What Causes Diabetic Foot Ulcers
The cause of a diabetic foot ulcer varies depending on the type of ulcer that develops. According to the University of California San Francisco Department of Surgery, there are three main categories of diabetic foot ulcers:
Neuropathic Ulcers Approximately 90% of diabetic foot ulcers are neuropathic ulcers. Neuropathic foot ulcers are caused by a condition called diabetic peripheral neuropathy. Diabetes can damage your nerves, which means that sensation in your feet could become limited. When youre unable to feel your feet, you might not notice the pain from a scrape or burn. When these injuries are left untreated, an ulcer can develop.
Ischemic Ulcers Ischemic ulcers are caused by peripheral artery disease . This is a disease that causes blood circulation to become restricted. Oxygen, glucose, and critical nutrients that are needed in your body are substantially reduced. PAD Is common in those with diabetes and can cause diabetic foot ulcers.
Neuroischemic Ulcers Neuroischemic ulcers are caused by a combination of PAD and neuropathic ulcers. Both of these conditions have been known to occur in diabetes patients at the same time.
Tips To Prevent Ulcers
Thereâs a lot you can do to lower your chance of having ulcers in the first place:
Keep your blood sugar in check. Good blood sugar control is the single best way to prevent small cuts and sores from becoming ulcers. If you have trouble managing your blood sugar, tell your doctor. They can work with you to make changes to your medication and lifestyle that will keep your blood sugar from getting too high. Even if your blood sugar level is fairly steady, itâs still important to see your doctor regularly. Thatâs especially key if you have neuropathy, because you may not feel damage to your skin and tissue.
Check your skin every day, and pay special attention to your feet. Look for blisters, cuts, cracks, sores, redness, white spots or areas, thick , discoloration, or other changes. Donât rely on pain even feeling more warmth or cold than usual can be a sign that you have an open wound on your skin, and itâs possible that you may feel nothing at all.
Ulcers are most likely to form on the ball of your foot or the bottom of your big toe, so be sure to check your feet every night. If you notice a problem, or you arenât sure if somethingâs normal, call your doctor.
Donât smoke.Smoking damages your blood vessels, decreases blood flow, and slows healing. Those things raise your risk of ulcers and amputation.
Dressings And Topical Products
Alginate and other dressings
Alginate dressings are derived from seaweed and come in the form of calcium alginate or calcium sodium alginate or alginic acid. These alginate products form a highly absorbent gel that can absorb large volume of wound exudates to avoid skin maceration yet still maintain a moist environment. A Cochrane review and meta-analysis in 2013 showed no significant difference in ulcer healing with alginate products when compared with basic contact dressings or silver hydrocolloid dressings. Another systematic review in 2016 also found no difference in healing time between other synthetic active dressings and traditional dressings, including wet to dry saline moistened gauze, Vaseline gauze, and hydrofiber. As an exception, moderate-quality evidence suggested that hydrogel was more effective in healing DFUs.
Topical antiseptics and antimicrobials
Other topical products
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Diabetic Foot Care Rules
1. Inspect your feet daily. Check your feet for cuts, blisters, redness, swelling, or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.
2. Wash your feet in warm water. Proper foot care requires that you keep your feet clean by washing them daily. Only use lukewarm water, like the temperature you’d use on a newborn baby. With hot water, you could burn the skin on your feet and not know it.
3. Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or patting, and make sure to carefully dry between the toes .
4. Moisturize your feet – but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But don’t moisturize between the toes. This could encourage a fungal infection.
5. Cut nails carefully and straight across. Also, file the edges. Don’t cut them too short, since this could lead to ingrown toenails.
6. Never trim corns or calluses. No “bathroom surgery” – let your doctor do the job.
7. Wear clean, dry socks. Change them daily.
8. Avoid wearing the wrong type of socks. Avoid tight elastic bands, they reduce circulation. Don’t wear thick or bulky socks as they can fit poorly and irritate the skin.
9. Wear socks to bed. If your feet get cold at night, wear socks. Never use a heating pad or hot water bottle.
11. Keep your feet warm and dry. Don’t get your feet wet in snow or rain. Wear warm socks and shoes in winter.
How Do Diabetic Foot Ulcers Form
Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation , and trauma, as well as duration of diabetes. Patients who have diabetes for many years can develop neuropathy, a reduced or complete lack of ability to feel pain 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 of the problem. Your podiatric physician can test feet for neuropathy with a simple and painless tool called a monofilament.
Vascular disease can complicate a foot ulcer, reducing the bodys ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the bodys ability to fight off a potential infection and also retard healing.
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Choice Of Outcome Measure
The primary outcome in the types of study being described should be clinically relevant. In studies of people with active ulcers, the ulcer-centered outcome of choice is healing by a fixed time or time to healing. An alternative measure is to document change in cross-sectional area , and this may not always be easily accomplished because of the curved surfaces of the foot . As change in early-phase cross-sectional area has been shown to correlate with later healing , the chosen primary outcome may be a relative short-term reduction in ulcer area. It is less precise as a measure but can potentially allow exploratory studies to be conducted more quickly.
But when expressed in person-centered termswhich is generally preferablethe outcome should ideally refer not just to the healing of the index ulcer but to the patient being ulcer free . If such a person-centered outcome measure is adopted, it might be expressed in terms of time to being ulcer free, being ulcer free after a fixed interval , or ulcer-free days from the date of randomization to a fixed point . The use of ulcer-free days as a primary outcome is also valuable in studies of attempts to reduce ulcer recurrence, just as antibiotic-free days may be used in studies designed to prevent or treat infection and amputation-free survival in people with limb-threatening PAD.
From Injury Or Blister To Ulcer
If a person with decreased sensation gets a blister or other injury, they may not notice it and it can develop into an ulcer.
Neuropathy:Neuropathy is a general term for nerve dysfunction. Peripheral neuropathy is the most common type of neuropathy in people with diabetes and typically affects the nerves of the feet, legs, and sometimes the arms and hands.
People with diabetes are at increased risk for peripheral neuropathy if they have a history of hyperglycemia and have had diabetes for a long time. Other risk factors for neuropathy include smoking and genetic predisposition.
Over time elevated blood sugar levels can affect nerve functioning and nerve signaling. Small nerve dysfunction results in the inability to feel pain, and large fiber dysfunction causes disturbances in balance, which can increase the risk of falls.
If a person has neuropathy and injures their foot without feeling it, they may not notice it until it gets much worse. Recurrent, unnoticed injuries to the foot can increase the risk of Charcot foot, in which progressive destruction of the bones and joints leads to foot deformity.
Autonomic neuropathy can cause a decrease in sweating, resulting in dry feet. Having dry feet can increase the risk of developing calluses. While calluses are healthy, if you have lost sensation, they can grow deeper cause damage to the skin surface known as breakdown, putting the foot at risk of blisters or ulcers.
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Quality Of The Evidence
One of the most important findings of the present review is the high or unclear risk of bias in all but one of the included RCTs. This was mainly caused by insufficient reporting. Usually methodological flaws lead to an overestimation of the effect size. Therefore, the few positive effects that were found should be interpreted with caution. In addition, unknown and unregistered cointerventions in the control groups of the included trials could have led to reductions in the effects of the experimental educational interventions. Finally, it must be stressed that foot care knowledge and patient behaviour were measured using subjective outcome measures and are therefore also prone to bias.
What Are Foot And Toe Ulcers
An ulcer is a wound or open sore that is either difficult to heal or keeps returning after it heals. Although there are several possible causes, youre more likely to get an ulcer on your foot or toe if you have diabetes specifically a complication called neuropathy that causes you to lose sensation. A scrape, cut or puncture can develop into an ulcer, but if you cant feel it you might not know its there.
Ulcers can lead to infections, and sometimes infections can lead to the amputation of a toe or foot. About 15% of diabetics will get a foot or toe ulcer. Around 14% to 24% of diabetes patients in the United States need an amputation after they get an ulcer.
Ulcers are sometimes painful, sometimes not. You may also experience:
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How Are Foot And Toe Ulcers Treated
The goal of treating a foot or toe ulcer is to relieve pain and heal your wound. Your treatment plan will be individualized based on what medical condition is causing your ulcers. If you cant correct the cause of your ulcer, its likely to come back after treatment.
There are both surgical and nonsurgical treatments for foot and toe ulcers. For simple, early stage foot and toe ulcers, nonsurgical treatments may work. Ulcers that are more advanced, especially ones that are infected, may require surgery.
Research Design And Methods
This was a single blinded, multicenter, randomized trial with a 15-month evaluation period. We randomly assigned 173 individuals at high risk for diabetic foot ulceration to three treatment groups . The three treatment arms involved a standard therapy group, a structured foot examination group, and an enhanced therapy group. The study was approved by the hospital institutional review board. We used a computer generated randomization list. The information was sealed in opaque envelopes and opened after randomization and verification that the subject met all of the inclusion criteria and had none of the exclusion criteria. Subjects were instructed not to discuss their group assignment with the treating physician.
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Diabetic Foot Care Has Been Traditionally Neglected
Despite the high morbidity and mortality associated with diseases of the foot in diabetes and despite its cost to both health care providers and the patient and their families , it is a topic that has generally failed to attract the same level of interest by health care professionals as other diabetes complications. Not surprisingly, the field continues to attract relatively few clinicians who are interested in research.
Prevention And Management Of Diabetes Complications
Diabetes is a chronic metabolic disease, which affects the vascular system extensively throughout the body. The metabolic complications of DM should be treated concomitantly with no bias in treating one metabolic complication over others. The metabolic diseases secondary to DM should be controlled and the target values should be kept below the recommended standard. As a result, the preventive measures should be taken in order to control the neuropathy and PAD, which are the main cause of DFU.
The preventive measures and management of diabetic complications consists of the following:
Life style modification
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Geographic Differences In Clinical Outcome
There is also wide variation in clinical outcome within the same country , suggesting that some people are being managed considerably less well than others. Among the many possible reasons is the lack of emphasis placed on DFUs in basic training and continuing education of doctors and nurses .
There is thus a clear need for acceptance of standard components of care , as well as standard pathways for referral between general practice and specialty care and between different specialist groups. Such principles have been published by the International Working Group on the Diabetic Foot and the National Institute for Health and Care Excellence however, adherence by professionals is not generally monitored, and the lack of a firm evidence base to underpin many aspects of management means that treatment choice is still very much influenced by opinion, as was illustrated in one small but important study .
Diabetic Foot Ulcer: Treatment And Prevention
Estimates are that by 2030 there will be 550 million individuals with diabetes in the world. Because almost a quarter of all people with diabetes will develop a foot ulcer at some point, health care workers need to know the best practices for diabetic foot ulcer prevention and treatment.
Determining which diabetic foot ulcer type is important to determine an effective treatment. Here are the different types of these wounds:
- Neuropathic ulcers arise when the nerve damage from diabetic neuropathy causes the individual with diabetes to not feel pain from an injury, which often leads to the ulcer progressing substantially before the person is even aware of it. Foot and toe deformities, corns, calluses and areas repetitive stress are likely places of injury. Footwear can not only hide these issues, but can exacerbate the injury if the shoe is ill-fitting.
- Ischemic ulcers or arterial ulcers as they are sometimes called may occur due to lack of blood flow to the extremity. When an ulcer occurs as the result of an injury to the extremity, the lack of blood flow makes these ulcers difficult to heal.
- Neuroischemic ulcers occur in individuals with both neuropathy and poor arterial blood flow and are the most difficult to heal.
- Infected wounds occur in about half of patients with a diabetic foot ulcer and require particularly close care.
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Tips For Healthy Feet
Get to the bottom of any foot problems by using a mirror or asking for help.
Check your feet every day for cuts, redness, swelling, sores, blisters, corns, calluses, or any other change to the skin or nails. Use a mirror if you cant see the bottom of your feet, or ask a family member to help.
Wash your feet every day in warm water. Dont soak your feet. Dry your feet completely and apply lotion to the top and bottombut not between your toes, which could lead to infection.
Never go barefoot. Always wear shoes and socks or slippers, even inside, to avoid injury. Check that there arent any pebbles or other objects inside your shoes and that the lining is smooth.
Wear shoes that fit well. For the best fit, try on new shoes at the end of the day when your feet tend to be largest. Break in your new shoes slowlywear them for an hour or two a day at first until theyre completely comfortable. Always wear socks with your shoes.
Trim your toenails straight across and gently smooth any sharp edges with a nail file. Have your foot doctor trim your toenails if you cant see or reach your feet.
Dont remove corns or calluses yourself, and especially dont use over-the-counter products to remove themthey could burn your skin.
Get your feet checked at every health care visit. Also, visit your foot doctor every year for a complete exam, which will include checking for feeling and blood flow in your feet.
Be sure to ask your doctor what else you can do to keep your feet healthy.
Future Directions New Guidelines
Much has been achieved in the last two decades with the incidence of major amputation being very much reduced, at least in some countries, but there is evidence that even more can be achieved. There is wide variation in the outcome of management, even in industrialized countries and those with nationalized health care systemssuggesting that many people do not receive optimal care. Two broad strategies are key to improving overall outcome. The first is a major investment in the conduct of the high-quality clinical trials that are necessary to improve the evidence base for routine clinical care. The second is to ensure that those responsible for the design and delivery of care for people with DFUs comply with such evidence-based guidance as is available.
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Summary Of Main Results
A wide range and combinations of patient educational interventions have been evaluated for the prevention of diabetic foot ulceration. These interventions varied from brief patient education to intensive patient education including demonstration and ‘handson’ teaching.
The ultimate aim of foot care education for people with diabetes is to prevent foot ulceration and amputations. However, these end points were assessed in only five of the 12 RCTs . The results of this review are presented in a studybystudy qualitative synthesis. Pooling of the results was precluded by marked heterogeneity , because participants, types of interventions, types of control interventions, outcome measures, outcome assessment tools, duration of followup and risk of bias varied widely between studies.