Tolio, Holio and Foot Rot, Oh My; Why You Need to Care for your Feet on the River
How to Prevent Foot Maladies on the Colorado River through Grand Canyon
by Sharon Hester
Foot Care on the River
Taking care of your feet is super important on a Grand Canyon rafting expedition. Most injuries on a river trip occur in camp and oftentimes to the feet and toes. Injuries can easily become infected. It is especially important to wear shoes in camp, not only to prevent injury, but also to prevent various foot maladies, such as painful Grand Canyon “Tolio” or “Foot rot” afflictions that can become serious problems for some people on river trips.
Photographs taken on Day 6 of a river trip, 2 days after the outbreak began, demonstrate the “punched-out” or pitted appearance on the surface of the skin consistent with pitted keratolysis.
Close up of pitted keratolysis sometimes referred to on river trips as “Foot Rot”.
Types of Foot Maladies on Colorado River
There are two common types of foot maladies seen on the river. “Tolio” or “foot rot” (guides use the two names interchangeably), seen on Grand Canyon River trips. The most common form, is medically known as pitted keratolysis (PK), which usually takes several days to develop. Most often appearing after someone has been on the river 6 days or more. Feet exposed to the abrasive action of sand can develop minute abrasions that allow bacteria to gain a toehold, literally. Typically originating between the toes, one may initially notice sharp pain in between the toes when walking. It may feel like something irritatingly sharp is caught between the toes. It is also possible that the presence of preexisting athletes foot fungus contributes to allowing bacteria to gain access. Occasionally “tolio/foot rot” is not noticed until it has spread to the soles of the feet. When observing it between the toes, it appears as red, raw skin in the toe crease area, sometimes pitting is observed. Once PK is on the soles of the feet, obvious pitting or small red, raw round holes are always observable. It is very painful to walk at this stage of progression. Sometimes guides use the the term “Holio” at this pitting stage.
The other foot malady or type of “tolio” seen in the canyon, although much less common, is chilblains. This malady can occur much sooner (even within 24 hours), especially if someone is susceptible to cold-related afflictions. Folks that are immunocompromised or have poor circulation are more susceptible to chilblains. This affliction is more likely to be seen in the spring when cooler air and water temperatures are prevalent.
On the river, chilblains are typically first visualized as blisters on the tops of toes, these bulbous pustules are rarely observed on the bottoms of the feet. Chilblain blisters can progress up the foot, even to the leg and are extremely painful. If the infected blisters progress up past the toes to the foot, ankle and even leg, it is potentially a medical emergency. It is thought that a bacterial component can also become secondarily involved with chilblains on the river, thus making this foot affliction much more serious.
Painful, pruritic inflammatory lesions with bulbous eruptions on the toes of a river guide in 2017, consistent with perniosis (chilblains). This commonly seen distribution on the toes helped influence the coining of the name “tolio” by river guides.
Fortunately, both foot maladies disappear quickly once off a river trip and are usually preventable while on the river. On rare occasions serious infections have persisted, especially in people with compromising illnesses such as diabetes. Prevention is the best method to prevent either of these toe/foot problems. Tolio/foot rot can be successfully treated (usually) on the river by adopting vigorous adherence to the prevention methods. There are some topical medications that can help with treatment, but adopting the prevention methods once tolio is present is particularly important to treating tolio.
Prevention and treatment of Tolio, (pitted keratolysis and chilblains) on a river trip:
1. Once in camp and done with getting in and out of the water, clean with soap such as Camp Suds) and dry feet at rivers edge. If the river water is muddy, rinse your feet afterwards with clear clean water. After drying feet, apply a thick salve (Super Salve, Eucerin or similar thick healing ointment) and or some anti-fungal cream. Lotion is acceptable but a thick salve is best. Next put on clean, dry socks and shoes.
2. Consider prophylactically treating your feet with an anti-fungal cream such as Lotrimin, Lamisil or Tinactin both pre trip and while on the river. This can treat any foot fungus you may already be harboring, so it will be unlikely to get worse. It is likely that skin fungus (such as athletes foot), which compromises the protective skin barrier, allow bacterias entry that cause pitting keratinosis to become established.
3. Do NOT go barefoot or wear wet shoes in camp. Sand abrades feet, allowing bacteria to enter, and wet shoes/sandals encourage bacterial growth.
4. While it is impossible to keep your feet warm and dry while on the river, you can dry them out occasionally throughout the day. You can remove wet river sandals or river shoes at lunch, or during warm, dry, flat water sections of the river. Dry feet and footwear while sitting in the sun for a bit. If the weather is unusually cool keep your feet warm while rafting by wearing thick wool or wet suit socks while rafting.
5. Wear dry shoes and socks on hikes, especially if symptoms of pitted keratolysis or chilblains are present.
6. If symptoms and pain are noticed, tell your guides right away, there are topical treatments available in the river trip first aid kit, such as over the counter antibacterial ointments and foot fungicides. These can help but cannot cure while on the river once the infection has become prevalent.
7. If chilblain blisters are the issue and are present, keep feet out of the sun as this irritates the pustules (personal experience) but keep them dry and warm as much as possible.
For a detailed medical review of these two notorious Grand Canyon foot maladies, go to a comprehensive medical report by Grand Canyon doctor, Dr. Tom Myers. His report includes case reports, photos, treatment, suspected pathogens, and origins, view report.