Foot Care in Epidermolysis Bullosa: Evidence-based Guideline

M.T. Khan; M. O'Sullivan; B. Faitli; J.E. Mellerio; R. Fawkes; M. Wood; L.D. Hubbard; A.G. Harris; L. Iacobaccio; T. Vlahovic; L. James; L. Brains; M. Fitzpatrick; K. Mayre-Chilton

Disclosures

The British Journal of Dermatology. 2020;182(3):593-604. 

In This Article

Recommendations

The key recommendations of this guideline are summarized in Table 2, with grades of evidence explained in Table 3. Detailed recommendations are provided below.

Blistering and Wound Management

Podiatric Education. We strongly recommend offering podiatry education programmes to prevent blistering and wounds ( Strength of recommendation grade: B ).

Foot blistering is a common problem in all subtypes of EB, and patients of all age groups may be affected (Quality evidence level ranging from 4 to 2+).[4–8] Blistering in EB usually results from friction or minor trauma.[3,9] Blisters on the feet can be caused by a dressing, sock, shoe or boot rubbing against the skin,[3] but they sometimes appear spontaneously. The size of a blister depends on the type of EB and the degree and duration of friction.[3] In EB, defective skin adhesion means that a shearing force causes skin components to separate, creating a space that fills with fluid. The resulting blister easily enlarges under pressure because there is a plane of weakness in the skin, so it should be burst to avoid this (Appendix S1a; see Supporting Information).

The usual technique is to lance intact blisters with a sterile needle at their lowest point to facilitate fluid drainage by gravity[9] and to stop blisters from refilling.[3] Some patients prefer to use sterile scissors. Gauze or other absorbent material may be used to wick the fluid from the blister. A saline soak, nonmedicated and medicated dressings, and topical antiseptics or antibiotics could be used to prevent secondary infection until the skin heals (Quality evidence level ranging from 3 to 1−),[3,5] existing guideline ⇒[9] (expert opinion, grade: D).

Generally the management of EB tends to be supportive and is aimed at preventing blistering by reducing friction and the amount of mechanical trauma to the feet (Quality evidence level 3).[5] Prevention is key and involves minimizing friction and mechanical trauma to the feet (Quality evidence level 3).[5] The evidence here supports the training of staff, patients and carers to improve understanding of the causes of blistering and wounds on the feet.

Prevention of blisters is facilitated by an assessment tool that the podiatrist can use to address the adequacy of hosiery (silver-lined socks) and footwear (Quality evidence level 4).[4] That study[4] presented the development of a universal assessment tool, which requires validation (Section A in Appendix S2; see Supporting Information). The Foot Health Status Questionnaire (FHSQ) is seen as a validated universal assessment tool, which is not specific to EB (Quality evidence level 1−),[10,11] (Section B in Appendix S2; see Supporting Information).

In a cohort of 57 patients with a localized form of EBS, all reported localized pain in the feet related to blisters. Six patients (11%) tried lidocaine 5% plasters on their feet, with good efficacy (Quality evidence level 2+).[6]

Footwear and Foot Biomechanics. Selection of appropriate footwear and the use of appropriate insoles can help to reduce blisters and improve foot function in patients with EB. In a prospective study of six patients with EBS, three reported no new blisters while wearing shock-absorbing moulded orthoses (Quality evidence level 3).[5]

In a qualitative study of 79 adults with all subtypes of EB, all patients improved in two to four key variables when using shock-absorbing insoles, custom orthotics and bespoke footwear. The investigators used a gait analysis system to capture the static and dynamic in-shoe foot pressure of bespoke footwear in seven patients, and provided an objective, quantifiable technique to identify biomechanical discrepancies and pathological foot function and to assess gait. Furthermore, the improved mobility and independence correlated to the reduced numbers and severity of blisters (Quality evidence level 2−)[7] demonstrating that the use of insoles and orthotics is also important (Quality evidence level 2−),[4] (Appendix S3 and Appendix S4; see Supporting Information).

  • Socks are helpful to provide ventilation, wick away moisture and reduce friction (Quality evidence level ranging from 4 to 2−).[3,4]

  • Footwear for patients with EB should ideally be firm and comfortably fitting, with appropriate length and width, a rounded toe and a flexible flat sole with heel support. It should also have laces or straps or equivalent to prevent excessive movement or slipping of the foot inside the shoe, and have a seamless internal lining (Quality evidence level ranging from 4 to 2−).[3,4]

Practical point: although it is not mentioned in the literature, healthcare professionals and patients alike have reported the benefit of using cornflour on the soles of the feet and in between the toes to help control excessive moisture and reduce friction. Both of these measures can help control blistering on a day-to-day basis.

Dystrophic Nails

We strongly recommend offering podiatry support to treat and manage EB dystrophic nails ( Strength of recommendation grade: B ).

  • Dystrophic nails can be very problematic in EB and may affect patients with all EB subtypes (Quality evidence level 2−).[12–15]

  • Dystrophic nails may be effectively managed by the application of a topical keratolytic agent, and the nail thickness can be further reduced by an expert podiatrist (Quality evidence level 2−).[3,4,12–15]

Nail changes occur in all subtypes of EB. In an Australian EB registry study involving male and female patients from childhood onwards, dystrophic nails were reported in 33% of patients with EBS, 90% with JEB, 83% with DDEB and 95% with RDEB (Quality evidence level 3).[12] Most reports focus on toenails rather than fingernails, although both can be dealt with by podiatrists (Box 1). A retrospective qualitative study reported on 201 adults (Quality evidence level 2+);[8] most other reports discuss the diagnosis, characteristics and familial inheritance in childhood.

Toenails should be preserved where possible because they protect the tips of the digits from friction and pressure (Quality evidence level ranging from 4 to 2−).[3,4] The treatment and management of dystrophic nails presented the strongest evidence in this CPG, and podiatrists are encouraged to be involved with all patients with EB (Quality evidence level ranging from 4 to 2−).[3,4] As EB nails are a rare condition, community podiatrists are unlikely to have the disease-specific knowledge and expertise to deal with EB-related complications (Quality evidence level 2+).[8] Therefore podiatry is an essential component of EB multidisciplinary care (Quality evidence level 2+),[8] (Appendix S1b; see Supporting Information).

EB podiatrists should be available to assess newly diagnosed patients, develop care plans, offer treatment at the specialist centre, and recommend appropriately trained podiatry services near the patient's home.

Patients with EB with dystrophic nails should be advised as follows (Quality evidence level ranging from 4 to 2−).[3,4]

  • Keep toenails trimmed straight across.

  • File nail surfaces with an emery board after softening the nails by soaking in warm saline water or a bath.

  • Daily to weekly, depending on the age of the individual and thickness of the nail, apply a urea-based cream, such as a keratolytic agent, to reduce the thickness of the keratin layer and hydrate the nail (Quality evidence level 4: expert opinion).

  • Removal of the toenails can be performed via chemical or laser ablation to prevent future problems. If an EB podiatrist does not undertake this procedure it is advisable for them to provide some guidance or advice to the podiatrist who is performing the nail surgery (Quality evidence level 2−).4

  • Surgical procedures can be carried out; please refer to the pseudosyndactyly section.

Hyperkeratosis (Callus)

We strongly recommend assessment of hyperkeratosis with a validated tool to facilitate monitoring. ( Strength of recommendation grade: B ).

  • Hyperkeratosis and fissuring of the feet have been reported in all EB subtypes (Quality evidence level 2+).[8]

  • The use of a validated tool can help to monitor, evaluate and manage EB hyperkeratosis (Quality evidence level 1−).[10,11]

  • Pressure redistribution and cushioning are helpful to prevent development of hyperkeratosis (Quality evidence level 2−).[3,4,7,8]

Hyperkeratosis (also called keratoderma or callus) has been reported in all subtypes of EB. EBS is often associated with mild-to-moderate hyperkeratosis (palmoplantar keratoderma), particularly of the soles.[4,5,7] In a retrospective qualitative study, carried out in an EB podiatry clinic covering both male and female patients with all subtypes from childhood onwards, 74 of 201 patients (36·8%) were treated for hyperkeratosis (Quality evidence level 2−).[8]

Hyperkeratosis may be defined as hard, thickened areas of the skin located on the tip of toes or between the toes and soles underneath the metatarsal heads.[3] If the skin is hard and yellow with a nucleus or plug of keratin, it is called a corn or helom.[3] A corn or callus will appear red if it is inflamed.[3] The central core of a corn extends downwards in a cone-shaped point and can cause notable pain and discomfort. Patients will often compare this to walking on a small stone or pebble.[3] A corn or callus enlarges if there is continuing friction as a direct hyperproliferative response of keratinocytes.[3] Hyperkeratosis is, to a limited extent, protective.[3] However, in EB, blisters can form under the thickened tissue and painful cracks can develop (Appendix S1a; see Supporting Information). The FHSQ is currently being used in studies with patients with EB with hyperkeratosis (Quality evidence level 1−).[10]

Podiatric management of hyperkeratosis and corns involves the following.[3]

  • Debridement of the lesions is a procedure performed regularly by podiatrists using manual debridement or paring of hyperkeratosis (Quality evidence level 2+).[8] The forms of debridement can include self-management using an emery board or nailfile. If the area is too painful or too thick, patients need to be seen by a podiatrist for a blade or scalpel debridement. However, in dealing with patients with EB, podiatrists are advised to be more conservative in their approach, as overdebridement can make the underlying skin susceptible to increased blistering and tenderness. After debridement, emollients and nonadherent dressings should be used carefully to protect the debrided skin.

  • Practical point: in the experience of the panel, many patients with EB have reported bad experiences regarding overdebridement from podiatrists who have not understood the nature of the condition or have sought advice from the patients themselves. This is why podiatry education in EB has been highlighted as a priority by DEBRA, and a specific training programme is currently being developed.

  • Assessment and correction of weight distribution, with cushioning to try to reduce hyperkeratosis build-up (Quality evidence level ranging from 2− to 2+).[4,7,8]

  • The use of EB-specific assessment tools (e.g. pressure assessment platforms and FHSQ; section B in Appendix S2; see Supporting Information). These assess the distribution of pressure on the skin leading to hyperkeratosis and evaluate how best to manage the condition by further assessing the quality of everyday function (Quality evidence level ranging from 2− to 1−).[4,7,8,10]

Special Considerations

  • Heloma (corn): the common corn is heloma durum. Heloma miliare (seed corns) are frequently seen in EB due to toe and foot deformity. Heloma neurovascular are encountered but to a lesser degree (Quality evidence level 4: expert opinion).

  • Neurovascular hyperkeratosis. This is a form of callus in which nerve endings and blood vessels become prominent in the epidermis in response to trauma and treatment. This condition can present in patients with EB (estimated < 1%). The area is sensitive, painful and difficult to treat, as normal debridement causes pain and bleeding. Although rare, it is very debilitating in the small number of patients with EB affected. It probably results from long-standing gross hyperkeratosis and usually affects skin overlying the calcaneum and hallux (Quality evidence level 4: expert opinion). Debridement of these lesions by a podiatrist is also recommended and can provide similar relief, but the patient should be advised that due to the nature of the lesion, treatment can often be more uncomfortable than is experienced with standard hyperkeratosis.

Footwear

We recommend suitable footwear and appropriate insoles or orthotics for management of the EB foot by podiatrists, patients, carers and healthcare professionals ( Strength of recommendation grade: C ).

Evidence that advice on footwear is beneficial has been reported in all subtypes of EB:[16–20] EBS,[4,5,8] JEB,[4,8] DDEB[8,21] and RDEB.[7,8]

EB footwear advice suggests that wherever appropriate, footwear should be supportive. Its primary focus should be aimed at minimizing blistering by reducing friction (Quality evidence level ranging from 3 to 2−).[3,5,7] Once blisters have formed, dressings and topical antiseptics or antibiotics may be used to prevent secondary infection until the wound heals (Quality evidence level ranging from 4[3] to existing guideline⇒[9]). Therefore, suitable shoes or footwear are essential to accommodate dressings and not lead to further trauma to the damaged area. Footwear that is adjustable may be beneficial in these circumstances.

Recommendations regarding footwear in EB are based on expert opinion, as evidence is lacking. The overriding recommendation is to minimize mechanical trauma to the feet by emphasizing the need for suitable footwear and appropriate insoles or orthotics (Quality evidence level 2−).[4]

Footwear advice should address the following:

  • Socks should be selected to improve ventilation. Silver-fibred cotton socks and silver vinyl covering (for example CoolSorb) can be used with simple insoles and orthoses (Appendix S3; see Supporting Information). These conduct heat away from the feet, reducing sweating and friction (Quality evidence level ranging from 4 to 2−).[4] Silver-fibre socks also have additional antibacterial action (Quality evidence level 2−).[4] Silver sock technology is readily available across the world through hiking and trekking products. Additional options for patients living with EB include bamboo socks and double-layer socks.

  • Shoes should ideally have the following features: firmness (Appendix 4; see Supporting Information), comfortable fit, appropriate length and width, rounded toe, plenty of room for the toes, flexibility, flat heel, heel support, laces or straps and flat or absent seams. These features are to prevent excessive movement or slipping of the foot inside the shoe (Quality evidence level 4).[4] The upper covering should be leather or fabric mesh to allow air to circulate, rather than plastic or synthetic (Quality evidence level 2−).[4]

The grey literature supports this by showing how different types of cushioning materials and insoles provide benefit in nonrelated diabetic foot ulcers. This can have a subjective relevance to support the benefits of footwear and orthotics in EB.[16–18]

Special Considerations

  • Care must be taken when a child starts walking, acknowledging that shoes are not always necessary indoors (Quality evidence level 4).[3] Allowing a child to walk barefoot or just in socks helps feet to grow normally and develops muscular joint strength. A child will also benefit from proprioceptive feedback when walking barefoot (Quality evidence level 4).[3] These benefits must be balanced against the risk of damage to the unprotected skin. Outside, children's feet should be protected in lightweight flexible footwear made of natural materials (Quality evidence level 4).[3] The soft cartilage within their feet can easily be bent while walking, and the layer of fat tissue will offer support and shock absorption, potentially masking abnormal development (Quality evidence level 4).[3]

  • Babies with EB may have one foot smaller than the other due to prenatal loss of skin and subcutaneous tissue: this can be managed by correctly fitting shoes of different sizes (Quality evidence level 4).[3] The child's foot should be measured at a reputable shoe store every 2–4 months (Quality evidence level 4)[3] or at the EB clinic, and it may be necessary to change the shoes and the socks every few months to allow room for growth (Quality evidence level 4).[3] Children with severe types of EB needing bulky dressings to the feet may have difficulty finding shoes to fit and need to rely on lightweight plastic shoes such as Crocs (Appendix S4; see Supporting Information).

  • All patients with severe EB should not be walking barefoot but should have layers of protective dressings. Special consideration should be given to the length of the Achilles tendon, which can tighten in response to pain on walking and application of dressings.

  • Cost implication for appropriate footwear is a large consideration in the global EB world. Some countries may use specific funded services for shoes for 'suitable' patients, while others are unable to provide such a service. Recommending suitable footwear can have its limitations and cost implications due to the type of footwear available, the age of the individual, their foot deformity, the type of EB they have, their occupation and changes in fashion. Not all services will cover or have international availability. However, the improvement in mobility, independence and quality of life in the long term outweigh this (Quality evidence level 2−),[7] (Appendix S4; see Supporting Information).

Mobility

We recommend measures to improve mobility, with assessment and monitoring for all subtypes of EB ( Strength of recommendation grade: C ).

  • Longitudinal mobility assessment and monitoring are essential in EB, as disease-related factors such as scarring and contractures can change an individual's ability to mobilize over time (Quality evidence level ranging from 4 to 2+).[3,5,7,19,20]

  • Gait analysis systems can be safely used in EB and can be helpful to diagnose pressure areas and walking patterns, and evaluate the effect of therapeutic interventions (Quality evidence level ranging from 2− to 2+).[6,7]

  • Podiatry interventions differ between EB subtypes and must be tailored to the individual patients to prolong mobility (Quality evidence level ranging from 4 to 3).[3,5]

The evidence of podiatric care can improve mobility. Both children and adults with all subtypes of EB may have affected feet.[18] Problems such as blistering, hyperkeratosis (callus), nail loss, altered gait and deformity (Quality evidence level ranging from 3 to 2+)[8,20,21] can result in reduced mobility and, eventually, wheelchair use (Quality evidence level ranging from 3 to 2+).[8,21] Preventing these problems can help children and adults with all subtypes of EB to stay mobile for longer and improve their quality of life.

A study of 425 patients with EB, of whom 140 were children, reported the percentages of children being able to walk independently or dependently within the different EB subtypes (Table 4).[19] The results showed children who were independent had differing walking abilities.[19] It was noted that DDEB showed a higher percentage of independent walking compared with EBS, JEB and RDEB.[19] The patients in the dependent groups showed very little ability to walk, with those with RDEB requiring the most support compared with EBS and JEB, and patients with DDEB requiring no support (Table 4).[19] The impact of dependency should not be diminished by these results, as the occasional use of wheelchairs is present among all forms of EB.[19]

Painful foot blistering is a common problem exacerbated by walking or standing in EB (Quality evidence level ranging from 3 to 2+).[6,19,22,23] A DDEB study reported that pain on walking was reduced in six of the seven patients by correcting the foot's balance and eliminating areas of abnormal weight bearing (Quality evidence level 3).[22] In a more recent cohort of cases of localized EBS, localized foot pain occurred before, during or after the onset of a blister (Quality evidence level 2+).[6] Blisters triggered by friction, walking, heat, trauma and hyperhidrosis tend to be worse in the summer (Quality evidence level 2+).[6]

Practical point: a case–control study reported that plantar injections of botulinum toxin effectively reduced pain from walking, and were a long-lasting and safe treatment for painful blistering and callosities in EBS (Quality evidence level 2−).[23] Blisters disappeared after botulinum toxin therapy and the pain reduction was sufficient to permit the patient to start walking more freely (Quality evidence level 2).[23] However, the procedure is painful and not tolerated by all patients (Quality evidence level 2−).[23]

Gait analysis and pressure measurement systems assess foot step pattern[2] (Quality evidence level 2−),[7] (section C in Appendix S2; see Supporting Information). Analysis of a person's manner of walking (gait) in EB facilitates the diagnosis and appropriate management of foot problems[3] (Quality evidence level 2−).[7] These platforms have proved essential in podiatry practice in diabetic foot management. The podiatrist can use gait assessment to identify areas that have more focused pressure when walking and translate this information into the development of patient-specific insoles (section C in Appendix S2). This practice can also be extended, where appropriate, to the development of bespoke footwear (Appendix S5; see Supporting Information). This is particularly useful when the type of EB results in such deformity that standard off-the-shelf footwear will not fit[3] (Quality evidence level 2−).[7]

The physiotherapist can also use gait analysis and assessment to help improve posture while walking and provide further advice and exercises to help develop core strength (Quality evidence level 4).[24] Furthermore, this approach can evaluate the effectiveness of the therapy (Quality evidence level 4).[24] From a practical view, gait platform mats are portable and can be fun to use, and above all do not damage the skin (Quality evidence level 4).[24]

The overarching recommendations here are as follows:

• Referral for podiatry assessment, treatment and monitoring to minimize blisters and pain while walking.

• Where appropriate and affordable, consideration of patient-specific insoles and bespoke shoes.

• Multidisciplinary therapy management should include the podiatrist, occupational therapist and physiotherapist to reduce pain while walking and encourage mobility (Quality evidence level ranging from 4 to 2++).[25–28]

• Use of a gait analysis system to assess the patient's walking pattern, and to monitor and evaluate therapy intervention (section C in Appendix S2; see Supporting Information).

• Plantar injections of botulinum toxin have been highlighted as providing therapeutic benefits in a small cohort of patients. Further research is required in this area, but it may be a consideration for adult patients with EBS who can tolerate the procedure, if conservative therapies have not worked.

• Tailoring podiatry interventions to the subtype of EB to prolong mobility.

   • Patients with EBS tend to require debridement of hyperkeratosis (callus), blister care management or simple insole and footwear advice.

   • Patients with JEB may require blister and wound management, and also simple insoles and footwear advice.

• All patients with EB require nail management from birth, plus wound care and footwear advice and insoles as they become older.

Pseudosyndactyly

We suggest consideration of surgery for pseudosyndactyly and mitten deformities of the feet, as well as for contractures of the lower extremities in patients with DEB (Strength of recommendation grade: D).

  • Foot surgery for joint contracture deformity release and digital amputation can be successfully performed in EB and may benefit patients by reducing pain, improving ability to wear shoes and improving mobility (Quality evidence level 3).[22,29–32]

The evidence for the surgical management of pseudosyndactyly, mitten deformities and contractures of the lower extremities largely concerns patients with DEB. The relevant literature is heterogeneous and consists mainly of case reports and case series. Surgery in this patient cohort is primarily undertaken in the hand to improve function. Surgery can be considered for pseudosyndactyly, mitten deformities and contractures of the lower extremities in patients with DEB. However, due to the relative short-term nature of any cosmetic improvement and limited functional improvement (if any), other surgical procedures that will help accommodate the foot in certain footwear, such as selective digital amputation, may be more appropriate. Patients should therefore consider any benefits vs. risks very carefully. Similar complications from other EB subtypes do not cause mitten deformities or pseudosyndactyly deformities and are therefore not highlighted in any of the literature (Appendix S1a; see Supporting Information).

RDEB generalized severe is characterized by progressive fusion of digits leading to pseudosyndactyly and a mitten-like deformity of the hands and feet. These complications occur to a lesser degree and later in RDEB generalized intermediate. Cutaneous scarring can also lead to joint contractures and deformities in the feet, resulting in reduced mobility and pain (Quality evidence level 3).[22,29–31]

Procedures Reported

  • Clawed toes were surgically released in three patients, by making extensive transverse incisions across the dorsal and/or plantar surface of the toes and distal forefoot, extending into the subcutaneous tissue (Quality evidence level 3).[22] This improved the foot contour, reduced pain on walking and allowed shoes to be worn (Quality evidence level 3).[22] The release of pseudosyndactyly makes it easier to wear normal footwear and it is of psychological benefit to the patient to observe a 'normal' foot with five toes (Quality evidence level 3).[22] Improvements were seen for several years, but due to the progression of the EB reoccurrence was likely.

  • Despite the long-term complications of surgery, early extension procedures to address contractures of the toes and equinus and cavus deformities using soft-tissue surgery were recommended by the experts reviewing six cases (Quality evidence level 3).[30]

  • In a case study of foot syndactyly in six patients with RDEB, the main foot surgery goal was to reduce extreme flexion or extension contractures to allow the patient to wear shoes and ambulate comfortably (Quality evidence level 3).[29]

  • Most surgical procedures to the foot in EB involved mitten release, although this procedure is used more for hands (Quality evidence level 4).[32] Syndactyly release to the foot reduced pain or difficulty in standing and walking, and improved ability to wear shoes due to hyperextension contractures of the toes (Quality evidence level 4).[32] The numbers are small, with only six patients benefiting out of 25 who had surgery in a New York cohort, and six of 50 patients in the St Thomas Hospital cohort who underwent foot surgery (Quality evidence level 4).[32]

  • Contractures almost always recur, and because of the lack of long-term benefit patients often refused further surgical interventions (Quality evidence level 3).[33]

  • RDEB mouse models have shown that losartan reduced tumour necrosis factor-β-mediated inflammation and supported matrix remodelling. Losartan administration in the RDEB mice with injured forepaws seemed to prevent digit fusion (Quality evidence level 2++).[34] A clinical trial to establish the safety, tolerance and efficacy of losartan in children with RBED is currently ongoing.[35]

Podiatrist Professional Development

Enhanced proficiency in the functional treatment of people with EB is recommended. It is expected that clinicians always use great care as an integral part of their professionalism as a podiatric clinician. However, EB is a condition requiring specialist intervention beyond just 'being more careful'. It necessitates specialist training and provision and recognition by podiatric practitioners of the extent of their practice and experience. This has important ramifications for undergraduate podiatry training in relation to informed knowledge of interprofessional referral pathways in instances where newly qualified students may inadvertently meet patients with EB for the first time.

Podiatrists managing EB must avoid causing secondary injury, by:

  • Handling feet and limbs with great care.

  • Avoiding the use of highly adhesive tapes, dressings and felt padding.

  • Removing any adherent dressings, ideally with silicone spray.

Continued professional development for podiatrists is encouraged, for example undertaking a specialist EB podiatric management course to integrate their professional knowledge and clinical skills in managing EB-related podiatric conditions.

This guideline is focused on helping people living with EB and their families to manage their foot problems. In countries where podiatrists are unavailable or not part of the healthcare system, a healthcare professional can aid to some degree. Nurses can offer expertise with wound care management, and they can offer advice on footwear and foot care with the guideline as a reference. There are restrictions with blade debridement, as this is not part of their scope of practice. Specialist podiatric knowledge to address biomechanical issues of the feet and prescription orthotics can only be delivered by a podiatrist, physiotherapist or musculoskeletal doctor. These key areas may also be addressed by a dermatologist, paediatrician, surgeon or 'doctor'. In countries where there is no podiatric support, the healthcare professional offering this care should make sure that they legally adhere to that country's scope for their profession.

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