Konsep Dasar Penyakit Clavus

KONSEP DASAR PENYAKIT CLAVUS  A. Pengertian Pengertian Clavus (klavus) adalah istilah kedokteran, di masyarakat awam biasanya disebut mata ikan. Clavus bukanlah tumor, bukan pula tanda awal kanker, melainkan penebalan dari kulit. Mata ikan adalah kelainan pada kaki berupa kulit yang menebal, tidak merata , tampak seperti kerucut terbalik dengan alasnya ada pada permukaan kulit. Kalau dipegang akan terasa keras, namun kalu dibawa berjalan akan terasa nyeri. Sumber  lain mengatakan bahwa clavus ini adalah semacam tumor jinak yang biasanya tumbuh pada kulit permukaan kaki. Bentuk mata ikan itu sendiri biasanya bulat dan berwarna putih persisi seperti mata ikan beneran. Ada juga yang berpendapat clavus merupakan pertumbuhan semacam “kapalan” dimana hanya terlokasi hanya pa da satu sisi dan menimbulkan rasa sakit tertekan yaitu pertumbuhan sel-sel tanduk yang tidak normal. Biasanya ditelapak kaki dan pertumbuhannya yang pesat menekan sel-sel sekitarnya termasuk jaringan dibawahnya ataupun sel-sel syaraf. Penyakit seperti ini tidak bisa dibiarkan, disamping mengganggu aktivitas kita, juga akan terus membesar dan melebar. Sehingga menjadi benjolan semacam tumor, bahayakan lambung secara langsung. Bersamaan saat nyeri terjadi akan meningkatkan keasaman dari lambung Berbagai profesi akrab dengan clavus misalnya pemain gitar di jari-jari yang menekan senar pada keher (neck) gitar, sepatu pada jari kaki, penjahit pada jari telunjul, dsb. Lokasi akan menentukan apakah ia akan basah atau kering. Ia akan kering bila terjadi di permukaan kulit dan basah bila terjadi disela jari. Bila terjadi demikian jangan menutup clavus dengan kapas karena tidak menyerap air. Mata ikan biasa berubah menjadi borok terinfeksi. B. Penyebab  Ada beberapa beberapa pendapat pendapat yang yang menyebutkan menyebutkan penyebab penyebab timbulnya timbulnya mata ikan. Pendapat Pendapat pertama yaitu mata ikan timbul disebabkan oleh virus yang kemudian masuk diantara kulit dan daging kemudian merusak jaringan bawah kulit, sehingga makin lama, makin mengeras, dan membesar. Pendapat kedua adalah Mata ikan tidak disebabkan oleh kuman, tapi disebabkan oleh gesekan atau tekanan dalam waktu yang lama, sehingga terjadi penebalan kulit. Penyebab terjadinya penebalan dari kulit ini adalah tekanan dan gesekan terus-menerus pada bagian kaki yang terkena. Misalnya, karena pemakaian sepatu yang terlalu sempit atau lama. Oleh karena tekanan terbesar pada telapak kaki, maka biasanya clavus timbul pada telapak kaki. C. Tanda dan Gejala Walaupun merupakan penyakit yang banyak terjadi,munculnya clavus kadang-kadang  juga dapat dapat berhubungan berhubungan dengan dengan penyakit penyakit lain. lain. Clavus dapat merupakan merupakan adanya adanya gangguan saraf tepi akibat kencing manis, atau pada penderita arthritis rematoid (salah satu jenis rematik) menjadi tanda sudah ada perubahan sendi tulang-tulang kaki. Jika clavus terjadi pada orang diabetes yang sudah mengalami gangguan saraf tepi kaki, biasanya tidak terasa nyeri. Tetapi hal ini malah dapat berbahaya, karena dapat mmeluputkan perhatian akan adanya luka/ borok yang dapat berakibat serius pada penderita diabetes mellitus. D. Pengobatan dan Perawatan Bila tidak mengganggu biarkan saja, bila mengganggu pengobatannya adalah operasi. Hanya clavus akan tumbuh kembali bila faktor tekanannya tidak dihilangkan. Sebenarnya pengangkatan clavus dengan operasi kecil merupakan cara cepat untuk

menghilangkan nyeri yaitu dengan mengeluarkan inti mata ikan atau eksisi total.Tapi  jika ingin mencoba cara tanpa operasi, mungkin dapat dicoba dengan mengoleskan salep keratolik pada mata ikan, memberikan obat-obat oles yang dapat menipiskan lapisan kulit yeng menebal yaitu yang mengandung urea, asam glikolat/malat/salisilat.Untuk mengurangi nyeri, sementara dapat ditempelkan plester  tebal pada clavus. Harus memperhatikan sepatu atau sandal yang dipakai selama ini. Apakah sudah nyaman atau terlalu sempit. Jika perlu , gantilah alas kaki selama ini. Yang penting, hindari hak tinggi. Jika clavus berulang kembali dan anda juga menderita rematik, mungkin perlu dirontgen untuk melihat kondisi tulang-tulang kaki dan sendi-sendinya, karena dikhawatirkan sudah terjadi perubahan pada tulang dan sendi. Bila hal ini terjadi ada baiknya konsultasi juga dengan dokter spesialis penyakit dalam, konsultan rematologi. (Djoerban. Z,2008) Selain dioperasi clavus dapat diobati dengan cara berikut : 1. Saat ini ada alat yang dapat menghilangkan kutil dengan cepat, yaitu dengan menggunakan electric cauter. Electric cauter adalah sejenis alat yang cara kerjanya membakar kulit secara electir dan dengan menggunakan metode tertentu sehingga kutil akan terbakar dan lepas dengan sendirinya sampai keakar-akarnya. Dengan pengobatan ini kutil dapat langsung dihilangkan tanpa mengeluarkan darah. Pengobatan ini bisa di dapatkan dari dokter spesialis kulit dan kelamin (Sp.KK). Disana anda dapat bebas berkonsultasi tentang permasahannya dan tentu saja dokter spesialis itu akan memberikan pengobatan yang terbaik buat kamu. Jadi jangan ragu, untuk pergi ke dokter, semakin awal dalam mengobati penyakit itu semakin baik. 2. Obat kutil dan mata ikan, yaitu dengan menggunakan salep herbal. Salep dioleskan pada pagi dan malam hari , ditutup kapas, diplester dan dibiarkan meresap. 3. Pengobatan tradisional Pengobatan tradisional kutil daun dewa juga dipercaya dapat menyembuhkan kutil. Daun dewa (Gynura divaricata, gynura segetum (lour) Meer, atau gynura pseudochina) cukup lama dikenal sebagai tanaman anti kanker. Dibeberapa daerah daun dewa dikenal dengan nama beluntas cina, atau samsit. Menurut penelitian dari Fakultas Farmasi UGM dan Badan Tenaga Nuklir Nasional ( BATAN), secara laboratoris ekstak etanol daun dewa mampu menghambat pertumbuhan tumor paru pada mencit (tikus putih kecil). Ekstark ini juga mampu menghambat pertumbuhan sel kanker. Pada beberapa tulisannya menngenai tumbuhan berkhasiat obat Indonesia Prof HM Hembing Wijayakusuma menyampaikan bahwa daun dewa memiliki banyak khasiat. Manfaat itu banyak berasal dari daun dan umbinya. Daunnya berkhasiat untuk mengobati luka terpukul, melancarkan sirkulasi darah, menghentikan perdarahan, pembengkakan payudara, melancarkan haid, dan lain-lain. Sementara umbinya berkhasiat untuk mengatasi bekuan darah, pembengkakan, perdarahan, tulang patah, dan lain-lain. Daun dewa tergolong tumbuhan semak yang subur pada ketinnggian 0-100 meter  diatas permukaan laut. Tinggi tumbuhan ini bisa mencapai 50 cm. Daunnya tunggal bertangkai pendek berbentuk bundar telur berujung lancip. Kedua permukaan daunnya berambut dengan warna putih. Warna permukaan daun dibagian atas hijau tua, sedangkan dibawahnya berwarna hijau muda. Bunganya terletak dibagian ujung batang, berwarna kuning berbentuk bonggol. Efek farmakologis daun dewa adalah anti kuagolan (koagulan=zat yang mempermudah dan mempercepat pembekuan darah), mencairkan bekuan darah, stimulasi sirkulasi, menghentikan perdarahan, menghilangkan panas, dan membersihkan racun. Daun dewa mengandung zat saponin, minyak atsiri, flavonoid, dan tenin. Efek farmakologis

didapatkan dari seluruh tanaman. E. Pencegahan Pencegahan dapat dilakukan dengan sebisa mungkin menghindari kaki dari tekanan yang terus-menerus. Sebaiknya pilih alas kaki yang baik, waktu yang tepat untuk memilih alas kaki adalah siang hari, karena saat itu kaki berada pada bentuk aslinya. Memakai alas kaki (sepatu) yang cukup (tidak terlalu sempit) pastikan kaki nyaman memakainya, selal ganti secara rutin kaos kaki, selalu jaga kebersihan kaki kalau perlu secara rutin dilakukan perawatan yang lebih intensif lagi. Jangan dibiasakan berjalan tanpa alas kaki meskipun itu didalam rumah, karena bisa beresiko kemasukan benda asing.

 A clavus is a thickening of the skin due to intermittent pressure and frictional forces. These forces result in hyperkeratosis, clinically and histologically. The extensive thickening of the skin in a clavus may result in chronic pain, particularly in the forefoot; in certain situations, this thickening may result in ulcer formation. The word clavus has many synonyms and innumerable vernacular terms, some of which are listed in the Table below; these terms describe the related activities that have induced clavus formation. Synonyms for clavus include callosity, a hyperkeratotic response to trauma; corn, heloma, or a circumscribed hyperkeratotic lesion that may be hard (ie, heloma durum) or soft (ie, heloma molle); and callous, callus, or a diffusely hyperkeratotic lesion. Localized callosities of the soles, which do not resolve, are termed plantar callus, heloma, tyloma, keratoma, or plantar corn .[1] When callosities occur over 1 or more lateral metatarsals, they are termed intractable plantar keratoses .[2] Clinically, all these lesions look like hyperkeratotic or thickened skin. Maceration and secondary fungal or bacterial infections are a common overlying feature in heloma molle and diabetes. Plantar helomas tend to have a central keratin plug, which, when pared, reveal a clear, firm, central core. The most common sites for clavus formation are the feet, specifically the dorsolateral aspect of the fifth toe for heloma durum, in the fourth interdigital web of the foot for heloma molle, and under the metatarsal heads for  calluses.[3] Table. Clavus Formation Named for Specific Etiology or Location (Open Table in a new window) Vernacular Term

Location

Association

Jeweler's callus, cherry pitter's

Thumb

Digital changes, including callosities related to

[4]

thumb, cameo engraver's

repetitive use of fine jeweler's instruments, which also

corn[5]

may be seen with the use of cherry-pitting tools

Weight lifter's callus[6]

Callosities over the palmar

Caused by the friction of weight-lifting apparatus (This

metacarpophalangeal joints

also may be seen in athletes who participate in crew.)

Prayer callus[7, 8]

Callosity on the forehead

From kneeling prayer with the hands on the forehead

Cigarette lighter's thumb[9]

Hyperkeratosis of the radial aspect of the

Caused by excessive cigarette lighter flicking

thumb

Knuckle pads[10]

Hyperkeratosis over the knuckles

Caused by boxing training

Russell sign[11]

Callosities of the dorsum of the hand over

Caused by the friction involved with self-induced

the metacarpophalangeal and

emesis in bulimia nervosa

interphalangeal joints

Screwdriver operator's

Palmar surface of the hand

Occurs at the site of contact with a screwdriver handle

Spine bumps

Hyperkeratosis over the spinal column

Caused by dancing with spinning on one's back

Hairdresser's hand

First finger on dominant hand

Callus formation at the site of friction caused by

clavus

[12]

scissors around the first finger on the dominant hand

Sucking calluses[13]

Lip, hand, or foot of a newborn

Callus formation at the site of an area of suction on the lip, hand, or foot of a newborn

Vamp disease[14]

Feet

Clavus formation due to wearing tight high-heeled shoes

 A clinical image of a screwdriver operator's clavus is below.

Screwdriver operator's callus (ie, clavus).

Pathophysiology The shape of the hands and feet are important in clavus formation. Specifically, the bony prominences of the metacarpophalangeal and metatarsophalangeal joints often are shaped in such a way as to induce overlying skin friction. As clavus formation ensues, friction against the footwear is likely to perpetuate hyperkeratosis. Toe deformity, including contractures and claw, hammer, and mallet-shaped toes, may contribute to pathogenesis. Bunionettes, ie, callosities over the lateral fifth metatarsal head, may be associated neuritic symptoms due to compression of the underlying lateral digital nerves. Furthermore, Morton toe, in which the second toe is longer than the first toe, occurs in 25% of the population; this may be one of the most important pathogenic factors in a callus of the common second metatarsal head, ie, an intractable plantar keratosis. Chronic or repetitive motion may also induce clavus formation, as is seen in computer  users and text messengers (ie, "mousing" callus) .[15] Callosities can also form from excessive leg crossing.[16]

Epidemiology Frequency United States 

Clavus is a common disorder because of the frequency of usage of occlusive footwear  and participation in repetitive activities, such as running.

Mortality/Morbidity Extensive thickening of the skin may result in chronic pain, particularly in the forefoot; in certain situations, ulcer formation may result. Clavus may be a sign of underlying neuropathy due to diabetes or neuroborreliosis, or due to the deformities of rheumatoid arthritis. In the case of neuropathy, a clavus may hide ulceration or denote abnormal

neurovasculature of the feet. In the case of rheumatoid arthritis, clavus may enhance the pain of deformed joints.

Race Persons of any race may be affected by clavus.

Sex Clavus is more common in women than in men because of their use of occlusive and poorly fitted footwear.

Age  Anyone can have a clavus, but most individuals acquire the risk factors for clavus formation after puberty because of the onset of traumatic footwear use, repetitive motion injuries, and progressive foot deformities.  A clavus forms because of inappropriate distribution of pressure onto a specific site, usually of the foot. A localized callosity of the soles, which do not resolve, are termed plantar callus, heloma, tyloma, keratoma, or plantar corn. When callosities occur over  one or more lateral metatarsals, they are termed intractable plantar keratoses.

Physical Clinically, all variants of clavus lesions look like hyperkeratotic or thick skin; maceration and secondary fungal or bacterial infections are a common overlying feature in heloma molle and diabetes. Plantar helomas tend to have a central keratin plug, which, when pared, reveal a clear, firm, central core. The most common sites for clavus formation are the feet, specifically the dorsolateral aspect of the fifth toe for heloma durum, in the fourth interdigital web of the foot for heloma molle, and under the metatarsal heads for  calluses. 

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Examination of patients should include assessment of the types of footwear worn, activities performed, gait, and current home therapy or previously prescribed therapy. Lesions should be palpated and pared to look for underlying blood vessels (black dots or  pinpoint bleeding), which are seen in warts, and to look for underlying ulcerations, as seen in neurovascular ulcerations (especially in patients with diabetes). Paring of callosities or corns, as opposed to plantar warts, should reveal normal dermatoglyphics .[17] Callosities are generally more painful with direct pressure, whereas warts are more painful with lateral pressure.[18] Pedobarographic studies are pressure assessments that may be used to detect an altered distribution of foot pressure. MRI may delineate diabetic foot problems more clearly. Biopsy of lesions reveals hyperkeratosis and, occasionally, mucin deposition.

Causes Conditions associated with clavus formation             

 Advanced patient age  Amputation (ie, stump callosities) Use of a brace or orthopedic stabilizing product Bulimia nervosa[11] Costa acrokeratoelastoidosis [19] Doxorubicin toxicity[20] Keratoderma palmaris et plantaris Obesity Pachyonychia congenita [21] Sensory neuropathies, including neuroborreliosis Tethered spinal cord syndrom e[22] Vascular occlusion syndromes[23] Warts (ie, verruca vulgaris)[1]

Faulty mechanics: Irregular distribution of pressure and repetitive motion injury (especially in athletes) are believed to be the main inciting causes; however, inappropriately shaped or constrictive footwear in the presence of bony prominences (eg, talar bone prominences [24] ) may exacerbate clavus formation. Furthermore, some

disorders may alter the shape or sensation of the soles of the feet. Bony prominences and faulty foot mechanics then allow clavus formation to continue .[25, 26, 27, 28, 29] 

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Rheumatoid arthritis [30] : About 17% of patients with rheumatoid arthritis present with intractable foot pain. Chronic arthritis leads to foot deformities and consequent callus formation. Bleeding into callosities in patients with rheumatoid arthritis may be a sign of  rheumatoid angiitis. Diabetes mellitus with associated peripheral neuropathy [31] : In patients with diabetes, chronic callosities in the presence of neurovascular deterioration may lead to ulcerations and superinfections. Obsessive-compulsive disorder (pseudo-knuckle pads) Ectopic nail        

 Acanthosis Nigricans  Acrokeratoelastoidosis  Arsenical Keratosis  Atypical Fibroxanthoma  Atypical Mole (Dysplastic Nevus) Nevi, Melanocytic Warts, Nongenital Warty Dyskeratoma

Medical Care Treatment of a clavus should be aimed at reducing symptoms such as pain and discomfort with walking. Paring of the lesions immediately reduces pain. Once the etiology of the foot pressure irregularity is determined, attempts at pressure redistribution should be made. The use of orthotics and conservative footwear with extra toe space are often beneficial. When all else fails, surgery may be performed. If abnormal dermatoglyphics or pinpoint bleeding is seen, wart therapy is initiated. If  normal dermatoglyphics are noted, salicylic acid compounds and orthotics may be beneficial. Relief of symptoms may be achieved by thinning and cushioning of the involved lesions. 

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Paring of the lesions immediately relieves pain, especially with helomas. Lesions may be maintained in this state if the patient uses short soaks and pumice stone debridement at home. Debridement may be enhanced with the use of keratolytic agents, such as ureas, alpha-hydroxy acid (eg, glycolic, malic, or lactic acid), or beta-hydroxy acid (eg, salicylic acid).[33] Garlic extracts have also been described as being helpful .[34] Self-adhesive pads are most effective for reducing thick lesions, whereas lotions, creams, and medicaments in petrolatum are best for maintenance. Most salicylic acid compounds are 1017%. High concentrations of salicylic acid (eg, 40%) may lead to severe maceration, and in patients with diabetes, it may lead to frank foot ulcerations .[35] Intralesional triamcinolone and topical vitamin A acid compounds also may reduce localized hyperkeratosis. Triamcinolone can lead to localized hypopigmentation .[36]  A carbon dioxide laser can be used to pare deep lesions .[37]  A combination product to be applied by physicians consisting of 1% cantharidin, a vesicant, mixed with 30% salicylic acid and 5% podophyllin has been described as effective for most people after just one session. In a study looking at 72 patients, 90.3% with callosities on the feet demonstrated that application of this agent after paring with a 15 blade effected clearance in 79.2%, 12.5%, 6.9%, and 1.4% after 1, 2, 3, and 4 sessions, respectively, with only one recurrence at 1 year follow-up.[38]

Reduced friction may be accomplished with the use of silicone-lined sleeves on the toes, padding, and, in select cases, silicone [39] or collagen injections [3] over the bony prominence in question. 

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Lamb's wool may be beneficial in interdigital corns. Pads or permanent insoles, which place pressure proximal to the metatarsal head, relieve stress on the region. Insoles may be made of silicone or soft plastics. Shoes with extra length are required for toe deformity, and shoes with extra width are required for lateral toe callosities. Shoes should be soft inside without seams that rub or press. Orthotics can be placed in the shoe for patients with abnormalities of the foot, such as cavovarus. Orthotics can be created by using insoles made to correct deformities noted on dynamic pressure molds. Reduction of heel height may be helpful for patients with metacarpal head callosities.[40]

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Vacuum orthoses have been described to aid in lesional clearance for diabetic patients with plantar callosities.[41]

Surgical Care Surgical options for clavus should be used when only conservative measures fail.    

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Chronic foot pain despite conservative therapy is the number one indication for surgery. Hallux valgus correction may aid in reduction of painful callosities over the long term .[41] Surgical corrections for claw, hammer, and mallet toes are simple procedures. Shaving of prominent condyles of bony prominences may be beneficial particularly on the fifth digit.  Arthroplasty of the fifth toe interphalangeal joint also may be performed. Metatarsal condylectomy or chevron osteotomy may be performed to relieve metatarsal head pressure.[42] Mann and DuVries described the use of a combination of arthroplasty and condylectomy. This combination results in 95% clearance, with only a 13% occurrence of transfer lesions .[45] When thinning of the plantar fat pads is contributory to the formations of callosities, injectable silicone can be used on the soles underneath the callosities and corns to reduce pressure related callous formation. Description of excision followed by either grafting, use of flaps, or grafting using split-thickness graft with or without a collagen/elastin matrix graft has been described as effective in a single resistant case.[45]

Consultations 

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 An orthopedist and a podiatrist can be helpful in adjusting abnormalities of gait or pressure distribution. Dermatologists are best consulted to assess for the possibility of other disorders in the differential diagnosis, especially warts and keratoderma.

Diet No special diet is required; however, weight loss relieves some of the foot pressures involved.

Activity  Adjustment of the footwear and the use of special insoles aid in the maintenance of full mobility and eliminate the need for activity limitation.

Medication Summary Debridement may be enhanced with the use of keratolytic agents, such as ureas, alphahydroxy acid (eg, glycolic, malic, or lactic acid), or beta-hydroxy acid (eg, salicylic acid). The use of these agents is not recommended in pregnant women and young children. Most salicylic acid compounds are 10-17%. High concentrations of salicylic acid (eg, 40%) may lead to severe maceration and frank foot ulcerations in patients with diabetes. Self-adhesive pads are most effective for reducing thick lesions, whereas lotions, creams, and medicaments in petrolatum are best for maintenance. Intralesional Kenalog and topical vitamin A acid compounds also may reduce localized hyperkeratosis. Kenalog may be injected during pregnancy because of its limited absorption; however, it can lead to localized hypopigmentation. Topical vitamin A derivatives are not intended for use in women who are pregnant or intending to become pregnant because their safety ranges from category C to category X.  A combination product to be applied by physicians consisting of 1% cantharidin, a vesicant, mixed with 30% salicylic acid and 5% podophyllin has been described as effective for most people after just one session .[38]

Keratolytics Class Summary These agents cause cornified epithelium to swell, soften, macerate, and then desquamate. Commonly used agents include urea, alpha-hydroxy acids (eg, lactic acid, glycolic acid), and beta-hydroxy acids (eg, salicylic acid). View full drug information

Ammonium lactate (Lac-Hydrin) May loosen the adhesion of the keratinocytes in the stratum corneum, thereby thinning the skin. View full drug information

Salicylic acid topical (Compound W, Panscol, Sal-Plant) May be compounded in petrolatum at any percentage, usually is used at 5-20%, beginning with lower percentage. Can be purchased over the counter as a liquid or pad preparation, ranging from 17-40% (multiple companies make these). Can be irritating or  cause blistering. View full drug information

Urea (Ureacin-40, Aquacare) Promotes the hydration and removal of excess keratin in conditions of hyperkeratosis.

Intralesional corticosteroids Class Summary These drugs have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. View full drug information

Triamcinolone (Kenalog, Amcort) Injectable version of triamcinolone is available in concentrations of 3-40 mg/mL. Generally, this compound is diluted to 1-4% for injection into lesions, such as a clavus. Corticosteroids cause the skin to thin, and this beneficial side effect can be used to reduce the thickness of a clavus. However, overusage also can lighten the skin and cause atrophy.

Retinoids Class Summary Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes, and they may reduce the potential for malignant degeneration. Retinoids modulate keratinocyte differentiation. These agents are not specifically approved for use in clavus therapy. Only tretinoin has been shown to be useful for clavus therapy in the topically applied form. These agents cause the skin to peel by loosening of keratinocyte adhesion. Irritation and discomfort are limiting adverse effects. View full drug information

Tretinoin topical (Retin-A, Avita) Inhibits microcomedo formation and eliminates lesions present. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Also available as 0.01% and 0.025% gels.