Heel Fissures: Causes, Treatment & Prevention Guide

What Are Heel Fissures?

Heel fissures are linear cracks that develop in the thick, dry skin of the heels. They occur when the skin loses moisture and elasticity, becoming hard and brittle. When pressure is applied during walking or standing, this inflexible skin cracks, forming fissures that can range from superficial lines to deep, painful wounds that may bleed.

The heels bear significant weight and pressure during everyday activities. Unlike other areas of the body, the skin on the heels is naturally thicker to provide cushioning and protection. However, this thickness also makes it more prone to drying out and cracking. The stratum corneum—the outermost layer of skin—can become excessively thick (a condition called hyperkeratosis) when chronically dry, creating an environment where fissures readily develop.

Heel fissures are medically classified under xerosis cutis (dry skin) with the ICD-10 code L85.3. While often considered a cosmetic issue, severe cases can significantly impact quality of life, causing pain during walking, restricting footwear choices, and potentially leading to serious infections. The condition tends to worsen during dry seasons, particularly in winter when indoor heating reduces humidity, and in summer when sandals expose heels to drying air.

Understanding the anatomy of heel skin helps explain why fissures occur. The heel pad contains fat deposits encased in fibrous chambers that act as shock absorbers. When standing, body weight compresses these chambers, causing the heel to expand laterally. If the surrounding skin lacks elasticity due to dryness, it cannot accommodate this expansion and cracks instead. This mechanical stress, combined with inadequate hydration, creates the perfect conditions for fissure formation.

Types of Heel Fissures

Heel fissures can be classified by their depth and severity, which determines the appropriate treatment approach. Superficial fissures affect only the epidermis and appear as thin, white lines on the heel surface. These rarely cause discomfort and typically respond well to moisturizing. Moderate fissures extend deeper into the dermis, appearing as visible cracks that may cause mild pain or tenderness. Deep fissures penetrate through multiple skin layers, often reaching the dermis where blood vessels are located, resulting in bleeding and significant pain.

What Causes Heel Fissures?

Heel fissures are caused by a combination of dry skin and mechanical pressure. The primary factors include prolonged standing, wearing open-backed footwear, obesity, dry climates, frequent barefoot walking, and underlying medical conditions such as diabetes, hypothyroidism, and eczema. Age-related skin changes also contribute to increased risk.

The development of heel fissures is typically multifactorial, meaning several contributing factors work together. The most fundamental cause is inadequate moisture in the stratum corneum, the skin's outermost layer. When this layer lacks sufficient water content (below 10%), the skin loses its flexibility and becomes prone to cracking. This dryness can result from external factors such as climate, footwear, and hygiene habits, as well as internal factors like hormonal changes and medical conditions.

Mechanical stress plays an equally important role. The heels support the body's entire weight during standing and walking, bearing forces that can exceed body weight during activities like running or jumping. When the heel skin is dry and rigid, it cannot flex to accommodate this pressure. Instead, the skin cracks at stress points, typically around the heel rim where the skin transitions from thick to thin. This explains why fissures commonly appear in a circular pattern around the heel's edge.

Environmental factors significantly influence skin hydration. Low humidity environments—whether from dry climates, air conditioning, or central heating—accelerate moisture loss from the skin. Hot water exposure during bathing strips natural oils from the skin, and excessive use of harsh soaps can disrupt the skin's natural barrier function. Occupations requiring prolonged standing on hard surfaces, such as healthcare workers, teachers, and retail employees, face increased risk due to sustained mechanical pressure.

Medical Conditions That Increase Risk

Several underlying health conditions significantly increase the likelihood of developing heel fissures. Understanding these associations is important because treating the underlying condition often improves heel health.

• Diabetes mellitus: Causes autonomic neuropathy affecting sweat gland function, reduced circulation, and impaired wound healing. Diabetic foot care is critical to prevent complications.
• Hypothyroidism: Thyroid hormone deficiency leads to reduced sweating and sebum production, causing widespread dry skin including the heels.
• Psoriasis: Accelerated skin cell turnover leads to thick, scaly patches that can extend to the heels and feet.
• Eczema (atopic dermatitis): Compromised skin barrier function results in excessive moisture loss and dry, cracked skin.
• Athlete's foot (tinea pedis): Fungal infection can cause skin dryness and scaling, predisposing to fissures.
• Peripheral arterial disease: Reduced blood flow to the feet impairs skin nutrition and healing capacity.

Lifestyle and Environmental Factors

Beyond medical conditions, everyday habits and environmental exposures contribute significantly to heel fissure development. Footwear choices are particularly important—open-backed shoes like sandals, flip-flops, and certain heels allow the heel fat pad to expand sideways, increasing lateral pressure on the skin. The lack of heel support in such footwear also increases mechanical stress during walking.

Obesity places additional strain on the heel pad, causing greater lateral expansion and increased pressure on the already vulnerable heel skin. Each additional kilogram of body weight translates to multiple kilograms of force on the heels during movement. Walking barefoot, particularly on hard surfaces, removes the protective cushioning that footwear provides and exposes heels to potential abrasions and contaminants.

What Are the Symptoms of Heel Fissures?

Heel fissure symptoms progress from dry, rough-feeling skin to visible cracks, pain when standing or walking, and potentially bleeding from deep fissures. Early signs include white or yellow discoloration, flaky skin, and a tight sensation in the heels. Severe cases may show deep cracks, callused edges, and signs of infection.

The symptoms of heel fissures develop gradually, often beginning with subtle changes that many people overlook. Initially, the heel skin feels dry and rough to the touch, similar to sandpaper. Visual changes follow, with the skin appearing dull, white, or yellowish rather than its normal pink color. As dryness progresses, the skin may flake or peel, and a feeling of tightness develops, particularly after bathing when the skin loses additional moisture.

As fissures begin to form, thin white lines become visible on the heel surface, especially around the rim. These superficial cracks may cause mild discomfort but are rarely painful. However, without treatment, the fissures deepen and widen. Pain typically begins when cracks extend into the deeper dermis layer, where nerve endings are located. This pain is often described as a sharp, stinging sensation that worsens with weight-bearing activities.

Severe heel fissures are unmistakable. Deep cracks may be visible from a distance, often surrounded by thick, callused skin that appears yellow or brown. These deep fissures frequently bleed, particularly during walking or after removing socks. The pain can be significant enough to limit mobility and affect daily activities. Standing first thing in the morning is often particularly painful as the skin has stiffened overnight.

Warning Signs of Complications

While most heel fissures remain a localized skin problem, some cases develop complications that require prompt medical attention. Recognizing warning signs early can prevent serious outcomes, particularly in vulnerable populations such as diabetics.

How Are Heel Fissures Diagnosed?

Heel fissures are typically diagnosed through clinical examination by visual inspection of the feet. No special tests are usually needed. A healthcare provider will assess the depth and extent of fissures, check for signs of infection, evaluate underlying conditions like diabetes, and may examine footwear patterns and lifestyle factors contributing to the condition.

Diagnosis of heel fissures is straightforward and based primarily on physical examination. A healthcare provider—whether a primary care physician, dermatologist, or podiatrist—will visually inspect the heels to assess the severity of cracking, the presence of thickened skin (hyperkeratosis), and any signs of secondary infection. They will also examine the overall skin condition of the feet, looking for signs of fungal infection, psoriasis, or eczema that might contribute to the problem.

The medical history forms an important part of the assessment. Questions typically cover the duration of symptoms, previous treatments attempted, footwear habits, occupation, and presence of underlying conditions such as diabetes or thyroid disease. For patients with diabetes, a more comprehensive foot examination is performed, including assessment of peripheral circulation (checking pulses), sensation testing (using monofilament), and evaluation for any ulceration.

Laboratory tests are rarely needed for diagnosing heel fissures themselves but may be ordered to investigate underlying causes. Blood glucose testing can identify undiagnosed diabetes, thyroid function tests can detect hypothyroidism, and in cases of suspected fungal infection, skin scrapings may be sent for microscopy or culture. A skin biopsy is only considered when the presentation is atypical or when conditions like psoriasis need confirmation.

Differential Diagnosis

While heel fissures are usually easily identified, healthcare providers consider other conditions that may present similarly or coexist with fissures. Psoriasis can cause thickened, scaly heel skin with cracks. Tinea pedis (athlete's foot) may cause scaling and fissuring between toes or on heel skin. Keratoderma, a group of skin disorders causing thick skin on palms and soles, can present with heel fissures. Contact dermatitis from footwear materials may cause heel skin changes.

How Are Heel Fissures Treated?

Heel fissure treatment involves a three-step approach: removing dead skin through gentle exfoliation, restoring moisture with urea-based creams (10-25%), and protecting heels with occlusive therapy (heel balms and socks). Mild cases respond to home care within 2-4 weeks. Severe or complicated cases may require professional debridement, medicated dressings, or treatment of underlying conditions.

Effective treatment of heel fissures requires addressing both the cause (dry, thick skin) and the result (cracks). The gold standard approach combines three elements: removal of excess dead skin, restoration of moisture to the remaining skin, and protection to allow healing and prevent recurrence. Consistency is key—heel care must become part of the daily routine for lasting results.

The foundation of treatment is proper moisturization with appropriate products. Regular body lotions are insufficient for heel skin, which requires more intensive hydration. Urea-based creams are the dermatological standard, with urea concentrations of 10-25% providing both moisturizing and keratolytic (dead skin-softening) effects. Higher concentrations (20-40%) are more effective for thick, severely cracked heels but may cause stinging if applied to open fissures. Salicylic acid and lactic acid preparations offer alternative keratolytic options.

Exfoliation removes the accumulated dead skin that contributes to fissure formation. This should be done gently to avoid causing further damage. After soaking feet in warm water for 10-15 minutes to soften the skin, a pumice stone or foot file is used in one direction (not sawing back and forth) to gradually reduce thickened areas. Aggressive filing or use of sharp instruments like razor blades is dangerous and not recommended, as it can cause injury and increase infection risk.

Step-by-Step Home Treatment

A systematic approach to home care maximizes healing potential for mild to moderate heel fissures.

1. Soak your feet in warm (not hot) water for 10-15 minutes. Adding Epsom salts or a gentle foot soak product can enhance softening.
2. Gently exfoliate using a pumice stone or foot file. Work in one direction, using light pressure. Avoid filing if fissures are deep or bleeding.
3. Rinse and dry thoroughly, paying particular attention to between the toes to prevent fungal growth.
4. Apply urea cream (10-25%) generously to the heels and all dry areas. Massage until absorbed.
5. Apply heel balm or petroleum jelly over the cream for occlusive protection.
6. Wear cotton socks to lock in moisture. Overnight use provides maximum benefit.
7. Repeat daily until heels are healed, then continue 2-3 times weekly for maintenance.

Professional Treatment Options

When home treatment fails or for severe cases, professional intervention may be necessary. Podiatrists can perform mechanical debridement using specialized instruments to safely remove thick callused skin without damaging healthy tissue. This professional approach achieves more thorough removal of hyperkeratotic tissue than home methods and can significantly speed healing.

For deep or infected fissures, medical-grade wound dressings may be applied. Hydrocolloid dressings provide a moist healing environment while protecting fissures from friction and contamination. Liquid bandages or tissue adhesives can seal superficial cracks. When bacterial infection is present, topical or oral antibiotics are prescribed based on the severity and extent of infection.

Why Are Heel Fissures Serious for Diabetics?

Heel fissures pose significant risks for diabetics because diabetes affects nerve sensation (neuropathy), blood circulation, immune function, and wound healing. What starts as a simple crack can progress to a diabetic foot ulcer or severe infection. Diabetics should inspect their feet daily and seek prompt medical care for any heel fissures.

People with diabetes face unique challenges with heel fissures that make this seemingly minor condition potentially serious. Several diabetes-related complications converge to increase risk: peripheral neuropathy (nerve damage) reduces sensation in the feet, meaning injuries and fissures may go unnoticed; autonomic neuropathy affects sweat gland function, leading to extremely dry skin; peripheral arterial disease reduces blood flow, impairing the skin's ability to heal; and immune dysfunction increases susceptibility to infection.

The combination of reduced sensation and impaired healing is particularly dangerous. A diabetic patient may develop a deep heel fissure without feeling pain that would normally prompt treatment. The fissure remains untreated, deepens, and potentially becomes contaminated with bacteria. Because blood flow is compromised, the immune response is weakened, and healing is slow, what might resolve quickly in a healthy person can progress to cellulitis, abscess formation, or even osteomyelitis (bone infection) in a diabetic patient.

Diabetic foot ulcers are among the most feared complications of diabetes, and heel fissures represent an often-overlooked entry point for such problems. Statistics indicate that up to 25% of people with diabetes will develop a foot ulcer during their lifetime, and heel ulcers are particularly difficult to heal due to the weight-bearing nature of the area. Prevention through proper foot care, including heel fissure management, is far more effective than treating established ulcers.

How Can You Prevent Heel Fissures?

Prevent heel fissures by moisturizing daily with urea cream, wearing supportive closed-back shoes, avoiding prolonged barefoot walking, maintaining healthy weight, staying hydrated, and using humidifiers in dry environments. Regular foot inspection allows early detection and treatment of dry skin before fissures develop.

Prevention of heel fissures is far easier than treatment, and most preventive measures are simple lifestyle modifications that benefit overall foot health. The cornerstone of prevention is consistent moisturization. Even after heels have healed from fissures, daily application of a quality moisturizer maintains skin hydration and flexibility, preventing recurrence. For those prone to dry heels, urea-based creams (10-15%) used preventively provide superior results to regular body lotions.

Footwear choices significantly impact heel health. Supportive, closed-back shoes distribute pressure evenly across the foot and prevent the lateral expansion of the heel pad that contributes to fissure formation. When sandals or open-backed shoes are worn, limiting time in them and following with moisturization helps reduce risk. Shoes should fit properly—too-tight footwear restricts circulation, while too-loose shoes increase friction.

Environmental modifications help maintain skin hydration. Using a humidifier during winter months or in air-conditioned spaces keeps ambient humidity at levels that support skin health. Avoiding prolonged hot showers or baths prevents excessive stripping of natural skin oils. When bathing, using lukewarm water and gentle, soap-free cleansers preserves the skin's natural moisture barrier.

Daily Foot Care Routine for Prevention

Establishing a simple daily foot care routine prevents heel fissures and maintains overall foot health.

• Morning: Apply lightweight moisturizer to heels before putting on socks and shoes
• After bathing: Pat feet dry (especially between toes) and apply moisturizer while skin is slightly damp
• Evening: Apply thick urea cream or heel balm, followed by cotton socks if sleeping
• Weekly: Gentle exfoliation with pumice stone after bathing (if no active fissures)
• Ongoing: Inspect heels regularly for early signs of dryness or cracking

When Should You See a Doctor?

See a doctor for heel fissures if you have diabetes, if fissures are deep and bleeding, if there are signs of infection (redness, warmth, pus, fever), if home treatment hasn't improved the condition within 2 weeks, or if you have underlying conditions affecting circulation or immunity. Prompt professional care prevents complications.

While most heel fissures can be successfully managed at home, certain situations warrant professional medical evaluation. Recognizing when to seek help prevents minor problems from becoming serious complications and ensures appropriate treatment for cases that need more than basic self-care.

People with diabetes should always consult a healthcare provider when they develop heel fissures, regardless of severity. The risks associated with diabetic foot complications make professional assessment essential. Similarly, individuals with peripheral arterial disease, immunocompromising conditions, or other diseases affecting circulation or wound healing should not attempt prolonged self-treatment.

Signs of infection require prompt medical attention. If redness extends beyond the immediate fissure area, if the heel feels warm to touch, if there's discharge or pus, or if you develop fever or feel unwell, see a doctor the same day if possible. Infected heel fissures can progress to cellulitis, which spreads rapidly and can become serious without antibiotic treatment.

Professional Consultation Is Recommended When:

• You have diabetes, peripheral neuropathy, or poor circulation
• Fissures are deep enough to bleed regularly
• Pain significantly limits walking or daily activities
• Signs of infection are present (redness, warmth, swelling, discharge)
• Home treatment shows no improvement after 2 weeks
• Fissures recur frequently despite preventive measures
• You suspect an underlying skin condition (psoriasis, eczema)
• You're unsure about proper care or product selection