Diabetic Foot Ulcers

Jun 14, 2017 /


Diabetes can be a devastating disease. The disease itself is chronic and painless. The consequences, however, are dire; though they develop over time and can be prevented with appropriate treatment and reasonable lifestyle. Diabetes affects almost all organ systems and leads to blindness, peripheral neuropathy (burning pain in the feet and lower legs as well as lack of sensation), nephropathy (kidney disease that in turn leads to kidney failure and dialysis), hypertension (elevated blood pressure causing increased risk of stroke and heart attacks), skin disorders (boils and abscesses), heart attacks and atherosclerosis (hardening of the arteries). Last, but not least, diabetes can cause diabetic foot ulcers (DFUs). They occur on the feet and result mainly from lack of sensation.

What are diabetic foot ulcers?

DFUs are non-healing, chronic wounds on the feet, resulting from poor control of diabetes and poor compliance with medical advice. Every diabetic should be and is instructed by his primary care physician (PCP) on the necessity of checking both feet on a daily basis. Rationale for it is lack of sensation in the foot by diabetes sufferer and necessity to make up for the loss of feeling with visual inspection. Discovery of redness, swelling, puncture wound, or callus formation should prompt the patient to seek immediate advice from the PCP, podiatrist (foot doctor) or a wound care physician. It is not infrequent in our Wound Care Center to treat a diabetic patient who has been walking for a week with a rusty nail in his foot without knowing it. In situations like that, amputation below the knee may sometimes be the only available solution. This is an example of a drastic situation that could be avoided by diligently adhering to the simple advice of your doctor.

Why do they (DFUs) happen?

Diabetic foot ulcers are the result of repetitive trauma in conjunction with loss of sensation. In other words, small traumatic experiences (too tight shoes, pebble in the shoes) that would cause great discomfort in a person with normal sensation, go unnoticed in diabetic patients until there is a visible ulcer or infection. The first symptom of an ulcer waiting to happen may be callus formation or redness in any given area of the foot. These are warning signs and should be addressed immediately. Loss of sensation and motor nerve function leads to multiple deformities in diabetic feet (hammer toes, claw toes, Charcot foot, flat foot, etc.) that further predispose the patient to DFUs by creating bony eminences exposed to trauma from the shoe wear.

Why diabetic foot ulcers need to be treated aggressively?

It is really simple. Most untreated diabetic foot ulcers lead to infection and, in turn, to amputation. Merciless statistics show, that about 50% of amputees (we are talking about major amputation, e.g. below knee or above knee) will die within the next five years. Properly managed patients usually avoid amputations and heal. Exceptions are relatively rare.

What to do when a DFU is noticed?

A DFU should be evaluated by a PCP, podiatrist, or wound care center (there is no need for referral) as soon as possible. Ulcers that do not respond to one month of treatment by a PCP or podiatrist should be seen by a wound care specialist.

How diabetic foot ulcers are treated?

Treatment must be aggressive and any diabetic foot ulcer should be taken seriously because even a small wound on the diabetic foot may end up as a major amputation in as little as 3 days (in the most extreme cases). While assessing diabetic for ulcers, several issues have to be addressed as soon as possible:

1. Circulation. Problems with arterial circulation (frequent in diabetics) may be either a direct reason for ulceration or a complicating factor. Either way, if the patient shows symptoms of circulation problems (Peripheral Arterial Disease) they are usually referred to a vascular surgeon. Surgical intervention allows the ulcer to heal much faster and prevents further complications.

2. Infection. Infected ulcers, especially the ones with circulation problems, constitute a serious challenge and substantial threat of amputation. Infection must be vigorously treated and in wound care center settings it is usually achieved by daily infusions of intravenous antibiotics. Infection of the bone may not respond to treatment with antibiotics alone and may require intervention of an orthopedic surgeon. Usually, removal of the infected part of the bone and occasionally minor amputation (tip of the toe or the entire toe, sometimes parts of metatarsal bones) are needed. Also, antibacterial dressings containing silver, antibiotics and other antibacterials are used in topical treatment of ulcers.

3. Offloading. In other words, taking the load off the foot. The effects of walking or standing on the affected foot can be compared to hitting the ulcer with a heavy hammer. This force has to be neutralized and it is achieved by the use of specialized shoes or Total Contact Cast. Total Contact cast is the method of choice for offloading diabetic foot ulcers, however, it cannot be used on every patient

4. Slough and callus. Slough and callus prevent ulcer healing and need to be removed frequently. It is called debridement (removing debris) and may be enzymatic (dissolving and digesting dead tissue by enzymes), autolytic (accomplished by the body after creating adequate conditions - a moist and bacteria-free environment), mechanical (by using wet-to-dry dressing that upon drying out sticks to the ulcer surface and lifts with it dead tissue fragments during dressing removal) and/or a sharp/surgical process(removal of debris with a scalpel, scissors or ultrasonic debrider).

5. Dormant status of the ulcer. Chronic, non-healing diabetic foot ulcers enter a dormant (sleeping) phase, when the cells are no longer multiplying and the production of growth factor decreases, slowing down or occasionally even arresting the process of healing. These cells must be woken up. This is usually achieved by sharp debridement or use of certain growth factors, cultured skin substitutes, and stem cells.

6.Lack of oxygen. Oxygen is needed for the cells to breathe and multiply. To address this issue Hyperbaric Oxygen Therapy (HBOT) is used. It is a very expensive treatment and the patient must meet specific and very stringent criteria to qualify. In the treatment, oxygen is delivered into a special acrylic chamber (large cylinder) under the pressure of 2.0-3.0 atmospheres. At 2 ATA (atmospheres) the pressure is comparable to diving 33 feet under the water surface. In the wound care lingo HBOT is therefore called “diving” despite no water is involved. It is a safe and very effective modality but is high in cost and patients must meet specific and stringent criteria to qualify.

Summarizing, every diabetic foot ulcer should be treated as a serious threat. It is easier to prevent, than heal. Prompt visits to your health professional’s office (PCP, podiatrist, wound care center) are advised. There are multiple modalities available to prevent amputations. Effectiveness of the treatment is excellent but often long (3 months or more) and requires significant patient resolve and cooperation.

For additional information on wound care treatment of diabetic foot ulcers or other wounds, please contact the Uvalde Memorial Hospital Wound Care Center directly at (830) 278- 6251 extension 1377