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Go to Healthy Extremes With Feet

Do your best not to get on a client’s nerves -- because you never know who might have peripheral neuropathy. The loss of sensation in feet and hands that marks this not-uncommon condition leaves the unaware client susceptible to infection.

“I have numbness in my legs and I can’t feel my feet, yet if you squeeze them too hard it’s painful,”describes Jill Tinetti, an R.N. and nail tech, explaining how peripheral neuropathy has affected her feet. “If I step on even a tiny pebble, it’s horribly painful.”

Tinetti had Type I diabetes for more than 15 years before peripheral neuropathy (a common complication of diabetes) began affecting her feet. Now, in addition to the rigors of monitoring her blood sugar levels and dealing with the other inconvenient, sometimes debilitating side effects of diabetes, she lives with numbness and tingling intermingled with unexpected, sharp pains in her feet.

Peripheral neuropathy is an unfortunate and not-uncommon complicating factor of diabetes. It can also strike anyone, although doctors say advancing age, immune system disorders, infection, trauma (such as carpal tunnel syndrome), smoking, and alcoholism heighten a person’s risk.

Currently, it’s estimated that 3%- 4% of people over age 55 suffer from peripheral neuropathy — and experts say the number will climb as the baby boomers progress into their senior years. And because the condition can sneak up over time — starting with the occasional numbness or tingling, and only gradually stealing sensation — many people may not know they have it. For these reasons, physicians caution nail techs to be watchful for the signs and symptoms of peripheral neuropathy and to take particular care with all clients — not just those known to have diabetes.

Show Some Nerve Knowledge

The human nervous system serves as a vast, intricate communications network for the body. The central nervous system comprises the brain and spinal cord and can be viewed as the hub, or center, of the body’s activities. The peripheral nervous system, on the other hand, connects the body’s muscles, skin, and internal organs and transmits messages back and forth. Damage to one or more peripheral nerves disrupts and may even disconnect those exchanges of information. Whether motor or sensory nerves — or both — are affected, neuropathy can impair muscle movement or deaden sensation.

Symptoms of peripheral neuropathy are divided into three types: sensory (sensation), motor (movement), and autonomic (involuntary). As the body’s most distant points from the central nervous system and the most exposed body parts, the feet and hands, respectively, are the most commonly affected by peripheral neuropathy. Symptoms may include:

• sensory changes such as numbness, tingling, burning, pain, decreased or lack of sensation

• motor changes resulting in muscle weakness, lack of muscle control,muscle twitching, and atrophy (wasting)

• autonomic changes such as a decrease in sweating

Take carpal tunnel syndrome (CTS), for instance, which is a form of peripheral neuropathy. CTS develops when peripheral nerves become compressed or trapped as they travel through the narrow carpal tunnel into the hand.The pressure on the nerve(s) slows the messages transmitted by the central nervous system. Over time, the weaker, more sporadic “messages” result in a loss of muscle tone and sensation, leading to a weakened grip accompanied by numbness, tingling, and pain.

CTS serves as a handy example of peripheral neuropathy, but peripheral neuropathy most commonly affects feet. “The process begins as a burning sensation in the toes and progresses up the foot in a ‘stocking distribution,’” explains Dr. Kirk Koepsel in “Diabetic Neuropathy” (which can be found on podiatrynetwork.com). According to Dr. Koepsel, discomfort can range from a persistent numbness, which some patients describe as feeling like they’re walking on clouds, while others suffer from sharp, persistent pain they liken more to walking on a bed of nails.

Over the long term, peripheral neuropathy typically progresses to affect the muscles and bones of the feet. For example, diabetics who develop peripheral neuropathy often suffer from calluses as well as foot deformities such as hammertoes or bunions.

Rather than worry about these worst case scenarios, however, consider the So where do salon foot treatments fit in? An excellent question — and one without a hard-and-fast answer from the medical community. On the one hand, pedicures and foot treatments can play an integral role in maintaining healthy feet. On the other hand, even the most skilled, best-intentioned nail techs occasionally nick or abrade a client’s skin during the course of a pedicure.

“Neuropathy of the lower extremities, especially in diabetics, must be everyday risks for individuals with peripheral neuropathy.What used to be a walk in the park for these clients is now better compared to playing with fire in terms of the long-term health risks. Sensation is the body’s first line of defense against injury because discomfort and pain alert us to potential problems. If you can’t feel the jabbing of a rock in your shoe or the throbbing of an ingrown nail, injury and infection can wreak havoc while you’re not looking taken seriously,” says Phoebe Rich, M.D., clinical associate professor of dermatology at Oregon Health Sciences University in Portland. “The potential pitfalls are that a minor cut or break in the skin may escape notice due to reduced feeling in the skin and nails. What starts as a minor cut can become a serious, limb-threatening infection if it’s ignored and becomes infected.”


The risk isn’t a small one, as Tinetti can attest: She once spent 10 days in the hospital as the result of a minor cut received during a pedicure that progressed to a raging infection before capturing her attention.

By the same token, Dr.Rich and other medical professionals agree that people suffering from mild-to-moderate peripheral neuropathy in their feet and hands can enjoy — and even benefit from — salon foot care. Regular pedicures help these patients keep foot health a priority, and an observant pedicurist may be able to alert them to potential problems. (See sidebar at end of story.)

Tips for Home Healthcare

Most clients happily leave their foot care regimen in the hands of a professional, pausing only for a closer look when something doesn’t feel right. Without that critical cue, however, people with neuropathy must check their feet daily for signs and symptoms of injury or infection.

Advise any clients who complain of lessened sensation — even if they don’t have diabetes — to begin and end each day with a quick visual exam of both feet. Remind them to look for injuries, built-up calluses, redness or swelling that could indicate infection, and any other abnormalities. Recommend they do the visual check-up at the same time as they apply a moisturizing cream to the tops and bottoms of their feet.

The doctors we asked say keeping the skin hydrated is top priority to minimize dryness. Some forms of peripheral neuropathy impact the autonomic nerves, which control the sweat glands in the feet and hands, promoting dryness. Dry skin is particularly prone to cracking and fissuring, both of which heighten the risk of infection.

Doug Albreski, D.P.M., an assistant professor and practicing podiatrist at the University of Connecticut Health Center, favors Lac-Hydrin Five, the over-the- counter version of highly effective Lac-Hydrin 12. While the prescription strength contains twice the lactic acid, Dr. Albreski says many patients find relief with the weaker version.


Alternatively, Dr. Judi Shakula, D.P.M., who works at the Grady Diabetes Clinic at Grady Hospital in Atlanta, also recommends moisturizers containing 10%-20% urea cream. “These types of moisturizers are good because they form a barrier,” she adds. “Apply these lotions when the feet are already moist, after a shower or bath, to trap that moisture,” Dr. Albreski recommends. Advise clients to cover their entire foot — except between the toes — at least once daily with the lotion. (Applying lotion between the toes traps moisture already present and increases the risk of a fungal infection.)


Additionally, Dr. Shakula advises her patients with excessively dry skin to wear socks and shoes at all times. “Walking around barefoot or in slippers dries out the feet quite a bit,” she comments. Exfoliating creams can be used at home, says Dr. Shakula, but only in over-the-counter strengths and only sparingly.“If someone has dry, cracking skin, I would say they’re good,” she says. “Just watch the strength, and only put [the exfoliant] on dry, hard skin.” When approached with an abundance of caution, clients with peripheral neuropathy can prove your most loyal because to them pedicures are preventive medicine and not just a pampering luxury.

Develop Your Service Sensitivity


Your job as a pedicurist is to protect clients from harm, not to diagnose or treat medical conditions. To that end, medical professionals offer the following tips on safely servicing pedicure clients with peripheral neuropathy.


Do examine the client’s feet to ensure the skin is intact, the nails are healthy, and the appendage warm. Do not service clients with ingrown or fungal nails, cuts or abrasions, or excessively cold feet (which may indicate a circulatory problem in addition to neuropathy).


Do wash the client’s feet with an antibacterial soap.  Do not soak her feet, even in tepid water as soaking dehydrates the skin and can risk burns from water that’s too hot.


Do trim toenails with straight-edged nippers and cut the nails straight across. Do not round the edges or trim the nail shorter than the natural crease of skin on either side of the nail bed.


Do use a cuticle remover to exfoliate excess cuticle from the nail plate.  Do not trim or push back the cuticles. Even when no blood is visible, trimming and pushing back the cuticles may break the skin’s natural barrier against foreign invaders.


Do use chemical exfoliants (ones containing AHAs, glycolic, etc.) to remove excess dead skin cells and to reveal softer, smoother skin. You also can lightly reduce calluses with a foot file — but use a fine grit and a light touch. Do not use coarse foot files or electric files.


Do massage the client’s feet and lower legs with a moisturizing lotion. Tinetti advises following the client’s cue. “Start with a gentle touch and ask her how it feels before continuing,” she says. “People with neuropathy can get lots of strange sensations and sensitivities.


• "Just rub, rub, rub to stimulate the circulation,” she adds. “I grab the heel in one hand and massage in circles, then circle the toes and stroke up the ankle.”


Do not send her home without reminding her to inspect her feet daily to maintain good health.

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 Ann Spilo, chairperson of the board of Spilo Worldwide and recipient of the ABA’s lifetime achievement award, died in April, 2003
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