Causes and Treatment of Diabetic Foot Ulcers, Toe Ulcers and Other Sores In Feet.

 

Diabetes is the leading cause of foot ulcers in the world. The diabetic ulcers are often found on the sole and more commonly on the pressure points where the foot remains in continuous contact with the ground. According to research conducted by the American Podiatric Medical Association (APMA), it has been estimated that approximately 15% of the people with diabetes are bound to get foot ulcers. They occur in both type 1 and type 2 diabetic patients. Their risk of lower limb amputation increases exponentially and such individuals are 8 times more likely to undergo a definite surgical intervention. Besides that, the mortality rate also increases if proper wound care is not ensured.

 

How Diabetic Ulcers Develop?

Diabetes can cause podiatric ulcers by 2 main mechanisms:

1. Diabetic Neuropathy:

A poorly controlled blood sugar level causes microvascular complications which especially include damage to the peripheral nerves. If the nerves present in the feet are damaged, there is an impending risk of complete loss of sensations. Such a patient is unable to feel any heat or cold, vibrations, and pain and even remains oblivious to any damage that might have occurred to his feet until it is noticed by him accidentally, or is pointed out by somebody else. The cuts or sores remain unnoticed and can become seriously infected which may further complicate the recovery of this problem.

2. Peripheral Vascular Disease:

This macrovascular complication of diabetes affects the flow of blood in the arteries and as a result, there is poor perfusion in the body extremities. Without proper oxygenation, wounds take a longer time to heal. The increased level of sugar also provides an optimum environment for the pathogens to flourish. The infected wounds do not heal in time and there is a significant risk of developing gangrene. If the sensory function of the limbs is still intact, this can lead to severe pain in the lower limbs.

 

Risk Factors for Diabetic Foot Ulcers

All people with diabetes are prone to develop this condition but some risk factors accentuate the onset of the problem in very early years of life. These include the following:

1.    Smoking

2.    Morbid Obesity

3.    Heart Disease and hypertension

4.    Alcoholism

5.    Poor hygiene

6.    Ill-fitting and poor quality shoes

 

Symptoms of Diabetic Foot Ulcers

People with a longstanding history of diabetes i.e., for more than 10 years are more likely to develop this disease. Following are a few symptoms which one can use to better judge the ulcers on his feet:

1.    Redness and swelling around the wound

2.    Foul-smelling odor from the lesions

3.    Cracks and open lesions on the soles

4.    Foreign material stuck in the feet

5.    Loss of pain sensation in the feet

6.    Discharge or pus on the socks

7.    Fever and chills in the early stages of ulcers

8.    Pain in the lower limbs

 

Treatment of Diabetic Ulcers

Early Management and Preventive Measures

As soon as the ulcer is noticed, seek the help of a podiatrist immediately. The physician helps identify the degree of severity of the problem and helps to map the best course of action for each specific patient. If not treated promptly, complications such as gangrene, cellulitis, and osteomyelitis may ensue. If the ulcer is in an early stage, the doctor may suggest adopting the following measures:

1.            Maintaining strict control of blood sugar levels.

2.            Ensuring a healthy diet and proper exercise.

3.            Cleaning the ulcer each day by using aseptic measures.

4.            Keeping the feet dry after every wash and use of proper dressings.

5.            Wear loose-fitting shoes such as diabetic offloading shoes which prevent excessive pressure on the heel and ball of the big toe.

6.            If specific diabetic shoes are not available, then inserts can be used as well which dissipate excessive pressure from the contact points of the feet. There are hole cutouts in the inserts which cushion the points of contact and prevent their ischemia.

7.            Wearing padded socks to provide protection and cushion from injuries.

8.            Trimming the toenails while taking care not to injure the edges of the toes.

9.            Checking inside of shoes to make sure no objects are left inside.

10.         Protecting the feet from heat and cold.

11.         Proper follow-up every 2 or 3 months for monitoring the health of the feet.

12.         Cessation of smoking/alcoholism to prevent further complications.

 

Surgical Treatment:

If the diabetic ulcers become chronic or the alignment of the bones becomes poor due to excessive damage then there is no choice but to intervene surgically. Following are the methods employed in this modality:

a. Debridement: In this procedure, the dead or infected tissue is entirely removed from an ulcer. After the debridement, the wound is washed with disinfectants and is covered with aseptic bandages. The wound then heals with time and the patient is counseled to change bandages regularly.

b. Surgical Revascularization: If poor blood flow is restricting the full recovery of a diabetic wound, vascular surgery may be attempted to boost the vascular perfusion. Atherectomy is carried out in which clogged arteries are cleared by removing the plaque inside them. Balloon angioplasty may also be done with stent placement to keep the vessels open. Both these methods help increase the oxygen flow to the affected limb and boost the wound healing capability of the ulcer.

c. Amputation: When an ulcer cannot be healed and is being repeatedly infected, it may lead to gangrene which increases the risk of mortality. To avoid a fatal outcome, amputation is the best treatment in such cases. Doppler studies of the affected limb are performed to locate the ideal site for amputation which helps prevent any recurrence.

 

Complications of Diabetic Foot

If proper management is not considered, then the following complications can develop:

1.    Abscess: A pocket of pus may form in the wound which can only be treated by drainage.

2.    Deformities: Nerve damage weakens the muscles and may lead to claw feet or a high arch which causes difficulty in walking.

3.    Charcot Foot and Deformities: It is due to walking on broken bones which eventually alters the contour of the foot.

4.    Gangrene and skin infections: Infected ulcers can lead to sepsis which is best treated with antibiotics. Severe cases often require hospital admission.