​Diabetes, Foot Care and Foot Ulcers

Some people with diabetes develop foot ulcers. A foot ulcer is prone to infection, which may become severe.

Knowing about foot ulcer

A skin ulcer is where an area of skin has broken down and the underlying tissue can be seen. Most skin ulcers occur on the lower legs or feet. The skin normally heals quickly if it is cut. However, in some people with diabetes the skin on the feet does not heal so well and is prone to developing an ulcer. This can be even after a mild injury such as stepping on a small stone in one’s bare feet.

Association of diabetes with foot ulcers

Foot ulcers are more common if one has diabetes because one or both of the following complications develop in some people with diabetes:

Reduced sensation of the skin of the feet

One’s nerves may not work as well as normal because even a slightly high blood sugar level can, over time, damage some of the nerves. This is a complication of diabetes, called peripheral neuropathy of diabetes.

The nerves that take messages of sensation and pain from the feet are commonly affected. If one loses sensation in parts of one’s feet, one does not know if his feet are damaged. For example, if tread on something sharp or develop a blister due to a tight shoe. This means that one is also more prone to problems such as minor cuts, bruises or blisters. Also, if one cannot feel pain so well from the foot, one does not protect these small wounds by not walking on them. Therefore, they can quickly become worse and develop into ulcers.

Narrowing of blood vessels (arteries) going to the feet

If one has diabetes one has an increased risk of developing narrowing of the arteries (peripheral arterial disease). This is caused by fatty deposits called atheroma that build up on the inside lining of arteries(sometimes called furring of the arteries). This can reduce the blood flow to various parts of the body.

The arteries in the legs are quite commonly affected. This can cause a reduced blood supply (poor circulation) to the feet. Skin with a poor blood supply does not heal as well as normal and is more likely to be damaged. Therefore, if you get a minor cut or injury, it may take longer to heal and be prone to becoming worse and developing into an ulcer. In particular, if you also have reduced sensation and cannot feel the wound.

Speculations on development of foot ulcers

If there is reduced sensation to feet – The risk of this occurring increases the longer one has diabetes and the older one is. Also if one’s diabetes is poorly controlled. This is one of the reasons why it is very important to keep one’s blood sugar level as near normal as possible.

If one has narrowed blood vessels (arteries) – The risk of this occurring increases the longer one has diabetes, the older one becomes and also if one is a male. Also, if one has any other risk factors for developing furring of the arteries. For example, if one smokes, does little physical activity, has a high cholesterol level, high blood pressure or is overweight.

If one had had a foot ulcer in the past.

If one has other complications of diabetes, such as kidney or eye problems.

If one’s feet are more prone to minor cuts, grazes, corns or calluses which can occur:

If one has foot problems such as bunions which put pressure on points on the feet.

If one’s shoes do not fit properly, which can put pressure on one’s feet.

If one has leg problems which affect the way that one walks, or prevents one from bending to care for the feet.

Gravity of foot ulcers

Although foot ulcers can be serious, they usually respond well to treatment. However, foot ulcers can get worse and can take a long time to heal if one has diabetes, particularly if one’s circulation is not so good. In addition, having diabetes means one is more likely to have infections and an infection in the ulcer can occur. Occasionally, more serious problems can develop, such as tissue death (gangrene).

Obviating foot ulcers

Regular examination of the feet

Most people with diabetes are reviewed at least once every 3 months. Part of this review is to examine the feet to look for problems such as reduced sensation or poor circulation. If any problems are detected then more frequent feet examinations will usually be recommended.

Therapeutics for diabetes and other health hazard aspects

As a rule, the better the control of one’s diabetes, the less likely one is to develop complications such as foot ulcers. Also, where appropriate, treatment of high blood pressure, high cholesterol level and reducing any other risk factors will reduce your risk of diabetic complications. In particular, if you smoke, you are strongly advised to stop smoking.

Foot care

Research has shown that people with diabetes who take good care of their feet and protect their feet from injury, are much less likely to develop foot ulcers.

Good foot care includes:

Looking carefully at your feet each day, including between the toes. If you cannot do this yourself, you should get someone else to do it for you. Looking is particularly important if there is reduced sensation in the feet, as anything wrong may not be noticed at first, until one looks.

If one sees anything new (such as a cut, bruise, blister, redness or bleeding) and doesn’t know what to do, then the doctor should be seen. Corns, calluses, verrucas or other foot problems should not be dealt with oneself. In particular, chemicals or acid plasters should not be used to remove corns, etc.

A moisturising oil or cream for dry skin, can be used to prevent cracking. However, one should not apply it between the toes, as this can cause the skin to become too moist which can lead to an infection developing.

One should look out for athlete’s foot (a common minor skin infection). It causes flaky skin and cracks between the toes, which can be sore and can become infected. If one has athlete’s foot, it should be treated with an antifungal cream.

Nails should be cut by following the shape of the end of one’s toe. But, the sides of the nails should not be cut down, or cut too short, or anything sharp used to clean down the sides of the nails. These things may cause damage or lead the nail to develop an ingrown nail.

Feet should be washed and regularly and then dried carefully, especially between the toes.

One should not walk barefoot, even at home. One might tread on something and damage the skin.

Socks should always be worn with shoes or other footwear. However, socks which are too tight around the ankle, should not be worn, as they may affect the blood circulation.

Shoes, trainers and other footwear should:

• Fit well to take into account any awkward shapes or deformities (such as bunions).
• Have broad fronts with plenty of room for the toes.
• Have low heels to avoid pressure on the toes.
• Have good laces or buckles fastening to prevent movement and rubbing of feet within the shoes.

When one buys shoes, the type of socks one is used to should be worn. Slip-on shoes, shoes with pointed toes, sandals and flip-flops, should be avoided. Break in new shoes gradually.

Always feel inside footwear before you put footwear on (to check for stones, rough edges, etc). If your feet are an abnormal shape, or if you have bunions or other foot problems, one may need specially fitted shoes to stop one’s feet rubbing.

Tips to avoid foot burns include:

• checking the bath temperature with one’s hand before stepping in;
• not using hot water bottles, electric blankets or foot spas;
• not sitting too close to fires.

On developing a foot ulcer

• Treatment aims to dress and protect the ulcer, to prevent or treat any infection and also to help one’s skin to heal.
• The ulcer is usually covered with a protective dressing.
• May need to remove any hard skin that prevents the ulcer from healing. Also, depending on the site and size of the ulcer, they may protect it from further injury by using padding to take the pressure off the area.
• You may also be advised to wear special shoes or have a cast made for one’s foot to keep the pressure off the ulcer.
• Antibiotics will be advised if the ulcer, or nearby tissue, becomes infected.
• Sometimes a small operation is needed to drain pus and clear dead tissue if infection becomes more severe.
• In some cases, the arteries in the legs are very narrow and greatly reduce the blood flow to the feet. In these cases an operation to bypass, or widen, the arteries may be advised.
• Many foot ulcers will heal with the above measures. However, they can take a long time to heal.
• In some cases, the ulcer becomes worse, badly infected and does not heal. Sometimes infection spreads to nearby bones or joints, which can be difficult to clear, even with a long course of antibiotics. Occasionally, the tissue in parts of the foot cannot survive and the only solution then is to surgically remove (amputate) the affected part.

Expected care on admission to hospital with a diabetic foot problem

One will have one’s diabetes assessed and checks will be made to make sure one has not developed complications such as kidney disease (or if one has already developed complications, to make sure they are not getting any worse).

One will have an examination of both feet to check for ulcers, cuts and abrasions to the feet, signs of poor circulation, areas of numbness and the development of Charcot’s arthropathy. This is a condition in which the sensation of pain is reduced because of the diabetes, resulting in damage to bones, such as tiny fractures.

One will have a general examination to make sure one does not have a high temperature (fever) or any other signs of a severe generalised infection.

If one has an ulcer, this will be checked for infection and baseline measurements of the size and depth will be taken.

One may be asked to have an X-ray or scan of one’s foot to make sure the bones have not been affected by one’s condition.

One might need MRI of foot to look for deep abscess.

If there is doubt about circulation the CT – ANGIOGRAM/MR – ANGIOGRAM will be necessary to evaluate the arterial supply to legs. Correction of any blood supply or re estabishing arterial blood supply is essential to ulcer healing.

One also needs to look for any venous disease as combination of diabetes and venous disease is leading cause of the ulcer. If vericose veins are present then it needs to be treated aggresively but only after ulcer had healed. Now a days if one can have enovenous laser treatment for vericose veins then it can be done even in presence of an ulcer.