Some patient challenges are like an episode of CSI. Deciding who the primary suspect is becomes the main focus. Very often it’s a gang or collection of related factors causing the crime.

This chap has identical symmetrical lesions on the bottom of his feet, a history of sweaty feet, wears boots on hard surfaces all day, and the mastermind behind it all, significant structural instability. The insoles show dramatic wear marks caused by the instability of his feet matching exactly the lesions on the skin and excessive maceration of the tissue.

The inside lining of his work boots were destroyed at the backs of his heels due to the motion of his foot. The aftermarket insoles were impregnated with copper, so it will be interesting to see if on top of everything else, there is a sensitivity to the exposed material combined with heat and moisture.

The first order here is new stable work footwear, disposal of the aftermarket insoles, stopping using the previously prescribed anti-fungal and antibacterial creams, and scrupulous attention to hygiene. Assuming this addresses the skin condition then we can work on his structural instability and get him moving and feeling much better.
It’s certainly not glamorous work but it’s very interesting and satisfying!

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