- Diabetic foot ulcer is the devastating complication of diabetes which is associated with neuropathy
- Self-examination and proper foot care may prevent diabetic foot ulcer and thus reduce the risk of amputation
- Dr. Gopi Chellan, Podiatric surgeon, spoke to Medindia about diabetic foot ulcer and the care to be taken to prevent complications
ulcer is one of the most dreaded complications arising out of diabetes. The
foot ulcer may start small, but if good care is not taken, it might even lead
to leg amputation. According to World Health Organization every 16 seconds, a
lower limb is amputated due to diabetes. India and China have the highest
number of diabetic patients and this adds to the increased burden of diabetic
Dr. Gopi Chellan, Podiatry Consultant, Aster Prime Hospital, Hyderabad, spoke to Medindia about diabetic foot ulcer and the care to be taken for preventing complications.
Q. What is the prevalence rate of diabetic foot ulcer in India and is there a study which shows any regional disparity in the prevalence?
Q. Why diabetic foot ulcers do not heal?
A. That's a very important question. There are a couple of factors which are important for wound healing.
Firstly,blood supply to the foot is one of the key factors for wound healing. When, one's blood sugar levels are not controlled for a prolonged duration, the inner lining cells of the blood vessels will be affected, which in turn leads to atheromatous plaques and eventually blocks the blood flow to the foot extremities. This condition is called peripheral occlusive vascular diseases. When there is no blood supply, macro-and-micro nutrients as well as medicines for wound healing will not reach the wound and hence delays the wound healing process.
Secondly, about 90% of diabetic foot wounds are infected with microbes like bacteria and fungi which warrant culture-specific antimicrobial therapy. Unfortunately, in rural and semi-urban as well as in urban areas, many of the clinical practitioners do not try to find out the bacteria growing in the wounds by culturing the wound tissue, instead, the patients are given empirical antibiotics. These practices contributed to increased microbial resistance to antibiotics and delayed wound healing.
Thirdly, non-off-loading of the foot with ulcer and poor wound care. When a wound occurs on foot, the patients must not walk with that foot, as walking would crush the already damaged tissue and delay the healing process. Also, the wound area must not be soaked in regular water, instead must be cleaned with sterile solutions such as normal saline or povidone iodine as advised by the doctor. Similarly, wound dressing must be done with sterile dressing materials for avoiding microbial contaminations and maggots.
Fourthly, identifying the reason for wound occurrence and appropriate treatment is important in wound management. Inadequate clinical evaluation will mislead the wound management plan. For example, if the foot bone is infected, then surgical procedure of removing the infected bone ought to be done. If the wound is malignant, wide excision or amputations may be required. If it is a vasculitic ulcer, steroid treatment may be needed.
Q. How long does it take to heal a diabetic foot ulcer?
A. The healing of diabetic foot ulcer takes about 4 to 8 weeks, based on all the positive conditions like blood supply, blood sugar control, wound care, foot off-loading, appropriate medications. Other factors like usage of sterile wound dressing materials, and ointments/lotions for wound care depending on the nature of the wound bed as recommended by the Podiatrist. Inappropriate wound care and non-compliance with doctor's instructions will prolong wound healing. I have seen a couple of patients whose foot ulcers did not heal even after 2 years.
Q. How can healing of ulcers be improved? Please tell us about the dressing that may be effective
A. There are different types of ulcers and the reasons for each ulcer development may also vary. However, wound management depends on the wound size, depth, location and severity of the infection. In the case of ischemic wound, which occurs due to lack of blood supply, revascularization procedures such as peripheral angioplasty or thrombolytic therapy to treat the blockage and improve blood supply are required in addition to wound care. If the infection is extending to bone (osteomyelitis), a surgical procedure may be required. In the case of venous ulcer, the underlying varicose vein must be treated with laser ablation or sclerotherapy. Apart from treating the root cause of the wounds, appropriate foot care and footwear are mandatory. As said earlier, the patient should avoid walking with the affected foot or use the Orthoses (custom made footwear) advised by the podiatrist.
As the wounds are of different nature, the wound dressing techniques also vary. For example, a highly exudative wound may need negative pressure wound therapy/vacuum therapy or adsorbant dressing. In the case of slough/biofilm on the wound, enzymatic digestion with papain and antimicrobial local application dressing may be required. If the ulcer is clean yet dry, then simple saline dressing will be sufficient. Growth factors such as epidermal growth factors or platelet-derived growth factors may also be used for facilitating granulation and epithelialization. In general, irrespective of the type of ulcers, wound dressing materials must be sterile. And if the dressing material is soaked, it needs to be changed immediately.
However, it is always wise to consult a trained wound care specialist or a podiatric surgeon regularly as he/she would recommend dressing pattern depending upon the nature of the wound.
Q. Can you please tell us about recent advancement in the field of podiatry? Are there any ways to improve blood circulation to the tiny blood vessels?
A. The branch of Podiatry has been expanding over a decade with the advancement of research and technology. Compared to traditional wound dressing materials, a number of modern wound dressing materials are available in the market which augments wound healing process.
Hydrocolloid dressing, Alginate dressing, Hydrogel dressing, semipermeable adhesive film dressing, foam dressing, biological dressing are a few newer dressing materials which have specific application in wound care.
Tissue engineered skin substitutes such as acellular and cell-containing matrices are being used to cover partial thickness or full thickness burns. Epidermal and dermal skin grafts are also found effective for non-healing diabetic foot wounds and venous ulcers. Stem cell therapy is being applied for managing ischemic and chronic non-healing wound for facilitating new blood vessel formation, but it is not widely used due to ethical and logistics and financial constraints. However, the long-term benefit of stem cell therapy is yet to be documented.
Controlled drug delivery to the wound is the other advancement in the field of Podiatry, wherein solid nanoparticles, liposomes, microemulsions and microsponges are being used for quick, deeper, wider or sustained delivery of medicines into/around the wound.
Low-level laser therapy, hyperbaric oxygen therapy and negative pressure wound therapy devices are the other promising techniques available for wound management.
Infra-red ray therapy and electromagnetic stimulation of cells are being found to be effective in inducing cell proliferation, and blood circulation of the foot thereby hastening wound healing.
The field of Orthotics and Prosthetics is another important area which has emerged lately with the focus on preventing foot ulcer development and also for rehabilitating the patients who had undergone major as well as minor foot surgeries. There are specialized insole materials that can be placed on the footwear which will prevent undue friction and abnormal plantar pressure. Specialized or custom made footwear is also available which help in preventing diabetic foot ulcer.
About improving blood circulation of the foot and legs, there are both medical and surgical procedures available. The newer thrombolytic drugs that are launched recently are promising for increasing blood circulation, but are expensive. Peripheral angioplasty is the mainstay of revascularization which has been saving many legs from major amputations of late.
Q. Are diabetic patients who have a good control of glucose also have a higher risk for diabetic foot ulcer?
A. Of course! All diabetic patients are at a higher risk for diabetic foot ulcer. However, patients with good control of blood sugars from the day of diagnosing diabetes will have relatively lower chances of foot complications compared to the uncontrolled group. In addition to blood sugar control, one should be very keen on practicing proper foot care and choosing the right footwear. Patients should care for their foot in the same way as they care their face. Daily self-examination of their feet is inevitable as it is the easiest way to detect foot abnormality at an early stage.
Q. Are co-morbid factors like diabetic retinopathy associated more with foot ulcers?
A. Diabetic retinopathy will affect the vision. Hence, the chances of traumatic wounds over the feet are high. The other way of looking at it is; for a patient who developed retinopathy which is a microcirculation defect, would also have the small blood vessels of the foot affected. Such microvascular defect will cause an increased risk of foot ulcers.
Diabetic Foot UlcerPeople with diabetes are at a higher risk of developing foot sores or ulcers. Diabetic foot ulcers are a common reason for hospital stays for people with diabetes. Diabetic ulcers are often painless, but it may take weeks or even several months to heal. The prevalence of diabetic foot ulcer in the diabetic population is 4 to 10 percent, and the condition is more frequent in older patients.
In diabetic patients with neuropathy, loss of sensation in the feet leads to injuries, which may consequently lead to foot ulceration. An untreated foot ulcer may be infected, which may even lead to foot amputation.
If the wound healing is slow for over two weeks, it is advisable to consult a Podiatrist. Certain tests like peripheral angiograms, nuclear scans, x-rays, duplex scans, tissue/pus culture and sensitivity, nutrition deficiencies should be taken to identify the causes of delayed healing and take remedial actions.
Lifestyle changes may help avoid diabetic foot ulcer and other complications. It is important to quit smoking and alcohol as it may affect the blood vessels and nerves. Constant monitoring of blood sugar level, healthy diet and medications are important to facilitate wound healing.
- Management of Diabetic Foot Ulcers - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508111/)