Treatment and Preventive Measures for Diabetic Foot Ulcers

By Ide Costa (RN, NSWOC, Ph.D.)

Introduction

Diabetes Mellitus (DM) is a serious systemic disease with a continuous rise in incidence rates worldwide. Canada has also perceived rising rates of diabetes in the population across all provinces. While in 2015, the prevalence of diabetes was estimated as 3.4 million or 9.3% of the population, it is predicted to almost increase to 5 million or 12.1% by 2025, representing almost a double (44%) rise from 2015 to 2025.1

Diabetic foot disease comes from chronic pathological processes such as neuropathy, biomechanical issues, peripheral artery disease (PAD), and impaired wound healing. While people with diabetic foot disease are at high risk to face lower extremity amputation (LEA), they have also reported fear of the consequences of amputation such as disability, and high mortality rates within five years of the procedure (Costa, 2018). The good news is that with early detection of foot disease and appropriate intervention by a wound care specialist, a great number of individuals with diabetic foot ulcers have achieved the deserved outcomes – healing and limb salvage.2

Diabetic Foot Ulcers: Unfolding its Complications for an Individual   

Evidence has shown that around 15% to 25% of individuals with diabetes are likely to develop foot ulceration at some point in their lifespan, and sadly it is estimated that 12% of those individuals with foot ulceration will require LEA.3  It accounts for nearly 2/3 of all non-traumatic amputations.4 

Its healing is complexed due to diabetic neuropathy, decrease in cellular synthesis, and enhanced chances of acquiring an infection.5   Diabetic foot ulcer is usually located on the plantar side of the foot, over the metatarsal heads, or under the heel.6 The ulcers are bifurcated by cellulitis or underlying osteomyelitis, even wound margins, granular tissue (unless the peripheral vascular disease is also present), a deep wound bed, and low to moderate drainage.6 

The engagement of the individuals with diabetes on everyday foot self-care such as inspection of the potential of their feet for any skin breakdown (e.g., callouses or blister) or self-care support from a family member or caregiver is an important component of the preventive measures. On the other hand, the primary care provider should find out how long the individual is living with diabetes; what they know about the disease; what they know about their role as self-care manager, what they need to know to be able to regulate it and provide everyday self-management.  Additionally, to the level of glucose control, as measured by the hemoglobin A1C (normally less than 7%) 22; the primary healthcare provider needs to find out whether the individual has neuropathy, as determined by testing for loss of protective sensation with the Semmes-Weinstein 5.07 (10 g) monofilament.

Screening for Diabetic Foot Ulcers

Individuals with diabetes should be screened 1-2 times a year for adequacy of circulation represented by extremity pain at rest or claudication, decreased or absent pulses, cool temperature, pallor on elevation, and ankle-brachial index (a simple test that compares the blood pressure in the upper and lower limbs). Additionally, a combination of radiology and non-invasive tests for the diagnosis of PAD have shown to be efficient, less expensive, and carry a lower risk of complication than invasive procedures. 7   

Diabetic ulcers are typically graded with the aid of the Wagner8,9 classification:

Grade 0 – no open lesions in the expected foot

Grade 1 – superficial ulcer including full skin thickness excluding underlying tissue

Grade 2 – deeper ulcer; affecting and penetrating to a bone, tendon, or joint capsule

Grade 3 – deeper ulcer with abscess formation or cellulitis, often with osteomyelitis or tendinitis

Grade 4 – localized gangrene

Grade 5 – extensive gangrene including the whole foot (Sibley et al., 2016)

Prevention of Diabetic Foot Ulcer is Better than Cure   

The most effective way to treat a diabetic foot ulcer is to prevent its growth in the first place. An individual should see a podiatrist or a foot care nurse regularly. The expert can examine if you are prone to developing a foot ulcer and implement comprehensive strategies for prevention.

Save Yourself from Being at High Risk: Check for These Symptoms   

  • A foot deformity (e.g., bunion, hammertoe)
  • Unregulated blood sugar
  • History of a previous foot ulceration
  • Neuropathy
  • Wearing incorrect shoes size
  • Poor circulation

Reducing additional risk factors, such as smoking, alcohol consumption, elevated cholesterol, and blood glucose level are vital aspects in the prevention and treatment of diabetic foot ulcers. Wearing the appropriate shoes and socks will go a long way in decreasing the risks. Your podiatrist can offer guidance in choosing the proper shoes.

Important Steps for Diabetic Foot Ulcer Treatment  

1. Wash your ulcer daily: You can utilize soap and water to keep it clean unless your wound care specialist recommends another cleanser. Avoid using hydrogen peroxide or soaking your wound in a bath or harsh soap, as it could slow down healing and may boost your odds of infection.

2 Do not put pressure on your ulcer: It means you need to use crutches, special footwear, a brace, or other devices (talk to your wound care specialist to learn more). Decreasing pressure aids ulcers in healing faster.

3. Keep your blood sugar level in check: In alignment with reducing your risk of ulcers, tight blood sugar control helps your body heal existing ulcers.

4. Keep your ulcer bandaged or covered with a wound dressing: While you may have heard that it is crucial to “air out” wounds, evidence has shown that not covering a wound increases the odds of infection and slows down the healing process. There are a variety of dressing options to help your body heal your ulcer. Talk to a wound care expert to receive guidance.

Do not Delay Healing: Get to the right Pathway Before it is Too Late

The onset of a diabetic foot ulcer may look easy to treat as it is represented by a “tiny hole”, calluses or blister. Yet, make sure not to try to “fix” your ulcer by yourself as it leads to complications. Keep in mind that over-the-counter medications or home remedies do not play any role in healing this type of chronic wound. By doing so, will delay healing and increase the risk of ulcer deterioration and lower amputation. Similarly, request your primary healthcare provider to refer you to a wound care specialist as they are the most knowable professionals to treat your ulceration and get you on the right care pathway.

References

1. Diabetes Canada. Diabetes statistics in Canada. 2017. Available from: http://www.diabetes.ca/how-you-can-help/advocate/why-federal-leadership-is-essential/diabetes-statistics-in-canada

2 Wukich, DK, Raspovic, KM, Suder, NC. Patients with diabetic foot disease fear major lower-extremity amputation more than death. Foot Ankle Spec. 2017;11(1): 17–21.

 3. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763–71. [PubMed]

4. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217–28.

5 American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Chronic Wounds of the Lower Extremity. 2007. [September 2012]. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Evidence-based-Clinical-Practice-Guideline-Chronic-Wounds-of-the-Lower-Extremity.pdf.

6 Hess CT. Lower-extremity wound checklist. Adv Skin Wound Care. 2011;24(3):144. [PubMed]

7. Sibley RC, Reis SP, MacFarlane JJ, Reddick MA, Kalva SP, Sutphin PD. Noninvasive Physiologic Vascular Studies: A Guide to Diagnosing Peripheral Arterial Disease. RadioGraphics. 2016;37(1):346-57.

8. American Podiatric Medical Association. Diabetic Wound Care. (n/d) Available at: https://www.apma.org/diabeticwoundcare

9. Wagner FW: The dysvascular foot: a system of diagnosis and treatment. Foot Ankle 2:64 -122, 1981

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