Preventing recurring cellulitis between close-set toes of disabled adult

June 28, 2017 1:15 PM

My brother is 46, has a developmental disability, and currently lives at home with our 83yo father. He loves swimming (public pool and water park) and works in a dish room 9 months out of the year (nearly full-time on his feet in damp surroundings). He's gotten athlete's foot a number of times, and is now getting over the second case of cellulitis between two toes (the first time was maybe 4 years ago) for which he was treated with antibiotics. I'd like to prevent a 3rd instance.

Regarding his disability: His cognitive level is around 4/5yo, his emotional level is closer to 13/14yo. He's interpersonally bright, but has intellectual and physical limitations. His toes are very close together, and getting in between them (to wash, dry, apply ointment, and bandage) is a struggle even for my smaller, more nimble fingers.

Regarding current treatment: Dad has been carefully washing, drying, and powdering his feet at the end of each day during the recovery process, but I know this isn't sustainable. He's on a wait list for a group home where a staffer could handle this (and teach him to do this himself, which is something our father doesn't have patience for).

Regarding work: We've gone through a series of various water-resistant boots (it is messy work, his boots come home caked with food that we then scrape/scrub off, he's done this for 20 years, we are open to suggestions and are considering orthotics).

Regarding recreation: My brother used to wear swim-socks every time he used a public pool or water park, but he hates them and our father hasn't been "enforcing" their use. Are they a good thing? Would orthotics help? Different socks? Toe socks? Wondering how I can help prevent cellulitis in future.

Regarding general health: Yes, my brother is significantly overweight (close to 100lbs) and we are working on a weight loss program, but see also: our father does not enforce rules ("secret" milkshakes, cakes, full-sugar sodas, cheese steaks, etc are their treats and this puts me in the role of "bad guy" - also, living 90 minutes away, I can hardly enforce rules when I'm not there in person). Blood work all comes back normal - no pre-diabetes, his cholesterol meds are controlling his cholesterol well, no signs of thyroid issues.

Any ideas? Trying to advocate as best I can from a distance. Longer-term I know "move closer" is the solution, but for now I'm 90 minutes south of them and 60 minutes north of my job (and home, and husband).

posted by pammeke to Health & Fitness (17 answers total)

Edit: I was unclear - home and husband are where I am (60 minutes north of job, 90 minutes south of brother & father).
posted by pammeke at 1:17 PM on June 28, 2017

Hmm...for work, I would think the converse of rubber boots would be helpful--you likely want something that breathes. Can you try moisture-wicking socks and some sort of breathable shoe, like Crocs? The 'professional' versions, if I recall correctly, have a closed toe but some ventilation holes along the base so your brother's feet wouldn't be soaking. Or perhaps some sort of moisture-wicking and quick-dry athletic shoe, like a high-performance trail runner? Similarly, I would think toe socks would be helpful for after work: something dry that will help keep the inter-toe spaces also dry and separated. The toe spreaders that are used after pedicures might also be helpful for making sure the interdigital space stays dry after washing.

Also, not sure how feasible this is, but I think that nail salons have some sort of fan to help dry nail polish...maybe there is a home version that he can use? (Or a hair dryer?)
posted by stillmoving at 1:50 PM on June 28, 2017

works in a dish room 9 months out of the year (nearly full-time on his feet in damp surroundings)

When I'm on long-distance hikes, where my feet are damp for extended periods because I sweat alot, I switch to a new, dry pair of socks halfway through the day. That seems to have taken care of the athlete's foot I would get before adopting that practice.

So perhaps he could be persuaded to switch into new socks at his lunch break or otherwise halfway through his shift? Or maybe even more frequently—if I had to work all day in waterproof boots in anything other than freezing temperatures I'm sure that I would have similar foot problems because with non-breathable footwear in warm temperatures they would be like steam baths inside with the amount I sweat.

Good job going out of your way for both of them; they are lucky to have you!
posted by XMLicious at 1:51 PM on June 28, 2017

Another thought—maybe socks could be washed with bleach, and it would be worth finding some sort of sanitizing spray for the inside of the shoes? It's never occurred to me before, but perhaps the fungus or bacteria causing the problem can persist on socks through detergent-only laundry washing like some other things can.
posted by XMLicious at 1:58 PM on June 28, 2017

I bet an OT could help teach him the foot care stuff. This sounds like exactly the kind of thing OT can help with.
posted by bq at 2:24 PM on June 28, 2017

Reddit.com/r/kitchenconfidential will love this question (they love dishies) and will be delighted to help.
posted by Mistress at 2:35 PM on June 28, 2017

Wool socks will help wick moisture and heat up and out of the shoes. Rotating between two pairs of shoes will additionally help each pair fully dry out before the next wearing (with the added bonus of helping each pair last longer than they would being worn daily).
posted by zebra at 3:05 PM on June 28, 2017

I use the hair dryer at the gym to dry between my toes (and other skin folds). I prop my foot on a stool and aim the med-high breeze at my feet for around 1min each foot.
posted by Jesse the K at 3:07 PM on June 28, 2017

This is a big problem for fishermen too. The waterproof boots traps moisture, don't dry out between wearings and before you know it you have trench foot. Absorbant boot insoles or liners that you switch out every day are really helpful.

Wicking socks or boot liners, changing socks frequently, drying your feet with a hairdryer and drying your boots and liners, if applicable, on an electric dryer overnight every night. Boot dryers are $20 or $30 at any sportsman or ski store.
posted by fshgrl at 4:28 PM on June 28, 2017

It's never occurred to me before, but perhaps the fungus or bacteria causing the problem can persist on socks through detergent-only laundry washing like some other things can.

Yep, never underestimate fungus's ability to persist. It's insidious.

Here are some things I'd do if I had to go nuclear on athlete's foot. These may not all be realistic for your brother, so go with what's feasible for him (and your dad):

* Nuke his current socks from orbit. I'd replace them with (light) hiking socks that are designed to deal with moisture, if at all possible (not cotton).
* Replace the shoes as well. Start fresh.
* The foot powder is a good idea. If he's got active athlete's foot, antifungal spray is better.
* Change his socks halfway through the work day, as people have mentioned.
* Go barefoot at home, so his feet get plenty of time exposed to the air so that any moisture can dry up.
* Clean the shower floor (with Comet or something similar) more frequently to keep him from reinfecting himself.
* Same deal with towels -- make sure those are getting changed frequently.

I like the ideas above about drying his feet with a hair dryer & getting a boot dryer for his work shoes too!
posted by Blue Jello Elf at 5:57 PM on June 28, 2017

They should provide deep rubber boots for him but if not, then Harbor Freight is a good place to get some. If they don't give him a waterproof apron long enough to cover the tops of the boots then get him one. His feet should be OK in cotton socks in rubber boots, they may need some soft insoles for comfort. He needs to sun his feet after swimming, no sunscreen. He should lie on his stomach and his back with his feet aimed at the sun. Think about a group home for him if dad is getting on.
posted by Oyéah at 6:19 PM on June 28, 2017

Fungus can persist in shoes and socks. Cotton socks washed after every wearing and dried in a very hot drier will help. Line drying would not be a good idea in this situation. Bleaching them will help, too. Drying, powdering between toes, and medication will all help, too.

Fungus loves damp environments, and the rubber boots he wears are ideal incubators. Crocs would be better, or even sneakers that can dry out between wearings. And he should not wear the same shoes two days in a row - switching off to allow the alternate pair to dry thoroughly would also help. If he has crocs, they can be thrown in a bucket of hot water and bleach between wearings.

Cellulitis is a big step beyond foot fungus. It can require hospitalization, IV antibiotics and cause severe systemic infections. I don't want to scare you, but it can lead to sepsis when untreated. It's really important that your brother and his dad get control of the situation. Perhaps your brother's doctor can have a chat with both your brother and your dad about the importance of keeping his feet clean and dry. If not, to protect his health he may unfortunately need to leave the job he is used to.
posted by citygirl at 6:40 PM on June 28, 2017

Is your brother on Medicaid? Can he get an HCBS waiver? If so, he and your dad can hire an attendant who can assist with foot care. They could also implement the program an OT designs. Memail me if you need more info on waiver!
posted by Snarl Furillo at 7:47 PM on June 28, 2017

Does he change into a pair of shoes after work - before he leaves work? Seems like he should. But - what they say about shoes is you should have two pair because your feet sweat and soak the shoe and so you are supposed to let one shoe dry for 24 hours while you are wearing the other. I think this mostly goes for leather shoes but seems like a good idea for all shoes. Let them air out for a day. I rotate my shoes - never wearing the same pair 2 days in a row.

The best way to dry sweaty shoes and boots

Another thing I do is whenever I can I wear massage thongs. He may think these are too weird - they take getting used too. But if he does like them they elevate the feet a bit and allow air to circulate underneath. After I got used to them, I think they feel fantastic and allow my feet to breathe. The newest ones I bought feel too tight I should have bought one size bigger than my feet.

I also think this is so important you should try to get someone to come to the house to help him take care of his feet. I have gained weight recently and I am really short and wow, it makes taking care of my feet so hard. Trying to lose the weight specifically for that reason. So glad he is not pre-diabetic! That's a blessing.
posted by cda at 5:15 AM on June 29, 2017

Thank you all for your answers! A few quick notes: He has 4 pairs of boots he cycles through weekly - he never wears wet or damp boots to work. He does favor white cotton socks, and during the summer his vulnerability to ticks (day program loves outdoors fun) means knee socks. He showers at the end of each work day and changes into open-toed sandals which he calls his slippers. He is at the beginning of his summer break, so we have a few months to figure this out (and for me to possibly break it to Dad that we have to toss almost $400 worth of footwear and buy more). Different socks seems like a smart idea, and I'm looking into all the options presented. Thank you all.

citygirl this is indeed our biggest fear. My brother doesn't complain about discomfort and I worry that our father might not always catch the little changes between "under control" and "dangerous". Granted, he and I are both somewhat neurotic about this, but he is 83 and I don't want him to have to be on high alert at all times nor to I want my brother to be endangered. I hear you on the possibility of needing to leave his job of 20 years. It is something I'm weighing, for sure.

He was in a group home for almost 7 years, after our mother died, but it closed due to lack of funding and regulations which they can't meet. There are only 2 group homes in their area that are still operational. One is set to close next year for the same reason. The last one he is #1 on the wait list for, but grimly, we are essentially waiting for someone to die or age out of their services (and be forced into a nursing home). Failing that, the choice is between me & my husband relocating (and either telecommuting or finding new jobs), or finding a home closer to us that is big enough for my brother (and possibly my father), one of us being at home to care for them until my brother qualifies for services in his new state (12 months as I understand it), and taking him away from the community he's known for almost 5 decades. I'm thinking the former makes a lot more sense than the latter, as much of a change as it would/will be.

I will look into a home health aide via Medicaid. Thank you for that idea, Snarl Furillo. And stillmoving he would *love* a pedicure style fan, he would feel so fancy. I'll poke around and see if I can find a good option for home.

I love the idea of massage thongs, but we generally need to have him in shoes which hold his feet (the sandals he wears have back closures and "hold" the top of his foot) as he is prone to tripping and falling. His boots are such that removing them and putting them back on again partway through his day would eat up his entire 30 minute lunch break and require assistance - his flexibility and dexterity is limited. Crocs are out of the question for work, because he'd come home with almost an inch of dried caked on wet food on his feet themselves rather than the boots. He works in a dining hall, so it's basically industrial dishwashing territory.

Thank you all so much for these suggestions, just getting out some thoughts in case they're helpful. Your advice and brainstorms are so helpful!
posted by pammeke at 6:23 AM on June 29, 2017

One other idea: could he soak his feet in a cleansing sort of way, say once a week? Anecdata: whenever I had a inflamed toe situation, my mom would have me soak my feet in hot soapy water for a bit, rinse and let air dry. It always seemed to help. I was thinking the hot soapy water would be an easier way to get between his toes cleaned. (All you need is a plastic tub that fits his feet and a place to sit for 10 or so minutes.) He could follow it up with a preventive athlete's foot spray. Make it a weekend ritual. Also might be more manageable for your father to help him with.
posted by purple_bird at 11:43 AM on June 29, 2017

I have found podiatrists can be helpful for people who need careful/meticulous foot hygiene. Might be worth seeing one. The best way to prevent cellulitis is to prevent the tiny wounds in the skin that provide a starting point for the infection.

I think you are doing the right thing by trying to find other solutions to this problem than quitting his job. Having a 46 year old with high cholesterol and a poor diet suddenly become completely sedentary would probably be pretty unfortunate for his health too. Yes cellulitis can become serious, but the vast majority of cases are not and are easily curable with pretty basic antibiotics.
posted by treehorn+bunny at 8:46 PM on June 29, 2017