Excessive cracking of heals in 14 years old female
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Excessive Cracked Heels in a 14-Year-Old Female
Overview
Cracked heels (heel fissures) in a 14-year-old adolescent girl are relatively common and usually multifactorial. The primary mechanism is: dry, thickened skin (callus) at the heel rim + pressure on the heel fat pad = fissuring. However, at this age, several specific causes must be considered and distinguished.
Most Likely Causes in This Age Group
1. Juvenile Plantar Dermatosis (JPD) - Most Common Diagnosis to Consider
This is an eczematous disorder classically affecting children from age 3 years to puberty, though it can persist into early adolescence. At 14, this is at the upper edge of the typical age range.
Pathogenesis: Occlusive plastic/rubber sports shoes worn all day without absorbent socks cause repeated maceration. The humid environment hydrates the stratum corneum, making it less resistant to friction. As the skin becomes xerotic, cracks form. The inherently dry skin of atopic individuals is a major predisposing factor.
Clinical features:
- Symmetrical shiny, reddish, dry, tender lesions on the balls of the feet and toe pads
- Glazed appearance, like parchment paper
- Fissures and scaling
- Forefoot usually more involved than the heel - but heel cracks can also occur
- Interdigital spaces are spared (helps distinguish from tinea)
- More common in atopic children (eczema, asthma, allergic rhinitis history)
- Dermatology 2-Volume Set 5e, Juvenile Plantar Dermatosis section
- Andrews' Diseases of the Skin, p. 97
2. Simple Xerosis / Dry Skin with Mechanical Fissuring
The most straightforward cause - especially in winter or dry climates. Dry skin loses elasticity, and repeated pressure on the heel fat pad causes the callus to crack. Contributing factors:
- Open-heeled footwear (sandals, flip-flops) - common in adolescent girls
- Long periods of standing on hard floors
- Low humidity / cold weather
- Inadequate foot moisturisation
3. Atopic Dermatitis (Eczema)
Adolescents with atopic diathesis have inherently dry, compromised skin barrier, making them more susceptible to heel fissuring. A personal or family history of eczema, asthma, or allergic rhinitis strongly supports this.
4. Palmoplantar Keratoderma (PPK)
Hereditary or acquired forms can cause thickened, fissured plantar skin. These may present in childhood/adolescence:
- Inherited PPK (autosomal dominant/recessive) - usually symmetric, diffuse thickening from early childhood
- PPK associated with hypothyroidism - an important acquired cause to screen for in an adolescent girl (see below)
- Dermatology 5e, Table 13.4
5. Hypothyroidism - Important to Rule Out in a 14-Year-Old Girl
Autoimmune hypothyroidism (Hashimoto's thyroiditis) is the most common thyroid disorder in adolescent females. It causes generalised dry, rough skin, and can specifically cause palmoplantar hyperkeratosis and heel fissuring. Other signs to look for:
- Fatigue, weight gain, constipation, cold intolerance
- Dry coarse hair, hair loss
- Irregular menstrual cycles
- Slow growth/delayed puberty
- Bradycardia
Screen: TSH, Free T4
6. Nutritional Deficiencies
At this age, adolescent girls are at risk for:
- Iron deficiency / anaemia - impairs skin repair and barrier function
- Zinc deficiency - essential for skin integrity; deficiency causes dry, fissured skin
- Omega-3 / essential fatty acid deficiency - causes xerosis
- Vitamin E deficiency - affects skin barrier
A dietary history is important, especially in girls who may be restricting food intake.
7. Psoriasis (Palmoplantar Type)
Palmoplantar psoriasis can cause thick, scaly, fissured plaques on heels. Look for:
- Well-defined, silvery-scaled plaques elsewhere (elbows, knees, scalp)
- Family history of psoriasis
- Nail pitting or onycholysis
8. Fungal Infection (Tinea Pedis) - Less Common in Children
Tinea pedis is uncommon in prepubertal children but does occur in adolescents. It typically affects the interdigital spaces first, but "moccasin-type" tinea pedis can cause diffuse dry scaling of the entire sole including the heel. A KOH preparation can confirm.
9. Allergic Contact Dermatitis (Footwear Dermatitis)
Allergy to chemicals in shoes (chromates, rubber accelerators, dyes) can cause dermatitis that fissures. It typically involves the dorsum and weight-bearing areas of the feet. Patch testing may be needed if suspected.
Differential Diagnosis Summary
| Condition | Key Distinguishing Features |
|---|---|
| Juvenile Plantar Dermatosis | Glazed, symmetric; forefoot > heel; atopic child; synthetic shoes |
| Simple xerosis | No erythema/scaling; dry climate/open shoes; no systemic features |
| Atopic dermatitis | Personal/family atopy history; other eczema sites |
| PPK (hereditary) | Symmetric diffuse thickening from early childhood; family history |
| Hypothyroidism | Fatigue, weight gain, dry coarse hair, cold intolerance |
| Psoriasis | Plaques elsewhere; nail changes; family history |
| Tinea pedis | Interdigital involvement; KOH positive |
| Allergic contact dermatitis | Dorsal feet involvement; resolves with shoe change |
Workup / Investigations
- Full history: Duration, footwear habits, atopy, diet, menstrual cycle, systemic symptoms, family history
- Skin examination: Distribution (forefoot vs. heel), glazed appearance, fissure depth, other skin findings
- Blood tests:
- TSH, Free T4 (hypothyroidism)
- FBC (anaemia)
- Serum ferritin, zinc, vitamin D
- Blood glucose (routine screen)
- KOH preparation/fungal culture if tinea pedis is suspected
- Patch testing if allergic contact dermatitis is suspected
Treatment
General Measures (First Line for All Causes)
- Emollients applied at least twice daily - thick creams/ointments (Eucerin, Cetaphil, petroleum jelly) are superior to thin lotions
- Keratolytic agents to soften thickened skin:
- Urea 10-25% heel balms - most effective
- Salicylic acid preparations
- Alpha-hydroxy acids (lactic acid, glycolic acid)
- Soak heels in warm water for 10 minutes, then apply emollient while still damp
- Gentle exfoliation with a pumice stone after soaking
- Heel socks overnight - apply thick emollient, cover with cotton socks to enhance absorption
Footwear Modification (Especially for JPD)
- Avoid open-backed shoes, sandals, flip-flops
- Wear well-fitted, closed shoes with cushioned soles
- Use thick absorbent cotton socks - change when soaked
- Alternate pairs of shoes to allow drying between uses
- Avoid barefoot walking on hard surfaces
When to Use Topical Steroids
- If significant erythema or inflammatory component (atopic dermatitis/JPD flare): mild-to-moderate topical corticosteroid (e.g. hydrocortisone 1%, mometasone) short course
- Note: topical steroids alone for JPD are of limited value without addressing the causative maceration
Treat Underlying Causes
- Hypothyroidism: levothyroxine replacement
- Nutritional deficiency: targeted supplementation (iron, zinc)
- Tinea pedis: topical antifungal (clotrimazole, terbinafine)
- Psoriasis: dermatology referral
Severe/Deep Fissures
- Tissue/skin glue (cyanoacrylate) can seal deep painful fissures to allow healing
- Wound dressings for bleeding fissures
- Dermatology referral if not responding to basic measures
Key Points for a 14-Year-Old Female Specifically
- Hashimoto's thyroiditis is common in this demographic - always screen with TSH if there are any systemic symptoms or the heel cracking is severe/unexplained
- Nutritional assessment is important - adolescent girls are at risk for iron and zinc deficiency which impairs skin repair
- Footwear choice in teenage girls (open sandals, flat flip-flops) is a very common and often overlooked trigger
- JPD typically improves as they reach adulthood due to development of a thicker plantar horny layer
- If the condition is bilateral, symmetric, and associated with a glazed appearance, juvenile plantar dermatosis is the most likely diagnosis and is managed primarily by footwear and emollient changes rather than medications
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