Wet Feet, Tinea, and Ulcers: A Needs Assessment of Foot Health in Miami Unsheltered Homeless Population
Taha Rasul, Dan Bergholz
Trauma or disease affecting the feet can greatly affect the lives of persons experiencing unsheltered homelessness. Our patients living nearby the Miami Medical District are subject to rain storms, hurricanes, and tropical climate conditions without protection from the elements. Homeless shelters have extended waitlists and sometimes are unable to accommodate a sharp increase in patient volume during times of inclement weather. This can lead to many health issues related to exposure to weather, their living environment, etc. which can greatly affect foot health. The Miami Street Medicine (MSM) team has been conducting weekly mobile clinics since April 2021, and has noticed large numbers of foot complaints among the unsheltered patients. This assessment investigates cases encountered thus far in order to provide information for solutions in the future. It is hoped that the assessment will also provide further direction for MSM and other concerned organizations to better address the needs of such a high-risk population.
Figures 1 & 2: A street team leader providing foot care to a USH patient.
Figures 3 and 4: Example of interdigital lesions encountered. Unlike tinea pedis, erosio interdigitalis blastomycetica has candidal and gram-negative etiology. We were grateful to have Dr. Morrison, Faculty Dermatologist at the University of Miami confirm the diagnosis and treatment plan. There is a high need for specialist dermatologic evaluation in this population.
Why feet in particular?
USH patients are constantly on the move and must walk to reach bare necessities.
Feet are in continuous contact with the high-risk street environment, and most susceptible to injury and infection.
Tropical environments further predispose to damp feet (from water and sweat).
Perfect environment for tinea pedis (ringworm) growth [2].
Breakdown of epidermal barrier opens the door for more severe complications (cellulitis, abscesses, ulcers, and osteomyelitis) [3].
The most common skin complaints encountered during MSM clinics are related to the lower extremities.
To date, socks have been the most requested and distributed item of clothing at MSM clinics. We've heard them called, "the currency of the street." Since most patients encountered by MSM often walk several miles daily, their socks are usually unclean and drenched in either sweat, water, or other liquids encountered on the street. This is why providing clean, cotton socks has been found to be a major quality-of-life improvement for our patients. Socks are also the only interface between a patient’s foot and often ill-fitting footwear, potentially causing blisters, scrapes, and calluses. Therefore, one of the most cost-effective interventions thus far has simply been the provision of clean and dry socks.
Clean socks were specifically documented by physicians in patient treatment plans of 25 individuals. We know the general importance of socks though, so the Operations Manual protocol is to offer socks for every patient during a curbside consult. Over the course of 8 months (April 2021 - January 2022), at least 400 pairs of socks were distributed, which was verified by our REDCap inventory and distribution ordering logs.
Walking excessively in dirty socks and often without shoes has led to worsening podiatric problems in many patients. For example, it has been noted that many patients seen after severe rainstorms had developed cases of immersion foot. Tinea Pedis was noted specifically in at least eleven patient-care instances, and frequently in the setting of damp footwear. A total of 12-16 patient encounters involved providing antifungal powder or cream. Chronic medical conditions are also frequently uncontrolled in this population. For example, in patients with a history of diabetes mellitus, this leads to many instances of ulcers and charcot deformities. Foot ulcers were noted in at least twelve unique patients. Several patients without history of diabetes also had the presence of lower extremity ulcers due to trauma.
Graph 1: Documented Instances of Podiatric concerns. Patients with each condition were treated and followed over an extended period of time (greater than 3 weeks).
Figure 4: Example of lower extremity wound care being provided on Street Run. Lower extremity lesions are some of the most common concerns the street team addresses.
In addition to socks and basic wound care, MSM dispenses antifungals regularly to patients at risk of or with confirmed tinea pedis. Most of the antifungals are in powder form (Desenex - miconazole) with a smaller proportion of cream provided. The powder is generally preferred due to its moisture-reducing properties which can further reduce dermatophyte growth [4].
Graph 2: Proportion of powdered antifungals dispensed versus cream-based antifungals.
We have categorized the most common
complaints encountered into fungal, ingrown toenail, unspecified itch, and ulcers (leg and foot).
Graph 3: Primary foot and lower extremity concerns addressed. It is important to note that patients with other primary concerns often had tinea pedis infections.
An important footnote is the potential complications that can arise as a result of longstanding tinea pedis infections. Patients with chronic illnesses or in a state of immunosuppression can suffer from refractory tinea pedis, especially if nutritionally deficient. Such cutaneous infections can also predispose towards pyoderma and more severe complications like osteomyelitis and bacterial superinfections [5]. Many PEH seen by the Street Medicine Teams have greater risk due to chronic disease burden. Therefore, preemptive recognition and management is essential in such a high-risk demographic.
Some examples of outreach include the footwashing event which took place in October 2021 (Figure 5). >50 patients were evaluated for lower extremity lesions, and some even had to be taken to the ED when cases of sepsis and DKA were discovered during this community health event. These community events are especially useful in a resource-limited street medicine setting. Footwashing events can help build a trusting therapeutic relationship while monitoring this community’s high risk foot health - and by extension, their overall health.
Figure 5: Photograph taken from foot-washing event. Some patients were noted to have long-standing ulcers and chronic skin lesions.
Next steps and Ideas?
Suggestions for street medicine outreach teams in tropical environments:
Ensure that the following supplies are packed in individual packaging for all street rounds:
1. Socks
2. Antifungal foot powder
3. Hygiene kits
4. Nail clippers
5. Wound care supplies
Ask about foot health at every visit
Inquire about plans for food and shelter to assess how far the patient needs to walk for basic necessities
Recruit board-certified dermatologists to most accurately assess skin lesions and form appropriate treatment plans
Encourage and incentivize follow-up with ... S O C K S!
At the end of the day, this is but one of many problems arising from a lack of stable shelter and housing. These recommendations are meant to improve the comfort and lives of persons experiencing unsheltered homelessness.
REFERENCES:
Bezgrebelna M, McKenzie K, Wells S, et al. Climate Change, Weather, Housing Precarity, and Homelessness: A Systematic Review of Reviews. Int J Environ Res Public Health. 2021;18(11):5812. Published 2021 May 28. doi:10.3390/ijerph18115812
Toukabri N, Dhieb C, El Euch D, Rouissi M, Mokni M, Sadfi-Zouaoui N. Prevalence, Etiology, and Risk Factors of Tinea Pedis and Tinea Unguium in Tunisia. Can J Infect Dis Med Microbiol. 2017;2017:6835725. doi:10.1155/2017/6835725
Akkus G, Evran M, Gungor D, Karakas M, Sert M, Tetiker T. Tinea pedis and onychomycosis frequency in diabetes mellitus patients and diabetic foot ulcers. A cross sectional - observational study. Pak J Med Sci. 2016;32(4):891-895. doi:10.12669/pjms.324.10027
Pereda J, Noguera X, Boncompte E, Algueró M, Izquierdo I. Efficacy of clotrimazole 1% powder in the treatment of tinea pedis. Mycoses. 2003 Apr;46(3-4):126-31. doi: 10.1046/j.1439-0507.2003.00849.x. PMID: 12870201.
Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev. 2007 Jul 18;2007(3):CD001434. doi: 10.1002/14651858.CD001434.pub2. PMID: 17636672; PMCID: PMC7073424.