Dr. Ahmed A diabetic foot ulcer is a common yet overlooked complication of diabetes. It is estimated that globally one million amputations are done per year.
In the United States alone, 1,50,000 amputations are done each year. This is equivalent to one amputation every 3.5 minutes.
Globally, one amputation is being done every 4 seconds. By the time you read this article, 15 to 30 patients worldwide will have lost a leg.
Diabetes and Its Complications:
As common as diabetes is, it brings with it a lot of various complications. Such complications can worsen the lifestyle of a diabetic patient.
It is crucial to learn about them and take immediate measures to treat them.
Most diabetic complications can be prevented by controlling blood glucose and following a healthy lifestyle.
Diabetes-related complications are broadly divided into:
- Microvascular complications, and
- Macrovascular complications
Microvascular complications include:
Macrovascular complications include:
- Ischemic heart diseases
- Cerebrovascular diseases like stroke
- Peripheral arterial diseases
- Atherosclerotic diseases
Other complications include:
- Diabetic Ketoacidosis
- Hyperosmolar Hyperglycemic State
- Diabetic infections include a diabetic foot ulcer, oral, and genital candidiasis, and medications-related side effects.
A diabetic foot ulcer is often taken lightly when it is about to develop. Once the ulcer deepens, it can severely impact the person’s mobility. It is important to examine your feet daily before going to bed to look for any developing ulcer.
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What is a Diabetic Foot Ulcer/ Diabetic Sore on Feet?
A diabetic foot ulcer is frequently found complication among diabetics and it typically develops due to poorly managed diabetes.
It is an ulcer-like open wound or sore that forms at the bottom of the foot and it reduces the quality of life greatly.
The ulcer may be clean in the beginning but usually gets infected. An infected ulcer and an ulcer that develops in the background of peripheral arterial disease is very difficult to heal.
A diabetic foot ulcer develops in about 5% of diabetic patients and 6% of them have to be hospitalized because of the infection or inflammation.
In addition, 1% of patients with a diabetic foot ulcer may need amputation of the infected foot [Ref]
It is one of the most prevailing diseases that lead to any non-traumatic lower extremity disorder which can then lead to amputation.
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Who is at risk of developing a diabetic foot ulcer?
Anyone who has diabetes is at risk of developing a diabetic foot ulcer. Diabetes weakens your immune system.
This leads to frequent infections especially foot infections and genital infections. Obese, smokers, and people who drink alcohol are at a high risk of developing a diabetic foot ulcer compared to lean, non-smokers, and non-alcoholics
The risk is also higher among diabetics who use insulin and those who have kidney, eye, or any other cardiovascular disease.
Insulin is itself not a risk factor, however, type 2 diabetic people on insulin usually have advanced and uncontrolled diabetes. Thus, their risk of developing diabetic foot infection is manyfold increased.
SGLT2 Inhibitors are a novel class of diabetes medications that have been associated with an increased risk of amputations and fractures.
Among the SGLT2 Inhibitors, Canagliflozin (Invokana) is greatly associated with amputations compared to other SGLT2 inhibitors.
In a study that evaluated the risk incidence of foot ulcers among diabetics, it was found that characteristics like more than 10 years of diabetes, over 50 years of age, status of education, fast blood glucose level of over 200mg/dl, presence of retinopathy and any deformities would increase the risk for foot ulcers [Ref].
Other factors like poor hygiene can also contribute to the enhancement of the risk.
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What Can Cause a Diabetic Foot Ulcer?
Excessively high blood sugar levels that remain untreated for a long time can lead to a condition called diabetic neuropathy.
Diabetic Neuropathy can affect any nerve in your body, however, the nerves that run the longest course in your body are mostly affected.
Nerves that supply the hands and feet are the longest and are affected the most. This is the reason why diabetic polyneuropathy commonly manifests in a “gloves and stockings” pattern.
Another reason is that diabetes significantly affects the blood flow to the extremities, e.g., in the hands and feet.
This reduction in blood flow enhances the chances of ulceration and infections developing in the feet. Peripheral artery disease can also happen due to poor circulation.
Hyperglycemia can reduce the healing process meaning that if an infection does develop in the feet or legs then it will not heal properly on time which is why it is critical to maintain your blood sugar level.
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Symptoms of a Diabetic Foot Ulcer?
If a person is aware of the visible symptoms of diabetic foot ulcer, then he can diagnose it on time and get treatment for its early management.
- Swelling in the feet that is localized, red, painful, and warm
- There is irritation or itching over or around the swelling
- The surrounding area is red and warm
- The ulcer may be discharging fluid which can be clear or turbid
- Infected ulcers are usually foul-smelling
- Dead black tissue may be present around the ulcer
- Gangrene may develop in advanced disease.
It is always best to see a doctor at the earliest as the infection/ ulcer may spread rapidly. Once it spreads to the muscles, ligaments, or bones, amputation or resection is usually required.
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What are the different stages of a Diabetic Foot Ulcer?
A diabetic foot ulcer is commonly staged into 5 classes using the Classic Wagner Grading System.
Grade 0: no open lesions; may have healed lesion
Grade 1: superficial ulcer without penetration to deeper layers
Grade 2: deeper ulcer, reaching tendon, bone, or joint capsule
Grade 3: deeper tissues involved, with abscess, osteomyelitis, or tendonitis
Grade 4: gangrene in a portion of the forefoot or heel
Grade 5: extensive gangrenous involvement of the entire foot
How Does a Foot Ulcer Develop?
It can develop in the following stages which shows the process of development of foot disease. [Ref]
Stage 1: a normal foot
Stage 2: a high-risk foot
Stage 3: an ulcerated foot
Stage 4: an infected foot
Stage 5: a necrotic foot
It shows the development of foot ulcers in the 3rd stage which calls for immediate action for its management.
It is best to take care of the foot in the initial two stages by controlling your blood sugar level and practicing proper hygiene.
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How to Prevent Diabetic Foot Ulcer?
It is essential to take measures and prevent the development of an ulcer because it can affect the quality of life greatly.
Following a healthy lifestyle and keeping good control over your blood sugar level is essential in this case.
Make sure your feet are kept clean. It is better to cleanse them regularly and keep them sanitized as well.
By doing this you are minimizing the chances of any infection by pathogens. Whenever you wash your feet dry them with a clean towel.
Keep your toenails shortened and not too long as they trap pathogens in them. Also, cutting them too short is also not a good idea.
Wear clean socks. Diabetic socks are available in the markets. These are made to absorb humidity or sweat. You should change your socks daily and wash them.
You may put a clean tissue in between your toes if your feet are sweaty and if you frequently develop fungal infections of the toes.
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How to Treat a Diabetic Foot Ulcer?
‘Off-loading’ helps in healing a diabetic foot ulcer that has developed over a pressure area. Off-loading means avoiding contact with the ulcer. This means staying off your feet for a while.
This helps with foot ulcers that are present at the bottom of your feet especially. For this, specialized footgear, casts, and braces are worn as recommended by your doctor.
Off-loading (relieving pressure) is especially helpful in patients with diabetic foot ulcers due to neuropathy.
Keeping the ulcer covered and moist can help greatly with wound healing. Your doctor might prescribe you some topical ointments for usage. Managing your blood glucose level is a key step in the healing process.
Surgical interventions are not necessary for treating ulcers that are not infected, however, the infected ones will require such measures. This includes shaving the bone or correcting abnormalities.
Along with debridement, appropriate culture-guided antibiotics may be used for a speedy recovery.
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