Temple University School of Podiatric Medicine Journal Review Club
Editor's note: This post is part of the Temple...
By the WoundSource Editors
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.
Diabetic Foot Ulcer Treatment
The first step in treatment of diabetic foot ulcers is to remove necrotic wound tissue from the wound. It is essential that the method of debridement utilized does not damage nerves, tendons, and blood vessels. Since many people with diabetes don't feel pain from the wound site, health care practitioners can't rely on the patient to let them know when sensitive areas are being examined. The debridement will:
- Reduce pressure on the ulcer.
- Stimulate wound healing.
- Allow the healthy underlying tissue to be examined.
- Help the wound to drain.
- Optimize the effectiveness of the wound dressing.
Infection Prevention: Aggressive infection control is necessary to prevent infection. High morbidity and mortality rates are associated with diabetic foot ulcers which means oral and topical antibiotics are recommended if there is any sign of infection. Typically, wound dressings impregnated with antimicrobial agents are used. Simple gauze may actually damage the skin. Alginate and foam dressings provide high absorbency for moderate to heavy exudate. For a diabetic foot ulcer with dying tissue, hydrogels or dressings with collagen and silver are most effective. Most important is matching the absorptive ability of the wound dressing to the amount of wound drainage.
Pressure Offloading: Pressure on the diabetic foot ulcer prevents healing. That is why one key aspect of treatment can be a device to redistribute pressure more evenly throughout the lower leg. This can be done with a non-removable total contact cast or a removable offloading device. Unfortunately, studies have shown that many patients with removable devices only wear them 30% of the day, which can affect the outcomes of the treatment significantly.
Advanced Therapies for Diabetic Foot Ulcers
Physicians of individuals with diabetic foot ulcers may have difficult decisions to make if wounds do not heal. Many of these patients have a significant cardiac risk and health care practitioners need to make complicated decisions about whether to perform invasive procedures like angiography. Other options can be:
- Covering the wound with cultured human cells.
- Heterogenetic dressings or grafts with recombinant growth factors.
- Hyperbaric oxygen therapy.
Preventing a Diabetic Foot Ulcer
Holistic treatment of the individual with diabetes can help treat the underlying health issues and not only promote faster wound healing but also minimize risk factors that may have contributed to the development of a diabetic foot ulcer. Good diabetic control and lifestyle modification include:
- Keeping blood glucose levels optimal.
- Good nutrition and eating habits.
- Reducing high blood pressure.
- No smoking.
Individuals with diabetes should be instructed to:
- Examine their feet daily with a mirror and to look carefully for fungal infections or any abnormality.
- Wash and dry feet at least once a day in lukewarm water (tested with elbow), paying special attention to dry between the toes.
- Not use heating pads or put feet close to heaters.
- Always use footwear inside and outdoors.
- Use close-toed shoes if they can't feel their feet.
- Always use socks and change them daily.
- Have their nails cut carefully straight across by a trained professional (individuals should not cut their own nails as the risk of injury is too great).
- Treat dry feet with lubricants containing urea or salicylates, but don't apply between toes.
In addition, every patient with diabetes should have a comprehensive foot exam yearly. Along with a careful physical exam, health care professionals should reinforce best practices of diabetic foot self-care at each visit to make sure the individual understands the recommendations and importance of caring for their feet.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.