Foot ulcers in diabetics

A diabetic foot ulcer is an open sore or wound that appears on the feet in a significant percentage of patients with diabetes. Chris Delpierre, a podiatrist specialising in diabetic foot ulcers, tells us how to prevent these.

They appear most commonly on the soles of the feet; however any part of the foot can be affected. Foot ulcers are a serious problem. Many patients with ulcers will require an amputation. For this reason, diabetes is the leading cause of non-traumatic lower limb amputation.

Any diabetic patient can develop an ulcer. The following factors can place the patient at higher risk of developing an ulcer:

• Poor blood glucose control
• Sensory neuropathy (loss of feeling in the feet)
• Long duration of diabetes
• Poor circulation
• Foot deformity
• History of previous ulceration
• Poor foot healthcare
• Inappropriate footwear

What causes a diabetic foot ulcer?

No single factor causes a diabetic foot ulcer, rather a combination of risk factors come together to form the ulcer.

A classic example would be a patient with neuropathy and reduced circulation going for a long walk in a new pair of shoes. The new shoes would be hard and unforgiving on the feet, causing chafing. The patient would not feel the chafing as a result of loss of feeling in the feet (sensory neuropathy). The chafing would eventually cause a blister, which the patient would still not be aware of.

The patient would then have a blister on the foot which would not heal as a result of the reduced circulation, and which would then form an ulcer. The ulcer would not heal as a result of high blood glucose levels; reduced circulation and the continual pressure placed on the area.

This is only one example of a possible scenario which could cause an ulcer.

Patients who have developed an ulcer should seek immediate medical care, reducing the risk of infection and ultimately, the need for amputation.

Treatment of diabetic foot ulcers

The most important goal of treatment is to heal the ulcer as soon as possible. The faster the ulcer heals, the less chance there is for an infection to develop.

Ulcer treatment has developed into a highly specialised skill. Most patients with a diabetic foot ulcer require regular wound dressing and healing may take place over a period of months or more. The following are important principles of ulcer treatment:

• Prevention of infection
• Regular debridement (removal of dead skin) of the wound and surrounding area.
• Pressure relief of the area also known as “offloading”. This can be by means of pressure relief padding, shoes with prescription insoles, special pressure relief boots or even total contact casts.

Listed above are the basics of ulcer care. Ulcer prevention is of far greater significance to the diabetic patient.

Preventing a diabetic foot ulcer

There are many things diabetics can do to prevent ulcers in the first place. The following steps are essential to follow for all people with diabetes:

• Check blood glucose regularly. Good blood glucose control is essential.
• Check the feet daily, using a mirror if necessary. This is particularly important in patients with neuropathy.
• Wash feet daily using warm water and mild soap. Dry feet well, especially between the toes.
• Use moisturising cream daily on the feet. Be careful not to get any cream between the toes.
• Use surgical spirits to dry out the area between the toes. This can be done by using a cotton bud dipped in the spirits. This is particularly useful for patients with athlete’s foot between the toes.
• Follow a healthy lifestyle. This cannot be emphasises strongly enough. Overweight patients are more at risk from developing foot complications. Regular exercise will keep the weight down, as well as improve circulation in the lower leg. Smoking can contribute to circulation problems and is especially dangerous to diabetic patients. Cut back or stop drinking alcohol altogether.
• Cut toenails carefully, straight across and never try to cut down into the corners of the nail as this increases the risk of an ingrown toenail. If you are unsure of how to cut your nails, consult your podiatrist.
• Do not attempt “self-podiatry”. It is dangerous to attempt reducing callus and removing corns yourself. Rather have these hard skin lesions professionally removed by your podiatrist.
• Appropriate footwear is essential for the diabetic patient. Make sure your feet are measured for width as well as length by a podiatrist. Your podiatrist will also assess if there is sufficient room in the toe box of the shoe for your feet. Avoid shoes with high heels and/or pointed toes as these will place too much pressure on parts of the foot. Make sure the shoe has enough cushioning. Always wear a new pair of shoes in gradually. Feet can change their shape and size over time so make sure your feet are properly measured every time you buy new shoes.
• Socks are also very important. Socks can be made of a cotton-acrylic blend but make sure they are thick with no prominent seams.
• Do not use a hot water bottle to warm the feet.
• Always make sure you have sunblock on the feet if they are exposed to the sun.
• Do not walk barefoot. Also avoid sandals or open-toed shoes. This can increase the risk of injury to the foot.
• Consult your podiatrist regularly. Podiatrists are specially trained to diagnose and treat foot problems. Regular check-ups are vital to prevent problems before they even start.

- (Health24, updated February 2009)