgical wound management, can lead to amputation. Systemic symptoms such as sudden fever, chills, or an unexplained deterioration in general condition in combination with a foot injury also demand immediate action.

Relatives should likewise consult a physician if the person requiring care complains of persistent resting pain in the legs that worsens when the legs are elevated. This is a classic sign of advanced peripheral arterial disease in Fontain stage III or IV. In such cases, no podologische Komplexbehandlung (comprehensive podiatric treatment) may be performed without prior vascular medical clearance.

What podiatric treatment can achieve

Podiatry is the medical treatment of the foot. In contrast to cosmetic foot care, which is limited to caring for healthy skin and beautifying nails, a podiatrist performs medical technology prevention, therapy, and rehabilitation measures. Relatives can find comprehensive information about this profession on the page /en/sectoral-practitioner.

A podiatric treatment always begins with a detailed medical history and diagnostic assessment. Skin condition, nail structure, pedal pulses, vibration sensation using a Rydel-Seiffer tuning fork, and protective sensation using a Semmes-Weinstein monofilament are evaluated. An individual treatment plan is established on this basis.

State-of-the-art, sterile rotating instruments are utilized, such as diamond burs, carbide cutters, and ceramic grinders operating with micro-fine dust extraction or water mist cooling. Thickened nail plates are reduced to a physiological thickness without pain. The sulcus, the lateral nail fold, is gently cleared of hyperkeratosis and debris. Ingrown nails can be permanently corrected using nail brace techniques, known as orthonyxia, without the need for surgical intervention. In cases of deep subungual hyperkeratosis or fungal infection, diseased nail material is precisely removed.

Calluses and corns are expertly lifted using rounded scalpel blades or hollow chisels without injuring the underlying germinative layer of the skin. If these measures are insufficient, podiatrists fabricate custom pressure and friction protection devices made of silicone, known as orthoses. These relieve stress on deformed toes over the long term.

The duration of a comprehensive podiatric treatment is generally between 45 and 60 minutes. Depending on the clinical picture and the rate of nail regrowth, treatment intervals of four to six weeks are recommended. A treatment overview can be viewed in the section /en/services.

For individuals requiring care who can no longer visit the practice independently, arranging home visits represents a vital care option. Podiatrists bring the necessary sterile instrument sets and mobile equipment directly to the patient's home or care facility. Billing for such a medically necessary treatment can be processed through statutory health insurance, provided an appropriate medical prescription is present.

Physicians can prescribe comprehensive podiatric treatment on standard prescription forms. The prerequisite for this is damage to the feet resulting from diabetic foot syndrome, polyneuropathy, or spinal cord damage. If the ambulatory mobility of the person requiring care is permanently restricted, the physician must check the box for home visits on the prescription. In this case, statutory health insurance also covers travel costs after deducting the statutory co-payment. Exempt patients pay no co-payment.

What you can do yourself

Relatives can make a significant contribution in daily life to maintaining the foot health of individuals requiring care and preventing damage. Daily inspection of the feet forms the foundation of home prophylaxis. If affected individuals cannot inspect their soles themselves due to restricted mobility, relatives assume this visual check.

Daily foot washing should be kept brief. Lukewarm water with a maximum temperature of 37 degrees Celsius protects the skin barrier. The washing session should last no longer than three to five minutes to prevent skin maceration. After bathing, the feet must be dried thoroughly with a soft towel. Particular attention must be paid to the interdigital spaces, as remaining moisture provides an ideal breeding ground for dermatophytes.

After drying, altered skin areas require care. Moisturising creams or foam creams with a urea content of 5 to 10 percent restore epidermal elasticity. Urea binds water in the upper skin layers and gently dissolves mild calluses. Relatives must consistently avoid applying cream between the toes, as introduced fats lead to maceration in those areas.

When selecting socks, natural materials such as cotton or sheep's wool should be preferred. Synthetic fibres encourage sweating. Socks should not feature constricting elastic bands or thick seams in the toe area. A daily change of socks is mandatory.

Footwear must offer sufficient space for the toes and possess a soft yet stabilizing sole. Relatives should regularly check the inside of shoes by hand for foreign objects, small stones, or wrinkled lining seams.

Relatives can use the following daily checklist as a guide:

• Visual inspection of the soles of the feet, heels, and interdigital spaces for redness, pressure points, or cracks.
• Checking the water temperature during washing using a thermometer to prevent scalds.
• Careful drying of the spaces between the toes without harsh rubbing.
• Application of a urea-containing care foam emulsion exclusively to the sole and dorsal aspect of the foot.
• Palpating the interior of the shoe for protruding seams, loose insoles, or intruding particles.

Common errors

In home care, complications often arise from long-standing habits that no longer suit the altered skin and tissue conditions of old age. A widespread error is soaking the feet in prolonged, hot foot baths. While individuals requiring care find warm foot baths pleasant, hot water strips the remaining lipids from fragile elderly skin. The stratum corneum swells, loses its natural protective function, and becomes susceptible to micro-fissures.

Another serious error is using unsuitable cutting tools. Household scissors, nail clippers, or callus planes have no place in daily care routines. When attempting to trim thick, dystrophic nails with clippers, the nail plate splinters unpredictably. This frequently generates sharp nail splinters that bore deep into the lateral nail fold, causing severe inflammation.

Attempting to self-treat corns or calloused pressure points using razor blades or sharp tweezers regularly results in deep cuts. Because epidermal regeneration slows with age and microcirculatory disturbances are often present, such removal attempts rapidly turn into chronic wounds.

A practical example illustrates this issue: An 81-year-old female patient with known polyneuropathy did not complain of pain. Her caring daughter noticed a thick callus on the ball of the foot and applied a corn plaster containing salicylic acid. After three days, the acid had penetrated the calloused tissue and burned the underlying, poorly perfused dermal tissue. A deep ulcer developed, requiring months of medical and podiatric wound care.

A lack of regular monitoring is also among the common errors. Relying on the person requiring care to report as soon as a foot hurts often delays diagnosis in neuropathy patients. Inspection must be performed proactively by relatives or professional nursing staff.

Current state of research and classification

Scientific evidence regarding the efficacy of preventive podiatric measures has grown continuously in recent decades. International studies clearly demonstrate that structured, regular podiatric care in high-risk patients significantly reduces the incidence of foot ulcerations and subsequent amputations.

Publications by the International Working Group on the Diabetic Foot (IWGDF) highlight that multidisciplinary preventive concepts can reduce amputation rates in high-risk patients by up to 85 percent [2]. The regular professional removal of hyperkeratoses measurably lowers internal tissue pressure on the underlying skin layers. Studies show that untreated calluses increase the risk of ulceration fivefold, as the hardened callus acts like a foreign body pressing on soft subcutaneous tissue [1].

The S3 guideline of the German Diabetes Society on the prevention and treatment of foot complications also emphasizes the necessity of ongoing podiatric care for patients with advanced neuropathy or peripheral arterial disease [3]. Research into the care situation of nursing home residents shows that over 70 percent of this population group suffer from nail or skin alterations requiring treatment, yet only a fraction receive professional podiatric care [4]. The integration of medical foot care into daily nursing routines demonstrably improves mobility and quality of life in old age [5].

Key scientific findings can be summarized as follows:

• Regular removal of hyperkeratoses by podiatrists reduces peak plantar pressure by up to 30 percent.
• Multidisciplinary care approaches drastically lower the rate of major amputations in high-risk patients.
• Neuropathic patients exhibit a fivefold increased risk of ulceration if calluses are not professionally removed.
• Early detection and prophylactic nail treatment prevent the occurrence of paronychia and wound infections in immunosuppressed individuals.

Treatment in Memmingen

For relatives in the Memmingen region, Unterallgäu, Allgäu, and Upper Swabia, FREITAG® Podologie GmbH offers professional medical foot care. Under the direction of Helga Maria Freitag, state-recognised podiatrist and sectoral practitioner in podiatry, the practice carries out therapeutic treatments according to the highest medical quality standards. Further details regarding the team and qualifications are compiled in the section /en/about.

The practice is located at Kempterstr. 25 in 87700 Memmingen. A particular focus is placed on compliance with strict hygiene requirements in accordance with the recommendations of the Robert Koch Institute. All instruments are consistently packaged in sterile wrapping following reconditioning. Relatives can inform themselves about hygiene standards under /en/hygiene. Appointments for consultations at the practice or questions regarding billing via medical prescriptions can be made by telephone. Further information regarding directions can be found under /en/practice, and contact details under /en/contact.