A diabetic foot ulcer is an open sore or wound that most commonly occurs on the bottom of the foot in approximately 15 percent of patients with diabetes. Of those who develop a foot ulcer, 25% will be hospitalized due to infection or other ulcer-related complication. Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States, and approximately 24 percent of patients with diabetes who develop a foot ulcer have an amputation. Research, however, has shown that the development of a foot ulcer is preventable, however anyone who has diabetes can develop a foot ulcer. Native Americans, African Americans, Hispanics and older men are more likely to develop ulcers. People who use insulin are at a higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and heart disease. Being overweight and using alcohol and tobacco also play a role in the development of foot ulcers.
How do Diabetic Foot Ulcers Form?
Ulcers form due to a combination of factors, such as lack of feeling in the foot (neuropathy), poor circulation (PAD), foot deformities (bunions and hammertoes), irritation, and trauma. Patients who have diabetes for many years can develop neuropathy, a reduced or complete lack of feeling in the feet due to nerve damage caused by elevated blood glucose levels over time. The nerve damage often can occur without pain and one may not even be aware a problem is developing. Vascular disease or poor circulation can complicate a foot ulcer, reducing the body’s ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the body’s ability to fight off a potential infection and also delay or inhibit healing.
What is the Value of Treating a Diabetic Foot Ulcer?
Once an ulcer is noticed, seek the care of a diabetic foot specialist immediately. Foot ulcers in patients with diabetes should be treated for several reasons such as, reducing the risk of infection and amputation, improving function and quality of life. The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for infection. There are several key factors in the appropriate treatment of a diabetic foot ulcer:
- Taking the pressure off the area, called “off-loading.”
- Removing dead skin and tissue, called “debridement.”
- Applying medication or dressings to the ulcer.
- Managing blood glucose and other health problems.
Not all ulcers are infected; however if you are diagnosed with an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary. There are several important factors to keep an ulcer from becoming infected:
- Keep blood glucose levels under tight control.
- Keep the ulcer clean and bandaged as directed.
- Cleanse the wound daily as directed.
- Do not walk barefoot and use the foot gear prescribed.
For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.” Patients may be asked to wear special footgear, a brace, specialized castings called a total contact cast, or use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.
The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications. Appropriate wound management includes the use of dressings and topically-applied medications. These range from antibiotic ointments to advanced products, such as growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers. For a wound to heal there must be adequate circulation to the ulcerated area. Your circulation level can be determined with noninvasive tests, which Dr. Giacalone can perform in the office. Tightly control of blood glucose is of the utmost importance during the treatment of a diabetic foot ulcer. Working closely with your medical doctor or endocrinologist to accomplish this will enhance healing and reduce the risk of complications. In addition you may require a special boot, brace or cast to take weight and pressure off the ulcer and maximized the healing potential.
Will I require surgery?
A majority of non-infected foot ulcers are treated without surgery; however, when this fails, surgical management may be appropriate. Examples of surgical care to remove pressure on the affected area include shaving or excision of bone(s) and the correction of various deformities, such as hammertoes, bunions, or bony “bumps”, and the application of skin substitutes or grafts. Healing time depends on a variety of factors, such as wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels and what is being applied to the wound. Healing may occur within weeks or require several months.
How Can a Foot Ulcer be Prevented?
The best way to treat a diabetic foot ulcer is to prevent its development in the first place. Recommended guidelines include seeing a podiatrist specializing in diabetic foot care on a regular basis. It can be determined if you are at high risk for developing a foot ulcer and implement strategies for prevention. You are at high risk if you:
- Have neuropathy
- Have poor circulation
- Wear inappropriate shoes
- Have uncontrolled blood sugar
- Have a foot deformity (i.e. bunion, hammer toe)
Reducing additional risk factors, such as smoking, drinking alcohol, high cholesterol, being overweight and maintaining elevated blood glucose are important in the prevention and treatment of a diabetic foot ulcer. Wearing the appropriate shoes and socks will go a long way in reducing risks. Learning how to check your feet is crucial in noticing a potential problem as early as possible. Inspect your feet every day, especially between the toes and the sole for cuts, bruises, cracks, blisters, redness, ulcers, and any sign of abnormality. Each time you visit a health care provider, remove your shoes and socks so your feet can be examined. Any problems that are discovered should be reported to Dr. Giacalone as soon as possible; no matter how “simple” it may seem to you. The key to successful wound healing is regular podiatric medical care to ensure the following “gold standard” of care:
- Lowering blood sugar
- Appropriate debridement of wounds
- Treating any infection
- Reducing friction and pressure
- Restoring adequate blood flow
The old saying, “an ounce of prevention is worth a pound of cure” was never as true as it is when preventing a diabetic foot ulcer.
If You Have Diabetes Already . . . DO:
Wash feet daily.
Using mild soap and lukewarm water wash your feet in the mornings or before bed each evening. Dry carefully with a soft towel, especially between the toes, and dust your feet with talcum powder to wick away moisture. If the skin is dry, use a good moisturizing cream daily, but avoid getting it between the toes.
Inspect feet and toes daily.
Check your feet every day for cuts, bruises, sores or changes to the toenails, such as thickening or discoloration. If age or other factors hamper self-inspection, ask someone to help you, or use a mirror.
People with diabetes are commonly overweight, which nearly doubles the risk of complications.
Tobacco can contribute to circulatory problems, which can be especially troublesome in patients with diabetes.
Do not cut you own toenails.
Never cut your own toenails unless you have been evaluated and cleared to do so by a podiatrist specializing in diabetic foot problems. If you are cleared to do so, never cut into the corners, or taper, which could trigger an ingrown toenail. Use an emery board to gently file away sharp corners or snags.
As a means to keep weight down and improve circulation, walking is one of the best all-around exercises for the diabetic patient. Walking is also an excellent conditioner for your feet. Be sure to wear appropriate athletic shoes when exercising. Ask your podiatric physician what’s best for you.
See your Diabetic Foot Care Specialist.
Regular checkups by your podiatric physician, at least annually, are the best way to ensure that your feet remain healthy.
Be properly measured and fitted every time you buy new shoes.
Shoes are of supreme importance to patients with diabetes because poorly fitted shoes are involved in as many as half of the problems that lead to amputations. Because foot size and shape may change over time, everyone should have their feet measured by an experienced shoe fitter whenever they buy a new pair of shoes.
New shoes should be comfortable at the time they’re purchased and should not require a “break-in” period, though it’s a good idea to wear them for short periods of time at first. Shoes should have leather or canvas uppers, fit both the length and width of the foot, leave room for toes to wiggle freely, and be cushioned and sturdy.
Don’t go barefoot.
Not even in your own home. Barefoot walking outside is particularly dangerous because of the possibility of cuts, falls, and infection. When at home, wear slippers. Never go barefoot.
Don’t wear high heels, sandals, and shoes with pointed toes.
These types of footwear can put undue pressure on parts of the foot and contribute to bone and joint disorders, as well as diabetic ulcers. In addition, open toed shoes and sandals with straps between the first two toes should also be avoided.
Don’t drink in excess.
Alcohol can contribute to neuropathy (nerve damage) which is one of the consequences of diabetes. Drinking can speed up the damage associated with the disease, deaden more nerves, and increase the possibility of overlooking a seemingly minor cut or injury.
Don’t wear anything that is too tight around the legs.
Panty hose, panty girdles, thigh-highs or knee-highs can constrict circulation to your legs and feet. So can men’s dress socks if the elastic is too tight.
Never try to remove calluses, corns or warts by yourself.
Commercial, over-the-counter preparations that remove warts or corns should be avoided because they can burn the skin and cause damage to the foot. Never try to cut calluses with a razor blade or any other instrument because the risk of cutting yourself is too high, and such wounds can often lead to more serious ulcers and infections.