What is a Diabetic Foot Ulcer?

What is a Diabetic Foot Ulcer?

TOPNURSE~A diabetic foot ulcer is an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot. Of those who develop a foot ulcer, 6 percent will be hospitalized due to infection or other ulcer-related complication.

Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States, and approximately 14-24 percent of patients with diabetes who develop a foot ulcer will require an amputation. Foot ulceration precedes 85 percent of diabetes-related amputations. Research has shown, however, that development of a foot ulcer is preventable.  

Causes

Anyone who has diabetes can develop a foot ulcer. Native Americans, African Americans, Hispanics, and older men are more likely to develop ulcers. People who use insulin are at higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and heart disease. Being overweight and using alcohol and tobacco also play a role in the development of foot ulcers.  

Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), 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 podiatrist can test feet for neuropathy with a simple, painless tool called a monofilament.

Vascular disease can complicate a foot ulcer, reducing the body's ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the body's ability to fight off a potential infection and also slow healing. 

Symptoms

Because many people who develop foot ulcers have lost the ability to feel pain, pain is not a common symptom. Many times, the first thing you may notice is some drainage on your socks. Redness and swelling may also be associated with the ulceration and, if it has progressed significantly, odor may be present.

When to Visit a Podiatrist

Once an ulcer is noticed, seek podiatric medical care immediately. Foot ulcers in patients with diabetes should be treated to reduce the risk of infection and amputation, improve function and quality of life, and reduce health-care costs.

Diagnosis and Treatment

The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.

There are several key factors in the appropriate treatment of a diabetic foot ulcer:

• Prevention of infection
• Taking the pressure off the area, called “off-loading”
• Removing dead skin and tissue, called “debridement”
• Applying medication or dressings to the ulcer
• Managing blood glucose and other health problems

Not all ulcers are infected; however, if your podiatrist diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.

To keep an ulcer from becoming infected, it is important to:

• keep blood glucose levels under tight control;
• keep the ulcer clean and bandaged;
• cleanse the wound daily, using a wound dressing or bandage; and
• avoid walking barefoot.

For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.”  You may be asked to wear special footgear, or a brace, specialized castings, or use a wheelchair or crutches.  These devices will reduce the pressure and irritation to the area with the ulcer and help to speed the healing process.

The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full-strength betadine, hydrogen peroxide, whirlpools, and soaking are not recommended, as these practices could lead to further complications.

Appropriate wound management includes the use of dressings and topically-applied medications. Products range from normal saline to growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.

For a wound to heal, there must be adequate circulation to the ulcerated area. Your podiatrist can determine circulation levels with noninvasive tests. 

Tightly controlling blood glucose is of the utmost importance during the treatment of a diabetic foot ulcer. Working closely with a medical doctor or endocrinologist to control blood glucose will enhance healing and reduce the risk of complications.

Surgical Options: A majority of non-infected foot ulcers are treated without surgery; however, if this treatment method fails, surgical management may be appropriate. Examples of surgical care to remove pressure on the affected area include shaving or excision of bone(s) and the correction of various deformities, such as hammertoes, bunions, or bony “bumps.”

Healing time depends on a variety of factors, such as wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels, wound care, and what is being applied to the wound. Healing may occur within weeks or require several months.

Prevention

The best way to treat a diabetic foot ulcer is to prevent its development in the first place. Recommended guidelines include seeing a podiatrist on a regular basis. Your podiatrist can determine if you are at high risk for developing a foot ulcer and implement strategies for prevention.

You are at high risk if you have or do the following:

• Neuropathy
• Poor circulation
• A foot deformity (e.g., bunion, hammer toe)
• Wear inappropriate shoes
• Uncontrolled blood sugar
• History of a previous foot ulceration

Reducing additional risk factors, such as smoking, drinking alcohol, high cholesterol, and elevated blood glucose, are important in prevention and treatment of a diabetic foot ulcer. Wearing the appropriate shoes and socks will go a long way in reducing risks. Your podiatrist can provide guidance in selecting the proper shoes.

Learning how to check your feet is crucial so that you can find a potential problem as early as possible. Inspect your feet every day—especially the sole and between the toes—for cuts, bruises, cracks, blisters, redness, ulcers, and any sign of abnormality. Each time you visit a health-care provider, remove your shoes and socks so your feet can be examined. Any problems that are discovered should be reported to your podiatrist as soon as possible; no matter how simple they may seem to you. 

The key to successful wound healing is regular podiatric medical care to ensure the following “gold standard” of care:

• Lowering blood sugar
• Appropriate debridement of wounds
• Treating any infection
• Reducing friction and pressure
• Restoring adequate blood flow

Additional information is available from the American Diabetes Association.

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What’s the Connection Between Diabetes and Wound Healing?

How diabetes affects your body

TOPNURSE~Diabetes is a result of your body’s inability to produce or use insulin. Insulin is a hormone that allows your body to turn glucose, or sugar, into energy. If your body has difficulty metabolizing glucose, it can lead to high blood sugar levels. This can affect your body’s ability to heal wounds.

In people with diabetes, wounds tend to heal more slowly and progress more quickly, so it’s important to know what to look out for.

Although cuts, grazes, scratches, and blisters can occur anywhere on the body, the feet are one of the most common places of injury. A small wound on the foot can quickly develop into a foot ulcer.

Foot ulcers can become serious if left untreated. Between 14 and 24 percent of people who have diabetes and develop an ulcer will end up having a lower limb amputation.

For this reason, it’s crucial that you do regular self-checks and closely monitor any wounds closely. Catching wounds early is the only way to reduce your risk of complications.

Keep reading to learn more about the healing process, ways to speed the healing process along, and how to improve your body’s healing powers long-term.

Why wound healing is slow

When you have diabetes, a number of factors can affect your body’s ability to heal wounds.

High blood sugar levels

Your blood sugar level is the main factor in how quickly your wound will heal.

When your blood sugar level is higher than normal, it:

• prevents nutrients and oxygen from energizing cells
• prevents your immune system from functioning efficiently
• increases inflammation in the body’s cells

These effects slow down wound healing.

Neuropathy

Peripheral neuropathy can also result from having blood sugar levels that are consistently higher than normal. Over time, damage occurs to the nerves and vessels. This can cause the affected areas to lose sensation.

Neuropathy is particularly common in the hands and feet. When it happens, you may not be able to feel wounds when they occur. This is one major reason why foot wounds tend to be more common in people with diabetes.

Poor circulation

People with diabetes are twice as likely to develop peripheral vascular disease, a condition of poor circulation. Peripheral vascular disease causes your blood vessels to narrow, which reduces blood flow to the limbs. The condition also affects red blood cells’ ability to pass through the vessels easily. And a higher-than-normal blood glucose level increases the thickness of blood, affecting the body’s blood flow even more.

Immune system deficiency

Many people who have diabetes also have problems with immune system activation. The number of immune fighter cells sent to heal wounds, and their ability to take action, is often reduced. If your immune system can’t function properly, wound healing is slower and your risk of infection is higher.

Infection

If your immune system isn’t functioning at its best, your body may struggle to fight off bacteria that cause infection.

Higher-than-normal blood sugar levels also increase the possibility of infection. This is because bacteria thrive on the extra sugar that’s available in the bloodstream. High blood sugar levels can also prevent immune cells from being able to fight off invading bacteria.

If your infection is untreated and left to spread, it can lead to complications such as gangrene or sepsis.

What can happen if wounds are left untreated

Wounds present a real cause for concern. If they’re not carefully monitored, they can quickly progress into an infection or more serious complication.

The most serious concern is amputation. People with diabetes are 15 times more likely to have amputations as a result of foot wounds or ulcers. Here’s why this happens and what you can do to prevent it.

How to help the healing process along

To help the healing process along, follow these tips:

Do regular self-checks. Catching wounds early is the key to avoiding infections and complications. Make sure you do daily self-checks and look for new wounds, especially on your feet. Don’t forget to check in between and under your toes.

Remove dead tissue. Necrosis (dead cells) and excess tissue often occur with diabetic wounds. This can promote bacteria and toxins and increase wound infection. It can also prevent you from being able to inspect the underlying tissue. Your doctor will often help you with the removal process.

Keep dressings fresh. Regularly changing dressings can help reduce bacteria and maintain appropriate moisture levels in the wound. Doctors often recommend special wound care dressings.

Keep pressure off the area. Pressure can cause wear and tear that damages the skin and leads to a deeper wound or ulcer.

When to see your doctor

If you’re dealing with a foot wound, consider wearing white socks during the healing process. This will make it easier to see blood or other signs of drainage on your socks.

See your doctor if you experience any of the following:

• tingling
• burning
• loss of sensation
• persistent pain
• swelling

You should also see your doctor if your symptoms worsen or last longer than a week.

Any break in the skin of your feet is cause for concern, so if you’re unsure about the wound, see your doctor. They can identify the wound and advise you on how best to care for it. The faster you get the appropriate treatment, the more likely you are to prevent complications.

How to promote long-term health and healing

There are a few things you can do to boost your immune system and aid in wound healing.

Eat a healthy diet. Diet has a direct influence on blood sugar levels, so maintaining proper nutrition is key. If you can consistently maintain healthy glucose levels, you’re more likely to avoid wounds and heal faster should a wound occur.

People with diabetes can often maintain better blood sugar control by avoiding processed carbohydrates, added sugars, and fast food. It also helps to increase your intake of fiber, fruits, vegetables, and legumes. Good nutrition provides what your body needs for faster wound healing, such as vitamin C, zinc, and protein.

Stay active. Exercise helps improve insulin sensitivity. This helps sugar in the bloodstream enter your cells more efficiently, which promotes healing and health.

Quit smoking. Smoking decreases your cells’ ability to carry oxygen. Smoking also disrupts the immune system and increases your risk of vascular disease.

Consider honey. Some research shows honey to be an effective alternative dressing for diabetic foot ulcer wound healing.

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