Foot Ulcer

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What are Foot Ulcers?

Foot ulcers are a major global healthcare problem. It is estimated that each year around 4 million people get a foot ulcer. A foot ulcer is caused by trauma to the foot in combination with nerve damage and blood circulation problems. 

Chronic foot ulcers mainly affect the elderly. If associated with poorly controlled medical problems it may lead to the loss of leg.

Foot Ulcers

What is the Appearance of a Foot Ulcer?

Foot ulcer is an erosive or penetrating lesion on the foot. It looks like a crater or open sore in the skin as if the surface of the tissue has been excavated. In most people such an injury heals up within a week or two. However, when there is an underlying problem such as poorly controlled diabetes, the skin does not heal and results in a leg ulcer. Foot ulcers may involve the skinís surface, full thickness of the skin, tendons and even bones. It is marked by inflammation, formation of pus and sloughing of damaged tissues.

Diabetic Ulcers have a callus, thickened and raised tissue surrounding the ridge of the ulcer. Stasis ulcers are red, shallow, with irregular edges; with a crust of necrotic tissue overlying the ulcer bed.

Ischemic ulcer has a punched out appearance, smooth edges and a pale base.

What are the Different Types of Foot Ulcer?

Neuropathic ulcers [Diabetic ulcers]: These are commonest cause for lower extremity amputation. Nerve damage results in impaired sensation in the feet. When a person has an injury, blisters, or cracks on the foot, they cannot feel it. The injury may go unnoticed and untreated, leading to an ulcer.

Diabetic foot ulcer is a major complication of Type I & 2 diabetes. In fact it is estimated that one in every six people with diabetes will have a foot ulcer during their lifetime. Foot problems such as ulcerations, infections, and gangrene, are the most common cause of hospitalization among diabetic patients.

Arterial leg ulcers [Ischemic ulcers]: These approximate 10 percent of all leg ulcers. They are due to insufficient arterial blood supply. They usually do not bleed.

Venous leg ulcers [Stasis ulcers]: These are found in people who have varicose veins or blood clots. Damaged valves or blocked veins cause the blood to pool in the vein. Sometimes, the blood leaks out of the vein into the surrounding tissue, causing the tissue to breakdown and form an ulcer.

What are the Common Locations of Foot Ulcer?

Diabetic foot ulcers usually occur on the pressure areas of the feet. The bottom of the foot, esp head of the second and fifth metatarsal bones. Diabetic foot ulcers can affect oneís quality of life.

Venous ulcers mostly occur above the medial malleoli.

Arterial leg ulcers are usually found on the heels, tips of toes, between the toes or where the bones protrude.

What Causes Foot Ulcer?

  • Diabetes: It is the commonest cause of ulcer. Diabetics who can't see their feet well enough to examine them may miss out on the initial foot damage.
  • Peripheral Neuropathy: As damaged nerves can no longer warn about pain, repetitive stress such as tight-fitting shoes, pebbles in shoes or stepping on sharp object may lead to ulcer formation.
  • Peripheral Artery Disease: Less blood reaches the feet, which deprives cells of oxygen and slows the foot's ability to heal. Causes include atherosclerosis [fatty deposits inside arteries],
  • Raynaud's phenomenon [sudden episodes of decreased blood flow to the fingers and toes], among others.
  • Abnormalities in the bones or muscles of the feet like fractures, claw feet, hammer toes, severe arthritis.
  • Venous Insufficiency
  • Injuries resultingintraumatic ulcers.
  • Prolonged pressure on the skin and excessive friction.
  • Skin cancer [squamous cell carcinoma].
  • Hypertension.
  • Inflammatory diseases including vasculitis, lupus, scleroderma, rheumatologic conditions.
  • Infections such as herpes simplex, leprosy, HIV, Epstein Barr virus.
  • Genetic disorders as Charcot Marie Tooth disease.
Causes of Foot Ulcer

What are Grading Systems Used for Diabetic Foot Ulcers?

The Wagner (grade) and the University of Texas (UT (grade and stage) wound classification systems are mostly used.

In the UT system within each wound grade there are four stages: clean wounds (stage A), nonischemic infected wounds (stage B), ischemic noninfected wounds (stage C), and ischemic infected wounds (stage D).
GradeWagner ulcer classification system [Grade 0-5]University of Texas [Grade 0,1,2,3] Stages A,B,C,D]
0No open lesion. Pre or post ulcerative lesionspre-or post-ulcerative lesion that has healed
1partial/full thickness ulcersuperficial wound not involving tendon, capsule, or bone
2ulcer extends into tendon, joint and or fascia without abscess or osteomyelitiswound penetrating to tendon or capsule
3deep ulcer with abscess or osteomyelitiswound penetrating bone or joint
4partial foot gangrene-
5whole foot gangrene-
Higher the grade and stage of ulcer, greater is the risk of amputation.

What are the Symptoms of Foot Ulcer?

  • Skin discoloration
  • Thickened or hardened areas in the skin (Callus)
Symptom of Foot Ulcer - Callus
  • Presence or absence of pain in foot
  • Swelling of the foot
  • Bleeding
  • Discharge from the ulcer
  • Difficulty in moving the foot

How to Diagnose Foot Ulcer?

Examination of Foot Ulcer

Local examination:
  • Check location of ulcer
  • Check size of ulcer
  • Check depth of ulcer
  • Check out edge of the ulcer
  • Check out presence of granulation tissue
  • Check out discharge from the ulcer
Physical examination:
  • Check leg for varicose veins
  • Check out for color changes, coldness, pain, loss of hair in legs
  • Perform nylon monofilament test. The test is abnormal if the patient cannot sense the touch of the monofilament when it is pressed against the foot with just enough pressure to bend the filament
Nylon Monofilament Test Evaluate the Sensation in Foot
  • Check out the peripheral pulses in the leg
  • Check Ankle brachial index [ABI]. It is the ratio of the systolic blood pressure at the ankle to the upper arm (brachium). Normal range is 0.9 -1.2. An ABI lesser than 0.9 is indicative of atherosclerotic disease. An ABI less than 0.3 is highly suggestive of poor chances of healing of ulcers caused by vascular insufficiency.
  • Check lymph nodes in groin
Laboratory tests to be done in Foot Ulcer:
  • Blood sugar / Glycosylated haemoglobin
  • CBC /ESR
  • C Reactive protein [CRP]
  • Cholesterol/ Triglycerides
  • Bacterial cultures of the ulcer
  • Biopsy of ulcer edges
Radiological investigations:
  • Doppler ultrasound scan to assess blood flow and extent of vascular insufficiency
  • Arteriography to define the site and degree of arterial obstruction in peripheral vascular disease
  • Bone scan
  • Magnetic resonance imaging (MRI)

How is Diabetic Foot Ulcer Treated?

Debridement to remove all necrotic tissue. This is done using surgical instruments, ointments containing enzymes or pulse lavage therapy. After debridement, the wound is irrigated with saline or cleanser and a dressing is applied.

Offloading or removing pressure from foot ulcers by avoiding walking, using crutches, wheelchair, wearing casts, braces, inserts, diabetic shoes.

Infection control: Polymicrobialinfectionsinclude β hemolytic streptococci, pseudomonas aeruginosa, enterococci, MRSA etc. Antibiotics such as Amoxicillin and Clavulanate Potassium, Ampicillin and Sulbactam, Cephalexin, Ciprofloxacin are started after initial cultures are taken.

Honey dressings are showing promising results in ulcer treatment. Also homeopathy medicines like Hepar Sulph, Merc Sol, Silicea, Kali bichromicum are very useful.

What is Advanced Treatment for Foot Ulcers?

This is advised if there is no significant improvement even after a month of treatment.
  • Skin grafting
  • Tissue treatment from bioengineered human cells and collagen
  • Hyperbaric oxygen therapy
Hyperbaric oxygen therapy - Advanced Treatment for Foot Ulcers
  • Using infrared radiation plus routine dressing is more effective according to clinical trials
  • Using Therapeutic Magnetic Resonance (TMR) causes a significant increase of granulation tissue according to randomized controlled studies in three highly specialized diabetic foot clinics
  • Aggressively incorporate Invasive Systemic Infection [ISI]
  • Allogenic acellular dermal matrix treatment can accelerate wound healing and reduce complications
  • Topical growth factors containing recombinant human platelet derived growth factor [rhPDGF] in gel form is used to stimulate healing
  • Electrical stimulation, ultrasound, MIST therapy [which uses ultrasound created mist to promote healing] is used for stubborn ulcers

Foot Ulcer Prevention Tips

  • Treat the underlying health condition. Proper control of blood sugar, cholesterol and triglyceride levels lower foot ulcer risk.
  • Examine feet every day for any cuts, blisters, or calluses.
  • Keep feet clean. Wash feet daily in warm water and dry them well, especially between the toes.
  • Soften your feet. Put a thin layer of lotion on the top and bottom of feet to prevent dryness.
  • Trim your toenails straight across and smooth them with a file.
  • Donít go barefoot. Always wear socks and shoes to avoid stepping on something and hurting your feet.
Wear Socks Or Shoes To Protect Your Feet
  • Make sure your shoes fit well and wear soft absorbent socks to avoid blisters.
  • Exercise regularly. This improves circulation, which is essential to fight infection.
  • Stop smoking
  • If you have corns or calluses, ask your doctor about how to care for them.
  • If you are overweight, follow a plan to lose weight.
  • Temperature control of feet can prevent ulcers in diabetics.
Tips for Patients who Have Recovered from Foot Ulcer:
  • As recurrence rates are as high as 50% one should be always vigilant.
  • It is advisable to wear customized shoes and have them evaluated on yearly basis.
  • Change shoe inserts every 3-4 months.
  • Have the feet examined regularly.
  • Keep abreast with advances in diabetic foot care and actively participate in the treatment process with your physician.

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