DIABETIC FOOT Why and How? Approach Treatment Care

Diabetes (Diabetes Mellitus) is a common health issue in our country as in other parts of the world. Whereas the prevalence of diabetes in people aged 20 and over was found to be 7.2% in the TURDEP I Study (Prevalence of Diabetes, Hypertension, Obesity and Endocrinological Conditions in Turkey) carried out in 1997-1998, the results of the TURDEP-II study published in late 2010 suggest that the prevalence of diabetes in the same age group has reached 13.7%. Studies conducted serve to indicate that about 25% of diabetes patients are prone to suffer from ulcers in their feet during their lifetime and that 10-15% of these patients out of the entire diabetes patient population are still suffering from these ulcers. Foot ulcers due to diabetes decrease the quality of life of this patient group, result in amputation in different extents in the majority of cases, and cause high treatment costs.

There are two main reasons for the formation of foot ulcers in diabetes patients, namely nerve tissue disorder (neuropathy) and vascular insufficiency.

Why and How?

Nerve Tissue Disorder: Due to high levels of blood sugar, nerve cells become unable to burn excessive amounts of sugar exceeding the cell’s breaking capacity. This causes sugar and its by-products accumulate in and thus damage the nerve cells. This damage manifests in three manners.

  • With the impairment of nerves stimulating foot muscles, the foot becomes deformed and the body’s weight cannot be distributed equally on the feet. Consequently, some parts of the feet are exposed to a higher load (pressure) whereas other parts are subjected to a lower burden. In time, keratosis occurs in areas of higher burden and wounds appear under the callous part.
  • As impairment of nerves perceiving pain and hot-cold sensation in the feet, these patients suffer from “cold feet”. As the patients can no longer feel pain, they cannot sense ulcers, sharp objects pricking the feet or heat.
  • Diabetics have dry skin due to the dysfunction of nerves stimulating subcutaneous glands keeping the skin moist, and this causes cracks in the skin which are the first signs of ulcers. Microbes penetrating via these cracks cause infection to develop easily on skin and in subcutaneous tissues.

The most commonly encountered signs;

  • Are loss of sensation and numbness in feet.
  • Tingling in case of nerve damage in the feet.

Vascular Disorder: In diabetics, elevated blood sugar damages the structure and function of blood vessels, causes plaque formation inside the vessels and consequently leads to a condition called as “peripheral arterial disease”. Due to plaque formation inside the vessels and reduced blood circulation, ischemic ulcers appear as a result of malnutrition.

Signs of arterial occlusion;

  • Are cold feet,
  • Decrease in/disappearance of hair on feet,
  • Rest pain,
  • Permanent rash in feet,
  • Gangrene,
  • Ulcers in toes, edges of feet and heels.

Approach

While assessing feet ulcers in diabetics, the duration, width, depth of the ulcer and the presence of infection must be carefully considered. Furthermore, the patient must also be examined to determine the presence of other concurrent conditions associated with diabetes (renal insufficiency, loss of vision etc.).

Treatment

Successful treatment of feet ulcers in diabetics starts with ensuring that risk factors are kept under control. To begin with, the patient’s blood sugar levels must be strictly regulated. Infection in the ulcer area must be carefully and systematically assessed and, if present, the physician must check whether the infection has penetrated bone tissue; and appropriate antibiotic treatment should be started in case of infection. Moreover, if required, the by-pass procedure to be carried out to increase blood circulation in the feet will increase the chance of success of the treatment and ensure that the ulcers heal faster.

On the other hand, removal of dead tissue on the ulcer and application of medical dressing are important aspects of diabetic ulcer treatment that must not be overlooked.

Wound care therapies such as Epidermal Growth Factor application in the ulcer, wound dressings, hyperbaric oxygen therapy and vacuum-assisted closure therapy are also used for the treatment of diabetic foot ulcers.

Among the above-listed wound care therapies, Epidermal Growth Factor applied into the ulcer via the injection method is a therapy only used for diabetic feet ulcers in many countries in recent years. The success of Epidermal Growth Factor applied into the ulcer in the treatment of feet ulcers in diabetics is proven by numerous scientific articles about the results of related clinic studies.

Care

Each and every patient diagnosed with diabetes can potentially suffer from feet ulcers in the future. Therefore, foot care and protection are considered to be a much easier and cheaper method than ulcer treatment in the prevention of feet ulcers. How to care for the feet:

  • The feet must be washed with warm water every day and dried thoroughly with a soft towel by paying attention to toe-webs.
  • The feet then must be moisturized with a cream. To this end, the cheapest and easiest method is to use Vaseline every evening.
  • Diabetic patients should never walk barefoot at home or outside and not use shoes and slippers that are either too wide or too narrow.
  • Feet must be checked with a mirror for potential cuts, wounds, athlete’s foot and blisters.
  • Callous and dead tissue must not be cut away and corns must be taken care by specialists.
  • When cold, the feet must not be propped against a heater or any other hot objects; woolen socks must be worn instead.
  • Toenails must be cut straight, with rounded edges.
  • Inside of shoes must be checked carefully before wearing.
  • Shoes must never be worn without socks.
  • Comfortable, soft, seamless, leather shoes with thick soles must be worn.
  • Ladies must prefer summer shoes with closed toes instead of flip-flops.
  • Smoking and alcohol use must be avoided at all costs.