Diabetes Complications

Diabetic Foot Ulcers: A Complication That Should Never Be Ignored

Diabetes can be a difficult disease to deal with. It requires regular blood sugar checks, diet management, and medications.

In other words, it’s a disease you have to think about constantly.

Despite these challenges, staying on top of diabetes is essential to avoid health complications.

One of the most serious complications of diabetes is diabetic foot ulcers. This article will provide an overview of this complication and how it is managed.

Primer on Diabetes

First, let’s review the basics of diabetes. Diabetes is a condition that is characterized by high blood sugars known as hyperglycemia.

Usually, the pancreas releases the hormone insulin in response to high blood sugars. Insulin allows blood sugar to be used up as energy, which restores the blood sugar levels to normal.

If insulin is not working correctly, sugar, or glucose, will stay in the bloodstream with nowhere to go. This rising blood glucose will eventually be caught in a blood test, and the diagnosis of diabetes will be confirmed.

There are two main types of diabetes:

  • Type 1 Diabetes: Typically affects younger people but can happen at any age. People with type 1 diabetes do not produce any insulin at all and are dependent on insulin medication for survival.

  • Type 2 Diabetes: The more common type of diabetes. Type 2 diabetes occurs when the body no longer responds to its own insulin; this is known as insulin resistance. Over time, this insulin resistance can also lead to insulin deficiency.

What are diabetic foot ulcers?

Diabetic foot ulcers are wounds that occur on the lower extremities, especially the bottom of the feet, in those with diabetes.

These diabetic foot wounds can vary in severity and are usually graded based on the degree of tissue loss:

  • Grade 0: No open skin, fully intact.

  • Grade 1: mild or superficial loss of skin

  • Grade 2: Ulcer that extends to joints, ligaments, or bone

  • Grade 3: Deep ulcer that becomes infected, known as osteomyelitis

  • Grade 4: Gangrene, or dead tissue, is present

  • Grade 5: Widespread gangrene.

What causes diabetic foot ulcers?

Uncontrolled diabetes can create a perfect storm leading to the development of diabetic foot ulcers. Many factors are involved, which are outlined below:

  • Poor blood circulation. High blood sugars can make the blood a thick, syrupy consistency that reduces blood flow. This is known as ischemia. Adequate blood flow is critical for wound healing factors and nutrients to reach the wound.

  • Peripheral neuropathy and atherosclerotic peripheral arterial disease. The nerves that supply the lower extremities are vulnerable to hyperglycemia. These damaged nerves will reduce sensation in the feet, so you could have a wound and not even feel it. The wound will thus get worse and worse without treatment.

  • High blood glucose. Despite contributing to the above two issues, high blood sugars can directly lead to foot ulcers by drying out the skin, preventing wound healing, and leading to toxic byproducts.

  • Skin Breakdown. Even with the above issues present, the skin needs to be broken to create a wound. Skin breakdown can occur at any time when walking on uneven surfaces, through exercise, or cuts and bruises.

Symptoms

Many times, due to peripheral neuropathy, diabetic ulcers can occur without symptoms.

In these cases, the wound will be unnoticed until severe enough to cause issues. This is part of the reason these wounds are so severe.

When symptoms are noticed, a person with a foot ulcer may experience the following:

  • Swelling of the feet

  • Redness

  • Numbness

  • Abnormally dry skin

  • Foul smell

  • Pain with touching

  • Thickened skin

These ulcers can also lead to diabetic foot infections that carry their own host of symptoms, including fever, chills, dizziness, fatigue, and dehydration.

Diagnosis

The diagnosis of a diabetic foot ulcer can typically be made with a careful clinical history and physical exam by a primary care physician or wound care specialist.

A doctor will ask about blood glucose control, diabetes medications, lifestyle habits, and how often feet are checked.

The presence of a wound is not enough to make a complete diagnosis. The stage of the wound, degree of inflammation or infection, presence of vascular (blood vessel) issues, and gangrene will all be important factors to assess.

For example, a simple foot wound from accidentally stepping on some rocks may be completely harmless or could represent a grade 1 diabetic foot ulcer. The difference will be in the ability of the body to heal the wound.

Who is at risk for a diabetic foot ulcer?

Fortunately, a diabetic foot ulcer can be avoided by controlling for risk factors. Many people with controlled diabetes will never go on to develop an ulcer.

Here are some risk factors for the development of diabetic foot ulcers:

  • Uncontrolled blood glucose. If you’ve been paying attention so far, this should come as no surprise. High blood glucose levels will directly contribute to the causes of wound formation. Keeping your A1c level under 7.0% is a goal for most people and will help to prevent foot ulcers. If your blood glucose regularly is high, try to think about what may be the cause of this.

  • Foot numbness. Doctors use a simple test called a monofilament test to assess the degree of numbness on the bottom of the foot. Using a fine wire tool, multiple points on the foot are pressed, and the patient is asked if they feel the pressing. If they do not feel the pressing, this is an early sign of peripheral neuropathy, which should be promptly addressed.

  • Peripheral artery disease. A complication of diabetes caused by high blood glucose and high cholesterol, peripheral artery disease, is when plaque buildup-up causes blockages in the arteries leading to the legs and feet. This will limit the body’s ability to heal wounds on the feet.

  • Visual impairment. If eyesight is poor, noticing a wound on the bottom of the foot will become much harder to detect. Especially if doctor appointments are few and far between.

  • Foot deformities. Abnormal foot structure can contribute to skin breakdown. Charcot foot is an example of such a deformity and is caused by diabetic neuropathy. People with Charcot’s foot have weakened bones that eventually change shape and affect walking posture. Hammertoes, Achilles tendon issues, and posterior tibial malfunctions can also contribute to foot wounds.

  • Smoking. People who smoke are much more likely to develop foot ulcers. Smoking increases oxidative stress and further reduces wound healing.

Complications of diabetic foot ulcers

Diabetic foot ulcers are a significant cause of amputations and hospitalizations among those with diabetes.

Without proper treatment, a non-healing ulcer will continue to break down and eventually become infected. Infected tissue will lead to further degradation and can cause flu-like symptoms leading to hospitalization.

Eventually, without proper blood flow, the wound tissue begins to die or become necrotic.

As the gangrenous tissue spreads, the decision is often made to amputate the foot and a portion of the leg to prevent further spread.

Amputation will likely halt the spread of dead tissue, but will, of course, lead to its challenges affecting mobility and quality of life.

Prevention

Though the complications of foot ulcers are grim, the good news is that are several strategies that can be used to prevent them from happening in the first place:

  • Check feet daily. At least once a day, make sure to visually inspect your bare feet for any signs of skin breakdown. Have someone help you if you have poor vision.

  • Wear proper footwear. Wear comfortable, well-fitting shoes and socks. Shoes that are too loose or tight can lead to chafing or irritation. Avoid walking barefoot for extended periods.

  • Wash and dry feet thoroughly. Do not neglect the feet when showering and make sure to dry the feet and toes properly.

  • Moisturize the feet. Dry, cracked skin is a breeding ground for infection and wound formation, keep the feet moisturized by applying lotion but do not use between the toes – these spaces are moist enough.

  • Take your medications properly. Staying on top of blood sugar control is very important, make sure to take medications as prescribed.

  • Focus on balanced nutrition. Eating correctly will not only avoid high blood sugars but also help to control cholesterol as well. Keep it simple with the diabetes plate method: half of the plate should include non-starchy vegetables, one-quarter should consist of lean protein, and the final quarter should be whole-grains or starches. Avoid sugar-sweetened beverages and limit eating out.

  • Follow-up regularly with your medical provider. People with diabetes usually need to visit their doctor a minimum of twice per year. Keeping regular follow-ups will help to detect problems before they become irreversible.

For those with chronic ulcers, there is almost always a preventable cause, although people can vary in their ability to manage their diabetes successfully. Do not be afraid to ask for help if there are barriers to achieving one of these preventable strategies.

Treatments and management

Once a diabetic foot ulcer is identified, prompt treatment will be required to prevent complications. There are many types of treatments for diabetic foot wounds, and choosing the right one will depend on the seriousness of the wound.

The approach to the management of diabetic foot ulcers consists of controlling any active infection, stopping the spread of dead tissue, and supporting the body’s natural healing abilities.

Here is a summary of approaches for treating diabetic foot ulcers;

  • Practicing wound care. The goals of wound dressings are to prevent infections, promote proper wound drainage and moisture control, and speed up healing. There are many types of dressings, such as gels, hydrocolloid bandages, foams, and more. Studies are not exactly clear, which on dressing is the superior choice.

  • Surgical Debridement. Debridement is removing dead tissue from a wound. The necrotic tissue will be removed entirely down to the healthy tissue to halt the spread.

  • Offloading. A foot ulcer will have difficulty healing if there is a constant weight on it. Thus, patients with diabetic foot ulcers are given individual casts (known as TCC casts) or told to use crutches or a wheelchair to avoid pressure on the wound.

  • Infection treatment. To manage any active infection, antibiotics will be used. Oral antibiotics can be used for mild infections, while hospitalization for Intravenous antibiotics becomes necessary for more serious diseases.

  • Hyperbaric oxygen therapy involves using a specialized chamber to expose the wound to pressurized oxygen – which is thought to speed up wound healing. Research is inconsistent on the effectiveness of this therapy, but it appears to help at least in the short-term.

  • Negative pressure wound therapy uses a vacuum device to remove fluids and waste products from the wound, while foam dressings are applied. The idea here is to allow a more favorable environment for wound healing. As with oxygen therapy, research is mixed on how well this works.

  • Other treatments. Growth factors and Ozone therapy are also used for wound healing. Growth factors are substances naturally present in the body that fight infections. Ozone therapy involves increasing the amount of oxygen in the body. Oxygen is used in all phases of wound healing, so the thought is that extra oxygen is helpful. For these treatments, more clinical trials are needed to recommend one over the other.

Conclusion

Diabetic foot ulcers are serious wounds that can lead to amputation if not controlled. They are caused by many factors, including poor blood glucose control, nerve damage, and peripheral artery disease.

These wounds can be prevented by staying on top of diabetes care, eating right, and practicing foot care often.

Once present, diabetic foot ulcers will need immediate medical attention to support wound healing and prevent any dead tissue. There are several approaches to the treatment of diabetic ulcers, and you should speak with your doctor to help decide which is best suited for your needs.

Sources

  1. CDC Features. (n.d.). Retrieved from https://www.cdc.gov/features/diabetesfoothealth/index.html.
  2. Grennan, D. (2019, January 1). Diabetic Foot Ulcers. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2720026
  3. .Iraj, B., Khorvash, F., Ebneshahidi, A., & Askari, G. (2013, March). Prevention of diabetic foot ulcer. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634178/.
  4. Kruse, I., & Edelman, S. (2006, April 1). Evaluation and Treatment of Diabetic Foot Ulcers. Retrieved from https://clinical.diabetesjournals.org/content/24/2/91.
  5. Rogers, L. C., Frykberg, R. G., Armstrong, D. G., Boulton, A. J. M., Edmonds, M., Van, G. H., … Uccioli, L. (2011, September 1). The Charcot Foot in Diabetes. Retrieved from https://care.diabetesjournals.org/content/34/9/2123.

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