Footnotes: Foothealth Practitioner News

Footnotes

Foot Health Practitioners News - Issue 6

WELCOME BACK TO FOOTNOTES!

Dear Colleagues, A number of our members and other readers of the ‘Review’ have asked if we could again incorporate the quarterly ‘Footnotes’ newsletter within the Review, so that its content is available to a wider audience than just the members of the College of Foot Health for whom it was originally designed.

As you will be aware, the Institute founded the College of Foot Health for the benefit of practitioners who have trained and qualified via the Institutes own Foot Health Practitioner course. Our course and membership of the College of Foot Health, was designed to set a benchmark for ethical practice, an appropriate level of training, meaningful indemnity insurance for public protection and responsible standards in the currently unregulated sector of Foot Health Practice, which sector has grown substantially in recent times.

In 2019 the Institute was invited by NHS Health Education England, along with other podiatry organisations, to sit on the leaders group of the Foot Health Consortium. This industry leaders’ consortium, chaired by Professor Beverley Harden, National AHP lead and Deputy Allied Chief Health Professions Officer, was set up in response to dropping recruitment levels into the registered sector, both NHS and Private, as well as the dramatic growth in the unregistered sector.

You, like myself, will be aware that the lack of a common level of education, scopes of practice, standards and ethics in the unregistered sector is an area that is long overdue for addressing. Whilst some FHP training courses are, as with the Institute’s, ethical, appropriate and fit for purpose, many are not and this is what the work of the consortium is designed to address. Decent FHP training, together with responsible support from ethical and professional organisations such as the Institute, can produce individuals who can safely and responsibly practice routine and general non-surgical/medical footcare. Additionally, by giving such individuals routes into further education they can aspire to progress through academic levels 4, 5 and 6 to ultimately gain degrees awarded by approved Universities and thereby qualify as Podiatrists – should they so choose to follow the extra years of education.

In recent times it has become apparent that many podiatry practices are following the model of dental practices, who now almost invariably include hygienists, by having suitably qualified assistant practitioners as part of the treatment team and the NHS has for some time employed podiatry assistants in support of the registered workforce. This makes it all the more important for podiatry to have a clear understanding of the benefits that appropriately trained FHPs can bring to our industry mix – be that as associates or with their own independent practices. Hence the renewed inclusion of Footnotes to help all parties to have a clear understanding of how the FHP sector operates and is evolving.

Martin Harvey, Chair Executive Committee Podiatrist Independent Prescriber

I hope that you are all well, and your businesses are finally getting back to normal. Now that we are once again nearly out of lockdown, I thought that things would resume very quickly. This is not quite true.

I have just taken part in a Covid friendly First Aid Course, it was very surreal. We were not allowed to touch anybody else and had to abide by the covid rules. Try putting yourself in the recovery position! Bandage your own leg. Put your own arm in a sling. You never know it may come in useful someday… I hope everyone has a long hot summer, with lots of time spent with friends and family.

Best regards, Ian

Tea Tree and Skin Preparations

I am always asked about skin preparations, especially as many practitioners still love the old favourites, they have used from their training days. For example, Savlon, where we covered the base of our spray bottle and added water to make a lovely smelling skin prep. Of course, you cannot buy that same Savlon any longer, with the lovely aroma, but there are some very good commercial skin preparations from the chiropody/ podiatry trade houses that are cheap and good to use, such as chlorohexidine gluconate products. And like any good skin preparation, they also disinfect, kill bacteria, and reduce the risk of spreading germs, including COVID-19.

Then I have been asked about tea tree oil as a skin preparation. Well, you may ask, and you might be right in thinking it will make a good skin preparation, and safer than other chemical skin preparations as it is ‘natural’, and kills bacteria, fungus, etc. This I am afraid is not always the case with tea tree oil or indeed many other essential oils.

Tea tree oil will not be miscible, which means it will not dissolve in water, unless you add some soap or detergent, and other ingredients that transforms it into a solution. This then will no longer render the preparation natural; but will make it into a very effective bathroom/ kitchen cleaner. Tea tree oil can be a good disinfectant for the bathroom and kitchen, but I would not advise it to be used as a regular skin preparation.

Although anecdotally it seems to work quite well as a treatment for nail conditions and has been used effectively to control athlete’s foot, where tea tree oil should be diluted in a carrier oil base. It can be used neat using only one drop on the nail, but the toxicity levels and chance of it reacting on a patient will gradually build up over time. Tea tree oil itself is particularly harsh on the skin and is not a good option for children, the elderly, and vulnerable patients. This is important, because it is dependent on the quantities that are used i.e., measured drops or percentage of tea tree oil in the solution.

The commercial cosmetic products such as shampoos and bath oils that contain tea tree oil use a concentration of less than 1% dilution, which is considered safe, because tea tree oil and its properties denature when mixed with other chemicals. Problems do occur with larger quantities of tea tree oil dilution when made up into a solution of a lot of different, or harsh chemicals; whereby, it can cause dermatitis and reactions to skin, especially over prolonged use.

A 2012 study by Larson & Jacob in Dermatitis. 2012 JanFeb;23(1):48-9. doi: 10.1097/DER.0b013e31823e202d.

The study’s abstract indicates that although:

Tea tree oil is an increasingly popular ingredient in a variety of household and cosmetic products, including shampoos, massage oils, skin and nail creams, and laundry detergents. Known for its potential antiseptic properties, it has been shown to be active against a variety of bacteria, fungi, viruses, and mites. The oil is extracted from the leaves of the tea tree via steam distillation. This essential oil possesses a sharp camphoraceous odour followed by a menthol-like cooling sensation. Most commonly an ingredient in topical products, it is used at a concentration of 5% to 10%. Even at this concentration, it has been reported to induce contact sensitization and allergic contact dermatitis reactions. In 1999, tea tree oil was added to the North American Contact Dermatitis Group screening panel. The latest prevalence rates suggest that 1.4% of patients referred for patch testing had a positive reaction to tea tree oil.

In the abstract of an older study in Australas J Dermatol. 2007 May;48(2):83-7. Rutherford, T; Nixon, R; Tam, M and Tate, B of The Skin and Cancer Foundation, Melbourne, Victoria, Australia Tea tree oil use is increasing, with considerable interest in it being a ‘natural’ antimicrobial. It is found in many commercially available skin and hair care products in Australia. We retrospectively reviewed our patch test data at the Skin and Cancer Foundation Victoria over a 4.5year period and identified 41 cases of positive reactions to oxidized tea tree oil of 2320 people patch-tested, giving a prevalence of 1.8%. The tea tree oil reaction was deemed relevant to the presenting dermatitis in 17 of 41 (41%) patients. Of those with positive reactions, 27 of 41 (66%) recalled prior use of tea tree oil and eight of 41 (20%) specified prior application of neat (100%) tea tree oil. Tea tree oil allergic contact dermatitis is underreported in the literature but is sufficiently common in Australia to warrant inclusion of tea tree oil, at a concentration of 10% in petrolatum, in standard patchtest series. Given tea tree oil from freshly opened tea tree oil products elicits no or weak reactions, oxidized tea tree oil should be used for patch testing.

Personally, as both a qualified aromatherapist and podiatrist for over 20+ years, I would not use tea tree oil as a skin preparation/ disinfectant for the feet. I would always recommend a patch test in case there is a reaction to any patient. Particularly, as I have heard and seen the results of many reactions, allergies and burns caused by the misuse of tea tree oil. It is hard to mix in water, being an oil, it will sit on the top of the water and not mix/ dissolve so the concentration of the oil will be greater when the solution is almost finished or at the bottom of the spray bottle, which is when it can cause the most damage. Most irritations of tea tree oil are because high concentrations are used, and as already mentioned when used neat can have dermal reactions. Although, nails seem to fair ok, if a fungus or other microbial factor is present. Most reactions will occur, because the oxidation products in the oil occur when the oils are aged or improperly stored, and especially in animals where paralysis and death can and does occur. There have been no deaths associated with humans, but as dogs and cats have more semi-permeable skin and a larger surface area than humans, it is more easily absorbed and will affect the animals’ nervous systems, etc. It does, however, affect the growing organs of children and can have a detrimental effect on the elderly and vulnerable people.

The storage of tea tree oil products is also very important and should be stored in a dark, glass bottle or containers, as tea tree oil is readily absorbed into plastic. If containers used for other purposes, it could cross contaminate products. Tea tree is known to rapidly degrade if it is exposed to air, light, and heat.

Other studies such as in the New England Journal of Medicine has stated that repeated use of tea tree oil may disrupt hormonal function and it has been revealed that boys have been warned against using hair oils and gels containing tea tree oil after three cases were found to have boys growing breasts. The growth of breasts disappeared when the boys stopped using the oils and gels. Whereby, US researchers believed tea tree oils may have hormone disrupters.

It is probably not what you wanted to hear, but the truth of the matter is that tea tree oil is a very aggressive oil that can dry out the skin and form blisters or rash. In addition, given the many studies produced in recent years and a great deal of them from Australia where tea tree oil is produced, it would be far safer not to use tea tree oil as a skin prep/ disinfectant for patient’s feet. If you have used tea tree oil as a skin preparation over the years without patients having the external, obvious signs of an allergic or dermatological reaction. It could be the unseen factors on the individuals body systems, i.e., growing organs in children, contribution to respiratory, nervous, skin, and other systemic problems in the infirmed and elderly that could be the real issue with using tea tree oil.

My suggestion is that practitioners please do not use tea tree as a skin disinfectant. As a household cleaner yes, and as an infrequent treatment for nail and fungal problems, but then only with extreme caution!

Take care, keep safe and well, best wishes.

Beverley Wright

Vice Chairperson, Board of Education