![\"Peeling](\"http:\/\/www.blister-prevention.com\/wp-content\/uploads\/2020\/05\/Peeling_macerated_skin_on_the_feet.jpg\")
<\/figure><\/div>\n\n![\"trench](\"http:\/\/www.blister-prevention.com\/wp-content\/uploads\/2020\/05\/torn_macerated_skin_on_feet.jpg\")
<\/figure><\/div>\n\n\nWhat causes skin maceration?<\/h2>\n\n\n\n
Macerated skin is a curse for the multiday ultramarathon runner and hiker. Imagine getting up on day three and having to run or walk all day on these feet!<\/p>\n\n\n\n
Skin maceration can occur in wet or<\/em> dry weather:<\/p>\n\n\n\n The condition is better known to some by various other names. But as Farafoot<\/a> discusses nicely in this article<\/a>, none of them are quite applicable to the condition experienced by ultrarunners and other endurance athletes:<\/p>\n\n\n\n Maceration is no fun for the athlete.<\/p>\n\n\n\n It’s no fun for the race medic either! It seems there’s so little that can be done to make a significant difference.<\/p>\n\n\n\n After running into a couple of nasty macerated feet at the ANZAC Ultra 2015, much like this foot (below), I decided I had to review the literature to see if there was any new developments in treatment; or prevention. I contacted a few colleagues, including Belinda Longhurst, who is a wealth of information on all things feet and dermatology-related. Belinda helped me locate some papers.<\/p>\n\n\n Quite a bit of research has been done to determine the microscopic effects of waterlogging on the stratum corneum (stratum means layer, corneum means horny). Remember, the corneum is the outer layer of the epidermis and unmistakably, the business end of the skin\u2019s barrier function. The skin cells (corneocytes) in the corneum are dead, dry and readying themselves to be shed. Skin cells (corneocytes) are attached to one another (by desmosomes) and they\u2019re embedded in a mortar of fat (lamellar lipid layer). The skin cells are hydrophilic (water-attracting). The lipid layer is hydrophobic (water-repelling).<\/p>\n\n\n\n As it turns out, the skin can handle quite a bit of water exposure. At one hour, it is relatively undamaged.<\/p>\n\n\n\n \u201cWhen water exposure is for one hour of less, even with repetitive applications during a day or over many days, water appears to have no effect \u2026 on stratum corneum morphology.\u201d<\/em><\/p>\nWarner, 1999<\/cite><\/blockquote>\n\n\n\n The corneum is where the majority of research has been done. But as the foot images at the top of this article suggest, the damage of maceration can happen to different degrees and to different levels of the skin. Of particular interest to me is whether maceration extends into the stratum spinosum – where blisters occur*? Or deeper? <\/p>\n\n\n There has been one study that investigated this. Below is a quote from this paper, with a reference to “mechanical stimulation”. This pertains directly to the types of forces that walking and running imparts to the skin.<\/p>\n\n\n\n Several studies have revealed structural changes in the stratum corneum. However, these results cannot explain the decreased skin tolerance to mechanical stimulation because skin strength is supported by intercellular junctions in the stratum spinosum and basale of the epidermis and extracellular matrix of the dermis.<\/p>\nMinematsu et al, 2011<\/cite><\/blockquote>\n\n\n\n These researchers discovered \u201cultrastructural changes in all skin layers\u201d of the epidermis. Water penetrated all epidermal layers, right down to the stratum basale. Not only that, chemical irritants and macro-molecules penetrated into the dermis and:<\/p>\n\n\n\n … should be considered direct evidence for the development of maceration-induced skin lesions.<\/p>\n<\/blockquote>\n\n\n\n More recently (2014), Ichikawa-Shigeta et al confirmed dermal changes due to skin maceration.<\/p>\n\n\n\n It should be noted that most research studying maceration do not use skin from the feet; or the palms, which is the closest match to plantar skin [the Minematsu study above did<\/em> use human and rat foot skin] . This could be important for at least one reason, outlined by Dr Cynthia Bailey<\/a> (personal communication, 2015). <\/p>\n\n\n\n On the palms and soles there is a layer between the granular layer and the horney layer called the stratum lucidum which appears under the microscope as a clear space. On other skin areas this clear layer will develop if there is a lot of rubbing\/friction.<\/p>\nDr Cynthis Bailey<\/cite><\/blockquote>\n\n\n\n I wonder whether this “clear space” has any effect on maceration? Does it limit the damage or does it exacerbate it? With this in mind, some caution must be taken when applying this information directly to the feet; and directly to the endurance athletic population. And that’s to mention nothing of the fact there’s no research that looks at maceration and the repetitive and ongoing forces involved in long distance walking or running.<\/p>\n\n\n\n Maceration: <\/p>\n\n\n\n We live in a dry atmosphere. Skin is designed to absorb moisture from the atmosphere so it doesn\u2019t dry out. This design is not suited to being submerged in water for a long time [Skin that is exposed to water and liquids for long periods (oral mucosa, swimming mammals) has a very different skin structure]. Our skin can tolerate water exposure for about an hour without structural damage. After that, the damage begins. This has implications for the general barrier function. But for runners, it also has implications for the skin\u2019s overall strength. With reduced structural integrity comes a reduced ability to remain intact when subjected to the shear forces of walking and running. <\/p>\n\n\n\n I dare say the substance of this article merely backs up what most have seen or experienced first hand at various races and events. The skin folds over on itself and tears much more easily as it becomes more water-logged. While it’s good to define the problem, of more use would be some substantiated information on treatment (and prevention) of this condition.<\/p>\n\n\n\n READ NOW – PART 2: HOW TO TREAT MACERATION<\/a><\/p>\n\n\n\n\n
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Maceration is a tricky situation for the medic and runner\/hiker alike<\/h3>\n\n\n\n
![\"Torn](\"http:\/\/www.blister-prevention.com\/wp-content\/uploads\/2020\/05\/Torn_macerated_skin_near_the_toes.jpg\")
<\/figure><\/div>\n\n\nThe damage of skin maceration on a microscopic level<\/h2>\n\n\n\n
Barrier function of the skin<\/h3>\n\n\n
![\"What](\"http:\/\/www.blister-prevention.com\/wp-content\/uploads\/2020\/05\/Skin_maceration_at_the_Western_States_100_fac5c5b3-c128-4242-9598-67cca98441d8-768x1024.jpg\")
<\/figure><\/div>\n\n\nUnder the microscope<\/h3>\n\n\n\n
a. Normal stratum corneum<\/h4>\n\n\n\n
b. After one hour<\/em> of water exposure<\/h4>\n\n\n\n
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c. After four hours<\/em> of water exposure<\/h4>\n\n\n
![\"the](\"http:\/\/www.blister-prevention.com\/wp-content\/uploads\/2020\/05\/stratum_corneum_After_four_hours_of_water_exposure-1024x522.jpg\")
<\/figure><\/div>\n\n![\"what](\"http:\/\/www.blister-prevention.com\/wp-content\/uploads\/2020\/05\/stratum_corneum_after_24_hours-1024x501.jpg\")
<\/figure><\/div>\n\n\n![\"Skin](\"http:\/\/www.blister-prevention.com\/wp-content\/uploads\/2020\/05\/the_layers_of_skin_involved_in_a_blister_1c3dd697-136f-4bf7-a45f-7464fa3fce4a.jpg\")
<\/figure><\/div>\n\n\nDoes maceration go deeper than the stratum corneum?<\/h2>\n\n\n\n
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More recently<\/h3>\n\n\n\n
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Conclusion<\/strong><\/h5>\n\n\n\n
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