Walking on Cracks: A Study of Heel Fissures and Their Management

Abstract

Cracked heels, affecting nearly 48% of the population, are more prevalent in females and individuals with high foot strain, such as housewives and farmers. Characterised by dry, thickened skin and fissures, the condition can lead to pain, bleeding and infection if untreated. Common causes include barefoot walking, ill-fitting footwear, obesity and systemic conditions such as diabetes and hypothyroidism. Though often benign, investigations and preventive care are essential. Traditional remedies and Ayurvedic practices remain popular, with modern interventions focusing on hydration and barrier repair. With rising awareness and demand, the irony is that though the cracked heel treatment market is predicted to reach USD 2.3 billion by 2033, there is not much literature available on cracked heels.

The prevalence of cracked heels is reported as 48%, with females (58.4%) having a higher incidence than males (33.3%). It is more common among housewives (63.7%) and farmers (41.9%). ¹ This condition is also referred to as ‘Heel fissure’ or ‘Xerosis of the foot’, which starts as a skin breach along the outer edge of the heel. In Hinduism, cracked heels symbolise a spiritual deficit in self-care and nourishment, highlighting the importance of nurturing oneself on a holistic level. ² The dryness occurs when the skin’s outer layer, the stratum corneum, loses its ability to retain moisture. The skin there becomes rough, progressively hard and flaky, breaking down into fissures. In most cases, if the cracks are minor, they are merely a nuisance and may be unattractive to look at. However, if left untreated and the heel fissures become deeper, walking can become painful, may bleed, and lead to infection. Though it’s an extremely common condition, not much modern literature or supportive evidence is available for medical professionals. Indian Ayurvedic medicine was probably the only treatment available for cracked heels, known as ‘Padadari’, with treatments such as Sirovdedha (puncture of veins) and topical applications of certain Ayurvedic oils and ointments. ³ Formulating effective treatment is the need of the hour as the target population has become high with an increase in the geriatric population, higher consumer awareness, lifestyle patterns, and high healthcare expenditure. The cracked heels treatment market size was around USD 1.4 billion in 2024 and is expected to reach USD 2.3 billion by 2033 at a compound annual growth rate (CAGR) of 6.2% from 2026 to 2033. ⁴

Causes of Cracked Heels

Cracked heels occur for a variety of reasons. Still, the most common predisposing factors are walking barefoot in hard terrain for extended periods, ill-fitting shoes, use of sandals or open-backed shoes that lack proper support around the heel regularly instead of closed shoes, living in dry climates that lead to thick, hard and inflexible skin around the heels, and walking or standing on heels for a long time. It can also occur during pregnancy due to hormonal changes, weight gain and increased pressure on the feet. Additionally, prolonged standing on hard floors and inactive sweat glands can contribute to dry skin. Taking long, hot showers, especially by obese or overweight people, is also a predisposing factor. Poor foot hygiene, like Athlete’s Foot or eczema; deficiency in minerals, vitamins or zinc; metabolic diseases like hypothyroidism or diabetes; flat feet or high arched heels; palmoplantar psoriasis; and peripheral vascular disease are other risk factors. As people age, their skin becomes thinner, less elastic, and produces fewer natural oils. This results in dryness, making older individuals more prone to developing cracked heels, especially in people engaging in high-impact activities like running, jogging or climbing.

The Young Townson Foot Skin Hydration Scale for Diabetic Neuropathy classifies anhidrosis (inability to sweat) as following: ⁵

Level 1: minimal to no anhidrosis or callus formation. The skin may appear normal or slightly dry.

Level 2: mild anhidrosis and callus formation. The skin shows some dryness and thickening, particularly on the heels and balls of the feet.

Level 3: Moderate anhidrosis and callus formation. The skin is noticeably dry, with thickened areas and potential for heel fissures (cracks).

Level 4: Severe anhidrosis and callus formation. The skin is very dry, with significant thickening and deep fissures, especially on the heels.

Clinical Manifestation

Besides the unsightly physical appearance of cracks around the heel, where it touches the floor, the patient can also experience pain and discomfort, especially while standing, walking and putting pressure on the heels; itchiness in the area—eczema, dermatitis, flaky skin; warmth, redness and swelling; and bleed and callus formation followed by open ulcerated wounds if there is an infection. A burning sensation in the affected area due to skin irritation may be present occasionally.

Investigations

While cracked heels is a benign condition, they can be a feature of diabetic foot; therefore, blood sugar estimation, both fasting and post prandial, should never be ignored. Other tests that can be prescribed are:

Complete Blood Count (CBC): Checks for infection or inflammation.

Nutritional Tests: Identify deficiencies in vitamins A, C, D, or E, which play a crucial role in maintaining healthy skin.

Pedobarographic Studies: These foot pressure studies analyse weight distribution on the feet, identifying high-pressure areas that may contribute to heel fissures. ⁶

Skin Biopsy: If an underlying skin disorder is suspected, a small tissue sample may be taken and examined under a microscope to rule out infections, psoriasis, or eczema.

Dermoscopy: A magnified skin examination to detect fungal infections or dermatological conditions.

Wood’s Lamp Examination: Uses ultraviolet light to diagnose fungal infections or skin conditions.

Management

A. Prevention

There are a number of methods to prevent cracked heels.

• Applying a thick moisturiser, such as a high urea-based moisturiser, on the heels and feet daily, to keep the skin hydrated and smooth. Can be repeated as many times as required in a day. It is best avoided in web spaces.

• Inspecting the feet daily to notice any early signs of cracks developing. This is particularly useful for diabetics, who have a high incidence of foot involvement.

• Wearing appropriate and supportive footwear whenever possible, so that drying of the skin is prevented. Must avoid walking barefoot, or wearing flip flops or open-back sandals.

• Wearing stockings and good-quality socks when possible.

• Avoiding standing for long periods of time.

• Drinking plenty of water to stay hydrated.

B. Domiciliary Treatment

The most important habit to adopt is never to stay bare feet. Another precaution is to keep the skin supple. A soft foot file used on cracked heels reduces the development of fissures by removing dry and dead skin cells. Another important measure is to keep the feet moisturised at all times.

1. Use Oils: Hydrogenated vegetable oils for massage over the cracked heels are helpful. Several oils—such as sesame, coconut, olive, and vegetable oils—are effective in treating cracked heels. Begin by thoroughly washing feet with soap and water, then pat them dry. Next, gently rub the heels with a pumice stone for a few minutes to remove dry, dead skin. Wipe the area clean with a tissue. Generously apply the chosen oil to the affected area and leave it on overnight. For best results, repeat this process daily before bedtime; noticeable improvement is typically seen within two weeks.

2. Ripe Bananas: May appear messy but can serve as an excellent natural moisturiser for dry and cracked heels. To use, mash a ripe banana into a smooth paste and apply it generously to the affected areas. Leave the banana paste on the feet for about 15 minutes, allowing the nutrients to penetrate the skin. Afterward, rinse the feet with warm water, followed by a splash of cold water to refresh and invigorate the skin. This simple remedy can help restore moisture and softness to feet when used regularly. ⁷

3. Paraffin Wax: Is used in the treatment of painful, cracked heels to give instant relief. The paraffin is mixed with coconut or mustard oil and then warmed until the wax melts. The thick liquid is then liberally applied to the cracked heels and left overnight, and washed off in the morning.

4. Lemon Juice: The acidic nature of lemon juice helps in softening the skin of the feet. Lemon juice is added to lukewarm water in a tub, and the feet are immersed in it for 10 to 15 minutes. Then the feet are cleaned with a pumice stone. The two cut halves of the squeezed lemon can once again be used to rub over the cracked heels before discarding them.

5. Rice Flour with Honey and Vinegar: A natural scrub made from rice flour, honey, and vinegar is very effective in removing dead skin cells from cracked heels. To prepare, mix two tablespoons of rice flour with two to three tablespoons each of honey and vinegar to form a thick paste. Soak the feet in lukewarm water for about 10 minutes, then apply the scrub to the heels. Allow it to dry before rinsing off with warm water.

6. Honey: Honey alone can also treat cracked heels as it has antibacterial and moisturising properties. Around 2–3 tablespoons of honey are mixed with warm water, and the feet with cracked heels are soaked in it for 15 minutes. Regular use will make the feet feel moist and supple and also improve the blood circulation to the feet. ⁸

7. Indian Lilac (Neem) leaves and Turmeric: Neem leaves are dried and powdered. These are then mixed with turmeric (Curcumin) and vegetable oil and converted into a paste. This paste is applied to cracked heels and left for 30-45 minutes. The feet can then be washed with lukewarm water and patted dry. This can be repeated every night for two weeks.

8. Petroleum Jelly: After scrubbing the feet with a pumice stone, if only petroleum jelly is applied on the cracked heels before you go to bed, the heels will get soft with time.

9. Drinking Water: Staying well-hydrated is essential to prevent dryness and cracking of the feet. Aim to drink 12-15 glasses of water each day to help maintain the skin’s elasticity and keep the heels healthy and less prone to cracking.

10. Calcium Intake: Adequate calcium intake is a must to prevent cracked heels. Food items such as curd, yogurt, milk, cheese and fish are rich in calcium and should be included in the diet.

11. Vitamin E and Iron: Vitamin E significantly aids in the healing of cracked heels. Foods such as vegetable oils, green vegetables, nuts and whole grains are great sources of vitamin E. Iron is also important for healing cracked heels, and can be obtained from meat, chicken and fish.

12. Omega-3 Fatty Acids: Foods such as flaxseeds, flaxseed oil, and cold-water fish are rich sources of Omega-3 fatty acids, which help reduce the problem of cracked heels.

C. Treatment

The basics of treating cracked heels in the outpatient setting remain the same: moisturise, cure, and prevent recurrences. Starting with a lukewarm water fomentation of the feet, followed by scrubbing with a pumice stone to remove any hard, dead skin that may prevent the moisturiser from being absorbed completely, and then application of a thick moisturiser 2 to 3 times a day. Soaking and exfoliating, followed by application of moisturiser and wearing comfortable heel-protecting footwear, form the basis of treatment.

Using a liquid bandage or a specialised heel repair product can help seal cracks, create a protective barrier and aid in the healing process. If cracked heels cause significant discomfort, heel pain relief medications containing lidocaine or benzocaine can provide temporary relief. Keratolytic agents, or antifungal medications are to be used to address any underlying infections. Debridement and strapping, in rare cases, are recommended to remove thickened, callused skin. Strapping may also be advised to help hold the edges of deep heel fissures together as they heal. Finally, appropriate protective footwear that cushions the heel pads is of paramount importance. Pedobarography can be used for the prophylaxis and early detection of a cracked heel.

Compeed Heel Crack Plasters are also an effective over-the-counter option for managing cracked heels. The hydrocolloid gel in these plasters provides cushioning, enhances healing and protects against further damage. ⁹ Recent research indicates that low-level laser therapy (LLLT) shows promise in treating cracked heels, particularly for pain relief and wound healing. Studies suggest LLLT can significantly reduce pain associated with heel fissures and promote faster healing, with some benefits lasting for months after treatment. ¹⁰ Additionally, trichloroacetic acid (TCA) has been explored as a treatment for deep heel fissures, showing improvement after a single application. ¹¹

An Ayurvedic medication from India marked with the brand name of ‘Amarantha Footcare cream’ (AFC), containing Madhuka Taila, Jatyadi Taila, Sarjaras Exudate, Tankan Bhasma and Pudina Satva as ingredients, has also been found to be highly effective in the management of cracked heels in several trials. ¹²

Conclusion

Cracked heels are a common foot problem caused by various factors, including dry skin, open-heeled footwear and certain medical conditions such as diabetes, hypothyroidism and obesity. Symptoms include dry, thickened skin, small cracks, pain, bleeding and increased risk of infection. Most cases can be managed at home with moisturisers and gentle exfoliation, but severe or persistent cases may require medical attention. Diabetics need to take extra care. Preventive measures such as using gentle exfoliation, a good moisturiser for the feet, and wearing closed-toe shoes can help keep your heels healthy and crack-free.