Diabetic
Foot Ulcers
Patients with diabetes do not
have normal feeling in their feet. The nerves stop conducting electrical
impulses correctly as a result of the abnormal sugar metabolism. Sensations in
the foot begin to change and decrease over time. This condition is called
neuropathy.
Due to the neuropathy, light touch, deep pressure and most skin sensations
cannot be adequately perceived. Any friction, rubbing, or pressure from a shoe
will lead to an increased concentration of pressure on the foot. This causes
skin breakdown and an ulcer develops. The pressure and friction are normal but
the inability to feel these sensations is abnormal. The patient cannot make the
fine-tuning and adjustments necessary to prevent an ulcer from forming.
An ulcer is not caused by lack of circulation or by infection. The ulcers are
usually associated with bone pressure and a bone prominence under the arch of
the foot. These ulcers can become very large and must be treated.
Causes
and risks
A diabetic
foot ulcer is caused by direct damage to the skin, such as a cut, or by
pressure, such as that from poorly fitting shoes. The following factors
increase a person's chance of developing a foot ulcer: diabetic neuropathy,
with damage to the nerves supplying the feet peripheral vascular disease, with
decreased blood flow to the feet a history of 10 years or more of diabetes
smoking male gender blood sugar levels that are not under control diabetic
retinopathy, or damage to the retina of the eye from diabetes cardiovascular problems
caused by diabetes kidney problems caused by diabetes, including chronic renal
failure a history of skin ulcers or amputation of a limb conditions caused by
increased pressure on the feet, such as corns and calluses foot bones that are
deformed or have limited movement, such as bunions thick toenails
Prevention
Prevention consists of following guidelines for foot care for people
with diabetes. These guidelines include regularly inspecting the feet and
wearing shoes and inlays that fit properly.
Diagnosis
Diabetic foot ulcers are usually first recognized by the affected
individual. The advice of a healthcare provider should be sought immediately.
The provider can diagnose the ulcer by looking at it. If the ulcer is draining
fluid, a culture of the fluid may be sent to the laboratory to check for
infection.
Long term
effects
If a diabetic
foot ulcer is not treated early and effectively, a person may experience:
- • an infection in the ulcer itself
- septicemia, an
infection of the bloodstream, which can be caused by bacteria from the ulcer
- loss of function and ability to
perform activities of daily living
- amputation of the
involved foot or leg
- death
In the United States, people with diabetes account for
50% of amputations for
reasons other than injuries. Most of these amputations are below the knee.
After a limb has been amputated, the opposite limb is often lost within a few years.
This happens not only because of ongoing problems and vascular disease, but
also because the opposite leg must bear increased pressure and workload.
Treatment
Options
There are 10
major areas of treatment:
- monitoring of peripheral vascular disease,
which causes decreased blood flow to the feet. Monitoring includes regular
measurement of oxygen levels in the skin, blood flow in the veins of the legs,
and pulses in the legs and feet. In some cases, imaging with special dyes and
X-rays will be used.
- monitoring of diabetic neuropathy (nerve damage from diabetes) in the feet
- correcting risk factors. A
person who smokes should quit smoking. A diet for diabetes should be carefully followed for blood sugar control. Blood pressure and cholesterol levels can
be controlled with medication.
- doing regular exercise for a person with diabetes,
to improve circulation to the feet. The healthcare provider may also prescribe
special support hose to improve blood flow from the legs to the heart.
- aggressively treating any sign
of skin damage. The treatment may consist simply of local wound care and
antibiotics. Infections, especially those that have reached the bone, must be treated
surgically. It is very important to avoid pressure on the ulcer during healing
because new tissue is delicate. Prescription inlays, or shoe inserts, can be
used to relieve pressure on the area.
- treating any fungal infections
of the foot, such as fungal nail infections,
with prescription medications from the healthcare provider
- wearing well-cushioned walking
shoes, athletic shoes, or special prescription shoes as recommended by the
healthcare provider
- following a team approach to
care. The team may include the person with diabetes, the primary care
physician, the physician's assistant, the diabetes educator, the nutritionist,
the surgical specialist and, if needed, a physician specializing in diabetes.
- performing daily foot care for a person with
diabetes. In addition, the healthcare provider should examine the
person's feet at each visit.
- learning about diabetes on an ongoing
basis. The individual must assume responsibility for self-care and learn how to
prevent ulcers.
After
treatment
After a
person gets a diabetic foot ulcer, he or she will be at risk for further skin
breakdown and infection for the rest of his or her life. Informed self-care and
monitoring are the best tools available to prevent skin lesions from becoming
life- and limb-threatening infections. A neglected blister or callous is the
most common reason for amputations in people with diabetes.
Monitoring
A person with
diabetes needs to follow foot care guidelines and monitor blood sugar levels
for the rest of his or her life. The healthcare provider also inspects the
individual's feet regularly and monitors his or her sugar and cholesterol
levels and blood pressure.
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