Diabetic Foot Ulcer: Risk Factors, Causes, Stages, & Treatment

Diabetic Foot Ulcer

diabetic foot ulcer bullous eruptions
diabetic bullous eruption

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.

Non-Insulin Dependent Diabetes Mellitus (NIDDM)


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. In some cases, these complications are preventable and can be prevented by following a healthy lifestyle but in other cases when a disorder has already developed it is important to keep it under control before it progresses towards a greater complication.

Symptoms of Hyperglycemia (High Blood Sugars)

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 diabetic foot ulcers, oral, and genital candidiasis, and medications-related side effects.

Here we have a detailed explanation of a condition known as ‘diabetic foot ulcer’ which can drop the quality of life greatly.

What is a Diabetic Foot Ulcer?

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.

This occurs in about 15% of diabetics and 6% of them have to be hospitalized because of the infection or inflammation. It is one of the most prevailing diseases that lead to any non-traumatic lower extremity disorder which can then lead to amputation. [Ref]

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Who is at risk of developing a diabetic foot ulcer?

Basically, anyone who has diabetes is at great risk of developing a foot ulcer because diabetes can weaken a person’s immune system which then increases the chances of any infection’s development.

People who are overweight have a higher risk of developing diabetic foot ulcers, including those who smoke and drink alcohol. The risk is also higher among diabetics who use insulin and those who have kidney, eye, or any other cardiovascular disease.

Insulin Dependent Diabetes Mellitus (IDDM) Type 1 and Type 2

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.

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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.

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 which involves the damage of a nerve that can happen anywhere in the body but most commonly it can occur in the lower limbs (legs and feet).

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.

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Hyperglycemia can reduce the healing process meaning that if an infection does develop in the feet or legs then it would not heal properly on time which is why it is critical to maintaining your blood sugar level.

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.

  • Uncommon swelling in the feet
  • Irritation in that area
  • Persistent redness in the skin of the feet
  • Bad odor
  • Drainage of fluid from your feet
  • Dead black tissue around the ulcer
  • Presence of gangrene, odorous discharge, and pain

In case any of the above symptoms are present then it is most suitable to talk to your doctor about it and get the proper diagnosis.

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How to Diagnose Diabetic Foot Ulcer?

A diabetic foot ulcer can be diagnosed 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 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 neat. 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 afterward and keep them moisturized.

Self Management and Physical Therapy for Lymphedema

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.

If you prefer to wear socks then make sure you repeatedly change them.

How to Treat a Diabetic Foot Ulcer?

‘Off-loading’ helps with treating diabetic foot ulcers. 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.

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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 of the bone or correcting abnormalities.

Along with debridement, appropriate culture-guided antibiotics may be used for a speedy recovery.

What do you think?

Written by Dr. Ahmed

Dr. Ahmed is an experienced Internist with over fifteen years of practice in the medical field. He strongly believes that true medical practice is about helping people, not just prescribing pills.
He has found that the best results come from motivating patients to make small lifestyle changes in addition to prescribing medications when necessary.
With a focus on managing obesity, diabetes, hypertension, asthma, depression, arthritis, migraine, high cholesterol levels, and many more medical conditions in his patients, he shares his knowledge and expertise through writing health-related articles for
He is committed to helping patients achieve optimal health outcomes and improve their quality of life. For direct contact, he can be reached at

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