• Diabetic Foot Ulcer

    Definition

    Ulcers are slow-healing wounds on the skin. Diabetic foot ulcers occur on the feet of people with type 1 and type 2 diabetes. Diabetic foot ulcers usually occur on the bottom of the foot.
    Foot Ulcer
    Foot Ulcers
    Copyright © Nucleus Medical Media, Inc.

    Causes

    Diabetes can damage the nerves of the legs and feet. This may make it difficult to feel a blister or sore. If you don't care for a sore it may become larger and infected.
    Diabetes also can cause problems with blood flow. Poor blood flow can make it difficult to heal.
    The ulcer itself is usually caused by:
    • Repetitive trauma or pressure on the foot
    • Puncture wound on the foot
    • Objects in the shoe that can damage the skin, such as a small rock

    Risk Factors

    Factors that may increase your chance of diabetic foot ulcers include:
    • Neuropathy—numbness, tingling, or burning sensation in your feet
    • Peripheral artery disease (PAD)—poor circulation in your legs
    • Improperly fitted shoes
    • A foot deformity, such a bunion
    • Diabetes for more than 10 years
    • Poor diabetes control (HbA1c > 9% )
    • Not wearing shoes
    • A history of smoking

    Symptoms

    Symptoms may include:
    • Sores, ulcers, or blisters on the foot or lower leg
    • Pain
    • Difficulty walking
    • Discoloration in feet: black, blue, or red
    • Fever, skin redness, swelling, or other signs of infection

    Diagnosis

    You will be asked about your symptoms and medical history. A physical exam will be done. Your primary doctor may refer you to a foot specialist.
    Your bodily fluids and tissues may be tested. This can be done with:
    • Blood tests
    • Wound culture
    • Ankle-brachial pressure
    Images may be taken of your bodily structures. This can be done with:

    Treatment

    The sooner a diabetic foot ulcer is treated, the better the outcome. Treatment options include the following:

    Wound Care

    Good wound care is important to help the ulcer heal and prevent infection. Make sure to clean the wound regularly. Change the dressings often to prevent infection.

    No Weight-bearing

    Constant pressure on the ulcer can make it difficult to heal. Pressure can be taken off the area with a special cast or boot. These will take the pressure off of the foot, but still make walking possible.

    Blood Glucose Control

    Infected ulcers can raise high blood glucose levels. High blood glucose levels can then lower the body's ability to fight infections. The high level also keeps the wound from healing.
    Improved blood glucose control will help fight any infections and heal the wounds. This control is often done with adjustments in diet or medications. Sometimes insulin shots are needed in the short-term.

    Healthy Habits

    Smoking can slow healing and should be avoided.
    Wear proper footwear. Make sure it fits well.

    Skin Graft

    Some large skin ulcers may have a hard time fully healing even with the treatments above. They may need a patch of skin to help close the wound. This process is called a skin graft. Bioengineered skin graft or human skin graft may be used.

    Medication

    If the ulcer is infected, antibiotics may be prescribed. They may need to be taken for 4-6 weeks. Do not skip doses. Finish the medication as directed.
    Your doctor may also recommend a growth stimulating medication to place on the ulcer. The medication may help speed healing.

    Surgery

    Dead tissue can build up inside and around the wound. This tissue will slow or prevent healing and increase risk of infection. Surgery may be needed to remove the dead tissue and clean the wound. This surgery is called debridement.
    Bypass surgery may be needed to improve blood flow to the legs. This surgery uses healthy blood vessels to carry blood past areas of unhealthy blood vessels. The improved blood flow may help with wound healing.
    Sometimes an infection is too severe or does not respond to treatment. As a last resort, amputation surgery may be needed. This is the removal of a body part to stop the infection from spreading to the rest of the body.

    Other Treatments

    Hyperbaric oxygen therapy may help with healing. This therapy is delivered in a chamber. Pure oxygen is pumped into the chamber. This helps to increase the amount of oxygen in the blood. The extra oxygen can improve healing.
    Another option to help speed healing is using negative pressure wound therapy. A vacuum device and dressing are used to create negative pressure on the wound. This can help the wound heal faster.

    Prevention

    To help reduce your chance of diabetic foot ulcers:
    • Clean your feet daily. Dry them thoroughly, especially between the toes, before putting shoes and socks on.
    • Do not wear garters and tight stockings around the legs.
    • You may want to use petroleum jelly or an unscented lotion to moisturize dry, leathery feet. Do not put lotion between the toes. The extra moisture may attract bacteria.
    • Inspect your feet daily. Look for sores that you may not be able to feel. Use a mirror or the assistance of another person to see all parts of your feet.
    • Your doctor should look at your feet and test the feeling, flexibility, and circulation in them at least once a year. If you find a sore at any time, make an appointment to see your doctor right away.
    • People with diabetes may have toenails that are brittle and difficult to cut. You may also want to have a foot specialist trim your toenails regularly.
    • Buy properly fitted shoes. Some insurance companies will pay for custom-made shoes with inserts. A doctor can give you a prescription for the shoes.
    • Avoid smoking.
    • Talk to your doctor about exercise. Daily exercise will help to improve blood flow and blood glucose levels.
    • Calluses can increase the pressure on the foot and lead to foot ulcers. Have your foot doctor remove any calluses. This could reduce the risk of developing a foot ulcer.
    • Ask your doctor if you should use a special infrared thermometer. It can check the temperature of your feet.
    • Improved control of your diabetes may reduce the risk of ulcers.

    RESOURCES

    American Diabetes Association http://www.diabetes.org

    American Podiatric Medical Association http://www.apma.org

    CANADIAN RESOURCES

    Canadian Diabetes Association http://www.diabetes.ca

    Canadian Podiatric Medical Association http://www.podiatrycanada.org

    References

    Bakker K, Apelqvist J, et al; International Working Group on Diabetic Foot Editorial Board. Practical guidelines on the management and prevention of the diabetic foot 2015. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:2-6. doi: 10.1002/dmrr.2694.

    Diabetic foot ulcer. EBSCO DynaMed Plus website. Available at: http://www.dynamed.com/topics/dmp~AN~T114270/Diabetic-foot-ulcer. Updated July 19, 2017. Accessed September 19, 2017.

    Markakis K, Bowling FL, Boulton AJ. The diabetic foot in 2015: an overview. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:169-78.

    Ndip A, Bowling F, et al. The diabetic foot in 2013: an update from the 14th Malvern Diabetic Foot Meeting. Int J Low Extrem Wounds. 2013 Mar;12(1):71-5.

    Nelson EA, O’Meara S, et al. Systematic review of antimicrobial treatments for diabetic foot ulcers. Diabet Med. 2006;23(4):348-359.

    2/7/2008 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T114270/Diabetic-foot-ulcer: Armstrong DG, Holtz-Neiderer K, et al. Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. Am J Med. 2007;120(12):1042-1046.

    2/7/2008 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T114270/Diabetic-foot-ulcer: Lavery LA, Higgins KR, et al. Home monitoring of foot skin temperatures to prevent ulceration. Diabetes Care. 2004;27(11):2642-2647.

    4/8/2011 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T114270/Diabetic-foot-ulcer: Löndahl M, Landin-Olsson M, Katzman P. Hyperbaric oxygen therapy improves health-related quality of life in patients with diabetes and chronic foot ulcer. Diabet Med. 2011;28(2):186-190.

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