Foot Ulcers and Tips for the Diabetic Patient

• Foot Ulcers
• Tips for the Diabetic Patient

Foot Ulcers

Ulcerations are a result of a break down of the skin. Ulcerations are classified based upon their depth and their cause. Common ulcerations are due to diabetes, ischemia (poor circulation), and venous stasis (varicose veins).

Diabetic ulcerations are by far the most common form of ulceration of the feet. These ulcerations occur in areas of the foot that are exposed to excessive pressure or irritation from the rubbing of the shoes on the skin. corns and callouses develop as a result of excessive pressure over bony areas of the foot. Over time the thickened callous that forms can act as an irritant that breaks down the skin under the callous, forming an ulceration. This is more likely to occur if the person with diabetes also suffers from diabetic neuropathy. Diabetic neuropathy is a condition that most commonly affects the nerves of the hands and feet. Diabetic neuropathy causes a loss or alteration in the ability to perceive pain associated with excessive pressure, heat or cold, sharp and dull, vibration and position sense. As a consequence, corns and callouses which would normally be painful do not cause pain and over time, breaks down the skin causing ulceration. Quite often, an infection will also occur which can result in bone infection (osteomyolytis) or deep tissue infection. If the person also has poor circulation, gangrene can develop.

Treatment is geared toward prevention. People with diabetes must learn to inspect their feet daily and obtain medical attention as soon as they notice anything suspicious or an ulceration forming. Callouses which have a black or blue appearance are in the early stages of ulceration. Corns and callouses should be treated regularly by a podiatrist. These areas should be protected from pressure by using pads and/or cushions. Over-the-counter corns removers must be avoided. These home treatments have acid in them, which can burn the skin and cause infection. Once an ulceration has started, every effort must be made to reduce the pressure to the area or it will not heal. Special shoe inserts, called orthotics, are useful in reducing abnormal pressure on the bottom of the foot in areas of callouses or ulcerations. There are also several different topical medications that are used for the treatment of ulcerations. Treatment should be guided and supervised by a physician.

Ischemic ulcerations occur in areas of poor circulation. Commonly they form on the feet, ankles and lower legs. As the circulation gets worse, the skin begins to thin and is less resistant to pressure and friction forces. Spontaneous break down of the skin can occur. These ulcerations tend to be painful, with a whitish or light-pinkish base. Treatment is focused on keeping the ulceration clean and free from infection. By-pass surgery may be indicated to improve the circulation to the area. Hyperbaric oxygen treatments may also be useful. It is important not to use bandages that can cut off the circulation, or adhesive tape, which can tear the skin when removed.

Venous stasis ulcerations occur in areas where the venous circulation is poor. Venous circulation is the blood flow that returns to the heart in the veins. Varicose veins are abnormal veins that do not allow normal blood flow back to the heart. As the veins become more and more damaged, there is a pooling of fluid that accumulates in the feet and ankle. This swelling of the tissue, over time will cause damage to the skin, and can result in open sores or ulceration. These ulcerations tend to weep a clear fluid, have a reddish base and become infected easily.

Treatment is geared toward prevention by reducing the swelling in the legs with the use of support stockings, medications to reduce the swelling, and elevation of the legs. Once ulcerations have developed, treatment consists of keeping the ulcerations clean and free from infection. This often requires the long-term use of oral antibiotics. A common form of treatment consists of wrapping the legs with a dressing called an unna boot. This dressing is a gauze wrap which has xinc oxide impregnated in it. This dressing helps to keep the bacteria that is in the ulceration from growing and also adds compression to help reduce swelling.

Tips for the Diabetic Patient

Ulcerations, infections and gangrene are the most common foot and ankle problems that the patient with diabetes must face. As a result, thousands of diabetic patients require amputations each year. Foot infections are the most common reason for hospitalization of diabetic patients. Ulcerations of the feet may take months or even years to heal. It takes 20 times more energy to heal a wound than to maintain a health foot.

There are two major causes of foot problems in diabetes:

1. Nerve Damage (neuropathy): This causes loss of feeling in the foot, which normally protects the foot from injury. The protective sensations of sharp/dull, hot /cold, pressure and vibration become altered or lost completely. Furthermore, nerve damage causes toe deformities, collapse of the arch, and dry skin. These problems may result in foot ulcers and infections, which may progress rapidly to gangrene and amputation. However: Daily foot care and regular visits to the podiatrist can prevent ulcerations and infections.



2. Loss of circulation (angiopathy): Poor circulation may be difficult to treat. If circulation is poor gangrene and amputation may be unavoidable. Cigarette smoking should be avoided. Smoking can significantly reduce the circulation to the feet significantly. There are certain medications available for improving circulation (Trental) and by-pass surgery may be necessary to improve circulation to the feet. Chelation therapy is an alternative form of treatment for circulatory problems that is not well recognized by the medical community at large. Daily foot care and regular visits to the podiatrist can often prevent or delay the need for amputation.

Do the Following to Protect Your Feet

1. Examine Your Feet Daily

• Use your eyes and hands, or have a family member help.
• Check between your toes.
• Use a mirror to observe the bottom of your feet.
• Look for these Danger Signs:
• Swelling (especially new, increased or involving one foot)
• Redness (may be a sign of a pressure sore or infection)
• Blisters (may be a sign of rubbing or pressure sore)
• Cuts or Scratches or Bleeding (may become infected)
• Nail Problems (may rub on skin, cause ulceration or become infected)
• Maceration, Drainage (between toes)

If you observe any of these danger signs, call your podiatrist at once.

2. Examine Your Shoes Daily

• Check the insides of your shoes, using your hands, for:
• Irregularities (rough areas, seams)
• Foreign Objects (stones, tacks)

3. Daily Washing and Foot Care

• Wash your feet daily.
• Avoid water that is too hot or too cold. Use lukewarm water.
• Dry off the feet after washing, especially between the toes.
• If your skin is dry, use a small amount of lubricant on the skin.
• Use lambs wool (Not cotton) between the toes to keep these areas dry.

4. Fitting Shoes and Socks

• Make sure that the shoes and socks are not to tight
• The toe box of the shoe should have extra room and be mace of a soft upper material that can "breath"
• New shoes should be removed after 5-10 minutes to check for redness, which could be a sign of too much pressure: if there is redness, do not wear the shoe. If there is no redness, check again after each half hour during the first day of use.
• Rotate your shoes
• Ask your podiatrist about therapeutic (prescription) footwear, which is a covered benefit for diabetic patients in many insurance plans.
• Tell your shoe salesman that you have diabetes.

5. Medical Care

• See your podiatrist on a regular basis
• Ask your primary care doctor to check your feet on every visit.
• Call your doctor if you observe any of the above danger signs.

Do Not Do These Dangerous Acts

• Do Not Walk Barefoot - Sharp objects or rough surfaces can cause cuts, blisters, and other injuries.
• Do Not Use Heat on the Feet - Heat can cause a serious burn, especially if the patient has neuropathy.
• Do Not Apply a Heating Pad to the Feet
• Do Not Soak Your Feet in Hot Water
• Do Not Use Chemicals or Sharp Instruments to Trim Calluses - This could cause cuts and blisters that may become infected.
• Do Not Cut Nails into the Corners - cut nails straight across.
• Do Not Smoke - smoking reduces the circulation to your feet.

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