Diabetic foot ulcer

Overview

Diabetic foot ulcer is an important and grave complication of diabetes, which results in ulceration of the foot. This occurs when the skin tissues break down and the layers of skin below, are exposed.  

Patients with diabetes can suffer neuropathy and/or peripheral arterial disease of the lower limb. It is estimated that nearly 4-10% of the diabetic population suffers from diabetic foot ulceration. The condition is more common in senior adults. Numbers point out that the risk of diabetic foot ulcer in diabetic patients in their lifetime, is about 15%.

In a nutshell, improper management of diabetes results in foot ulcers. The complication of foot ulcers happens when diabetes has not been managed properly with insulin treatment, exercise and diet. Ulceration in the foot occurs most commonly below the big toes, and padded part of the sole. Ulcers can affect the feet up till the bones. The risks of developing foot ulcers are high for all diabetics, but it is also possible to prevent this condition with proper care of the feet.

With age and the duration of diabetes, the risk of foot ulcers and amputation of the limb goes up. Therefore, it is imperative to prevent diabetic foot ulcers since they also adversely impact the patients’ quality of life.

Symptoms – diabetic foot ulcer

There may not be very obvious signs of a foot ulcer all the time. In many patients, the symptoms may not become visible till the ulcer is infected.

Some of the tell-tale symptoms of a diabetic foot ulcer are the following:

• Leaking or draining of fluid that stains the socks or the shoe
• A bad odour from the foot or feet is also one of the initial symptoms of foot ulcer
• Abnormal inflammation on one or both the feet Patients can also experience redness and irritation on the foot
• Black tissue also named as ‘eschar’ around the ulcer, due to hampered flow of blood in this area
• Numbness, pain and skin discolouration
• Complete or partial gangrene

The presence of any of these symptoms indicate the need for consultation with a specialist to diagnose and begin the treatment.

Diagnosis

The specialist at first evaluates the symptoms patients present at the time of consultation. The examination of the patient is done and results are compared using the Wagner ulcer Classification System. The doctor estimates the gravity of the diabetic foot ulcer on a scale of 0 to 5.

Wagner ulcer classification:

0: Absence of open lesions or possibility of healed lesions

1: Ulcer on the outer layer with no penetration into underneath layers

2: Penetrating ulcer reaching into bone, joints and tendon

3: Penetration of ulcer into underlying tissues. Presence of abscess

4: Visible gangrene in a portion of the heel or front of the foot

5: Complete foot gangrene

Causes-diabetic foot ulcers

Ulcers in people with diabetes are most commonly caused by:

• Improper circulation of blood to the feet which is a type of vascular disease. This impedes healing of ulcers
• Improper management of blood sugar can cause blood glucose levels to be high. This can affect healing of foot ulcers which are infected. This is why it takes time for those suffering from diabetes to deal with infections from ulcers
• Nerve damage resulting in loss of sensation in the feet. This can cause a tingling sensation in the feet and lower sensitivity to pain. This leads to wounds that ultimately results in ulcers
• A visible lump in the feet which may not be painful. This area may also drain fluid which could be giving a bad odour

Risks of diabetic foot ulcers

Approximately one out of seven diabetics will develop a foot ulcer. This is because diabetes can cause nerve damage specially those in the feet. Statistics shows that diabetes is a significant cause of stroke, renal failure, blindness, heart attacks and amputation of lower limb.

The risk of diabetic foot ulcers is very high among people suffering from diabetes. The most crucial risk factors for foot ulcers are, peripheral arterial disease, diabetic neuropathy and resulting foot trauma. Although there may be many causes of foot ulcers , some factors such as the points listed below can elevate their  risk.

• Ill fitted shoes or use of low-quality footwear
• Feet hygiene inadequate such as improper washing of feet, or wet feet after washing
• Long toe nails without proper trimming
• Consumption of alcohol
• Obesity
• Kidney disease
• Eye problems due to diabetes
• Heart disease
• Nicotine use which can impede circulation of blood
• Older male diabetics

Treatment

It is important to know that with proper treatment nearly 60–80% of foot ulcers will heal.  According to statistics, close to 10–15% of foot ulcers remain active. In the absence of timely and proper treatment, 5–24% of foot ulcers result in amputation of the limb. This can occur in a timeframe of 6–18 months following the initial assessment.

The treatment for diabetic foot ulcers depends upon the severity of the condition. Doctors’ advice the use of certain types of footwear or the use of specifically designed protective gear that can protect the feet. 

The specialists may also prescribe medication or perform surgical procedures to reduce the pressure on the ulcer.   

For all forms of diabetic ulcers, doctors’ advice a technique called offloading, which means staying off the feet to offset pain resulting from ulcers.  Ulcers can make walking difficult and any extra pressure on the feet with any activity can make the infection worse.  

The specialist may advice anti-pressure ways to protect the feet as a first line of treatment.

• Braces for the foot
• Inserts for the shoes that protects against corns
• Use of special shoes designed for diabetics
• Casts
• Compression wraps

In some cases, doctors treat foot ulcers with a with a debridement, and do away with the cause of the ulcer which can be dead skin or the presence of extraneous substances.

If the foot ulcer is infected, this needs quick treatment. Specialists may use different techniques to treat different infections.

For instance, in severe cases of infection, the specialist may order further investigation such as an X-ray to check for the presence of infection in the bone.

Medications

The specialist may prescribe medicines to manage the ulcers in case the infection does not abate even after preventive treatment. The medicines will be antibiotics and anti-clotting medicines to deal with staph infections. Patients must also discuss if they suffer from any other medical condition that could elevate the risk of infection triggered by bacteria.

Surgery for foot ulcer

The specialist may discuss the option of surgery to help with ulcers, especially in the presence of certain abnormalities of the foot which may be exerting pressure. In this case, a surgical procedure to reduce pressure by shaving down the bone or eliminating certain abnormalities, such as hammertoes and bunions can be the line of treatment.

Patients may not need surgery to treat the ulcer. But in cases where none of the treatment actually works, surgery may at least stop the ulcer from worsening.

Preparation for surgery

Once the decision is made about the surgery, the specialist will slot the date for the surgery.  The surgeon takes this opportunity to explain the procedure in detail. At this time, the specialist also conveys possible risks and benefits of the surgery to help patients make the right decision.

During this session, patients must lay bare their medical history, as well as communicate clearly about the medicines and supplements

Procedure

The types of surgical procedures to treat diabetic foot ulcer are the following:

Debridement

This procedure permits the specialist to do away with dead and infected tissues from the foot ulcer. This also enables proper evaluation of the degree of damage to the tissues. This procedure also aids in faster healing.

Local anaesthesia is given to the patient prior to commencing debridement procedure. The surgeon uses a scalpel to remove skin or tissues. Once this is over, the doctor uses a disinfectant solution to clean the wound.  A sterile bandage is used to cover the wound. During the post-procedure phase, patients will need to keep the wound clean by changing the bandage every day.

Patients may also need to apply an ointment on the wound during the healing phase. This ointment supports the healing process and assists in eliminating dead tissues.

Debridement may not be a one-time procedure. Patients may need to undergo this procedure many times in a span of weeks or months to completely heal.

Patients may need to take over-the-counter medication if they face any discomfort after this procedure. It is good to follow the doctor’s prescription. Medicines that can help with easing pain and discomfort are acetaminophen and ibuprofen.

Lengthening Achilles tendon

For some patients, the Achilles tendon can exert pressure on the bones that are present on the heel and leg. This excessive pressure can lead to the formation of ulcers. In such cases, the specialist may perform a surgery which helps in correcting the gait. This procedure also assists in reducing build-up of tension in the tendons. This helps in correcting the alignment of the body, thus relieving pressure from the ulcer.

Doctors perform this procedure in the hospital or clinic. Patients are given general anaesthesia. During the procedure, small incisions are made by the orthopaedic surgeon at the back of the foot to be able to access the Achilles tendon.

The surgeon performs a stretching exercise on the tendons and cuts them. The tendons now gain length. After this process, the surgeon applies a splint to ensure the foot and lower leg are covered. Patients need to wear the splint for close to six weeks

Patients may also need to use a leg brace for few weeks after removing the cast.

Post op care and things to keep in mind

Patients may be able to return home the same day after the debridement procedure. Hospital stay for one or more days is needed for patients that undergo surgery to lengthen the Achilles tendon.

• It may take many weeks for complete healing. Patients must strictly follow the guidelines and plan of treatment. During the healing period, it is good to stay off the feet and lower pressure.
• When there is continued pressure on the wound, the healing becomes slower. This gets worse if the blood sugar is also high.
• Patients must follow a strict diet which keeps the blood sugar stable. Taking care of the foot and offloading pressure is a good way to enable faster healing.
• After the wound has completely healed, patients must follow good preventive care that can offset the ulcer from coming back.

Cost of treatment for diabetic foot ulcer

The cost of treating diabetic foot ulcers is much less in the initial stages, and may be anywhere from Rs.35,000 to Rs. 55,000. If the condition becomes severe, the cost of treatment will increase and fall in the range of 3-4 lacs.

The cost of the treatment will also depend upon the degree of illness, the type of treatment, Doctor’s charges, cost of medicines, type of hospital and facilities as well as diagnostic tests.

Prevention

A review published in 2017 in the New England Journal of Medicine, has stated that more than 50% of foot ulcers worsen with infection. What is worse is, that nearly 20% of the severe and moderately infected foot ulcers in diabetics result in amputation.

According to statistics, close to 1 in 11 adults suffers from diabetes. A forecast trend points out that by 2045, close to 629 million people worldwide will have diabetes.This is why prevention of foot ulcers is imperative.

Ways to prevent foot ulcers:

• Reduce the risks of complications of high blood sugar by managing blood sugar and keeping it stable
• Ensure the use of precise fitting shoes
• Dress the ulcer frequently and keep it dry
• Use calcium alginates in the dressing to protect against growth of bacteria
• Ensure timely removal of callus and corn with the help of a podiatrist
• Keep the foot clean by washing everyday
• Foot bath
• Apply a disinfectant on the skin, close to the ulcer and around it
• Trim the toe nails regularly
• Apply moisturizer to the feet regularly
• Ensure frequent change of socks

Even the foot ulcers that are treated can resurface, since infection can set in the scar tissue. It is therefore important for diabetics to wear the appropriate shoes designed for them. This will prevent the foot ulcers from returning.

When is it crucial to seek medical attention?

If patients observe flesh that has turned black around a region that is numb, it is important to seek medical attention. This can be a sign of infection in the foot ulcer. In the absence of treatment, foot ulcers can cause abscesses. The infection can also spread to other regions in the legs and feet.

Doctors assess the infection and decide if they need to perform surgery or amputation or need to use synthetic skin substitutes to replace the lost skin.

The risk for diabetics to experience an amputation is 10 to 20 times more than non-diabetics. Close to 85% of all lower-limb amputations are complications from a foot ulcer.

Best option

The good news is, early diagnosis makes foot treatable. Patients must consult a specialist without delay if there is a sore on the foot.  If there is a delay in seeking treatment, the chances of infection increase. The risk of amputation is very high if foot infections are not treated in time.

goficure has partnered with an efficient team of diabetologists, surgeons and specialists that can provide effective care for diabetic foot ulcers. This healthcare service offers complete solutions for diabetic foot ulcers under one roof. The service will encompass the following:

• Getting an appointment with a specialist
• Assisting with the diagnosis
• Slotting the appointment for the procedure
• Providing support completely to the patient during the procedure
• Enabling post-operative care guidelines and support
• Scheduling follow up appointments
• Providing advice on diet, lifestyle and nutrition
• Transportation logistics before and after surgery
• Processing the paperwork for the insurance claim
• Support until full recovery

References