This post was written by Raul J. Guzman, M.D., a staff vascular surgeon in the Adult Clinic of Joslin Diabetes Center for U.S. News and World Report’s For Better blog.
Diabetes is a multifaceted disease that if not managed properly can affect different parts of your body such as your eyes, kidneys, blood vessels, and even your feet.
Problems with the feet are some of the most common complications of diabetes and approximately 15 to 25 percent of patients with diabetes will develop a foot ulcer at some point during their lifetime.
The good news is that with proper medical treatment, many diabetic foot ulcers can heal without any major interventions or amputation.
How to Identify and Treat a Diabetic Foot Ulcer
A diabetic foot ulcer – also called a wound or sore – is an opening in the skin that exposes the underlying tissue. They can look like a blister with fluid underneath, or sometimes there is red or yellow tissue at the base because skin has worn away. In some cases, a toe or part of the foot may turn black.
Although diabetic foot ulcers may have many different appearances, there are only three basic types. They can be neuropathic, ischemic, or a combination of the two, referred to as neuro-ischemic ulcers.
Neuropathic ulcers occur when there is a loss of feeling in the foot. They develop from a combination of factors including foot deformity, swelling, and minor trauma. Because diabetic neuropathy causes a lack of feeling in the foot, even minor cuts, blisters, or bruises can become infected or develop into ulcers without the patient noticing.
Ischemic ulcers occur in part because of a lack of blood flow. They can develop for the same reasons as neuropathic ulcers, but they are less likely to heal because there is not enough blood flow to the foot.
Finally, certain people with diabetes can have both decreased sensation and poor blood flow to the foot resulting in neuro-ischemic ulcers.
What should I do if I develop a foot ulcer?
If you have diabetes and develop a wound, sore or skin defect on your foot and it has not closed within a few days, it could be a diabetic foot ulcer. It is important to seek advice immediately from a medical professional skilled in evaluating diabetic foot problems. Your primary care provider (PCP) may perform the initial evaluation. While some PCPs offer excellent wound care, a podiatrist, wound care, or vascular specialist usually provides treatment of diabetic foot ulcers.
How will my doctor assess my foot ulcer?
During initial appointment, your doctor will evaluate your general health, including looking for risk factors that can lead to ulcers. Such factors include foot deformity, swelling, arterial disease and a recent history of trauma.
One of the most important parts of the initial evaluation is assessing blood flow to the foot. The arterial Doppler is a simple device that is placed on the skin to record the sound of blood as it passes through arteries. The test provides useful information on blood pressure and flow in your foot. It is performed by placing blood pressure cuffs around the thigh, calf, and ankle and then using a Doppler probe (that looks like a pencil) to obtain measurements at several sites along the leg. The procedure is relatively painless and takes about 30 minutes to complete. At Joslin, we believe that every patient with a diabetic foot ulcer should undergo arterial Doppler testing.
If the arterial study comes back with abnormal results, then your doctor will determine the best course of action to improve blood flow to your foot so that your ulcer can heal as quickly as possible.
Once the diagnosis is made, how will treatment protocols be determined?
There are several treatments used to encourage healing of diabetic foot ulcers:
- Wound care is the general term used to describe the methods, frequency, and types of treatments used. Most patients will require one or a combination of the following:
- Debridement is the removal of dead or infected tissue from the ulcer, usually with scissors or a surgical blade.
- Offloading is the use of casts or boots that can be removable or non-removable to help decrease pressure at the ulcer site.
- Dressings are the application of special materials, solutions, or ointments to the wound. They are an important part of treatment and many dressing types are currently available. Most practitioners adhere to the idea that a moist ulcer bed is best for healing, but there are many ways to treat ulcers. For this reason, your wound care specialist may choose specific products to obtain the best results for you.
- Revascularization is the general term for procedures aimed at improving blood flow to the foot. Only patients with abnormal or decreased blood flow will need this.
What if the wound does not heal?
When a diabetic foot ulcer fails to heal, there is usually a reason such as persistent infection or lack of blood flow. If your ulcer has not decreased in size by 50 percent within 30 days, you may need advanced wound care therapies. You should consult with your wound care or vascular specialist to determine the next step.
What is my risk of amputation?
One of the biggest concerns among patients with diabetes is that a foot ulcer will lead to amputation. Prior studies suggest that one in five in diabetic patients who develop an initial foot ulcer will require amputation.
It is important to note, however, that the risk varies greatly depending on age and risk factors. Early ulcer evaluation and treatment can greatly reduce this risk.
There are several types of amputations but ultimately the decision on what needs to be removed is made by the surgeon. Amputations can range from relatively minor procedures that involve a single toe to major amputations above the knee (AKA).
Generally, toe amputations will have a minimal effect on overall walking ability while amputations above the ankle can have a more significant effects. At Joslin, researchers are working on new treatments aimed at preventing foot ulcers and reducing the risk of amputation in patients with diabetes.
Diabetic foot ulcers are frightening for patients and family members, however, most will heal with proper treatment. It is important to seek care as soon as possible for any cut or wound on the foot. With early and appropriate initial evaluation followed by good wound care, the chance of healing improves so that patients can prevent amputation.
This article first appeared on U.S. News and World Report’s For Better Blog on March 25, 2016.