Synonyms and Keywords
Diabetic foot, foot ulcers, neurogenic ulcers.
What are Diabetic Ulcers?
Diabetic ulcers are sores that occur at the pressure points on the foot, and usually on the sole where contact against the ground is most common. Pressure from the shoes worn can also produce ulcers on the sides or top of a foot.
One of the major complications of diabetes, foot lesions is responsible for more hospitalizations than any other diabetic condition.
What Causes Diabetic Ulcers?
Those with diabetes are prone to peripheral neuropathy (nerve damage), which dulls or robs completely the feeling in the feet and causes changes in the sweat-producing glands. Feet are naturally stressed from walking, and someone with numbed sensation may not feel a skin tear or breakdown. That, coupled with a decreased circulation to the feet, can lead to the wounds not getting the proper blood flow and thus not only slower to heal, but also increased risk of infection, turning a small cut, scrape, or irritation in a diabetic into an ulcer. As well, it is common for these types of ulcers to keep coming back in diabetics.
Who Gets Diabetic Ulcers?
According to The National Institute of Diabetes and Digestive and Kidney Diseases, about 16 million Americans are known to have diabetes. 15% of them develop a foot ulcer, and 12-24% of individuals with foot ulcer require amputation. The more serious or severe a patient’s diabetes is and more out of control or higher the blood sugar levels are, the more likely the person is to develop diabetic ulcers.
Foot ulcers can affect anyone with an impaired sensation of the feet, diabetic or not. Peripheral neuropathy, present in 60% of diabetic persons and 80% of diabetic persons with foot ulcers, lends the greatest risk. Because the condition tends to occur about 10 years after the onset of diabetes, diabetic ulceration happens sometime thereafter.
Ill-fitting shoes or hose, irritating chemicals such as “corn remedies,” extreme heat or cold, accidentally self-inflicted wounds, and faulty weight distribution from bad postures or instruments (such as crutches and walkers) can lead to diabetic ulcers. Microvascular disease that affects or damages the walls in the small blood vessels (such as the capillaries) also contributes to the cause, as will obesity, heart disease, and smoking.
What are the Symptoms of Diabetic Ulcers?
Foot ulcers are open sores or wounds that can be deep enough for you to see down to the bone. They may or may not be painful, since the surrounding nerves may have already been dulled by peripheral neuropathy. Generally, the patient has a swollen foot, possibly with a burning or itching sensation. There may also be a rash, redness, brown discoloration or dry, scaly skin.
Usually, depending on the patient’s blood circulation, the ulcer itself has a pink/red or brown/black margin, and the immediate skin appears spongy. A callus often overlies the ulcer on the foot surface. Any discharge is watery and serious.
How do You Diagnose Diabetic Ulcers?
You doctor may run tests that include MRI (magnetic resonance imaging), nerve conduction tests (measuring how fast the nerves in your arms and legs conduct electrical signals), and vascular studies (non-skin-piercing procedures used to assess blood flow in arteries and veins). In the case of a new ulcer, the doctor may want to take an X-ray of the affliction to make sure there is no infection (osteomyelitis), fracture of the bone, or foreign objects lodged in the ulcer, as you may not feel them.
You can develop peripheral neuropathy without even being aware of it. So, it is important for diabetics to take a comprehensive foot exam every 6 months.
How do You Treat Diabetic Ulcers?
Foot ulcers in diabetes can require an assessment across multiple medical disciplines, usually by diabetes specialists, podiatrists, and surgeons. The treatments vary depending on the ulcer’s severity and location as well as whether it’s infected, from appropriate bandages, antibiotics, debridement (removal of dead, damaged, or infected tissue), to arterial revascularization (restoration of blood supply).
All ulcers should receive treatment. See your health care provider if you experience a lack of sensation in your feet, if there is any discoloration, pain, swelling, redness, oozing, or fever. Diabetic ulcers can lead to amputation if care is delayed, so visit your physician or podiatrist as soon as possible.
Self-Care at Home
It is important to remember that if you have had an ulcer previously, it is very common to get more. Follow the tips below to reduce the chance of recurrence or help relieve your current condition:
1. Vitamin C has been found to inhibit the bacteria, Helicobacter pylori, that cause ulcers, so it follows that taking high doses of vitamin C will block the condition’s development. Because the same bacteria also lead to vitamin B12 deficiencies, supplement your diet with plenty of vitamin B12 to retain the regeneration and growth of your cells.
2. Some doctors have also found that drinking lots of water, approximately 8-12 glasses a day, along with a sensible, healthy diet can resolve ulcers in well over 95% of their patients.
3. Avoid certain medications, such as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), which can increase the risk of ulcers. Do not use medicated pads to treat corns, calluses, or warts on the feet, since these pads can cause ulcers too.
4. Make sure to change foot dressings daily as directed by your doctor.
5. Never go barefoot. Put on shoes that are well-fitting, cushioned, and pressure-reducing, both indoors and outdoors to cut down risk of injury. Better yet, always wear special footwear recommended by your doctor to minimize pressure and speed up recovery. When wearing socks, make sure that any folds in the socks are smoothed out before putting shoes on. Avoid wearing flip-flops and wearing shoes without socks.
6. Decrease pressure on your feet by trying to walk less. Try exercise that won’t put weight or exertion on your feet, like swimming, cycling, or rowing. Consider changing to a job that does not require much walking or standing.
7. No tobacco! Smoking can worsen blood flow, further slowing down healing.
8. Keep your blood sugar levels under tight control. Elevated blood glucose weakens the body’s ability to fight infection and slows down wound healing.
The steps for professional treatments may include:
1. Weekly or twice weekly debridement of dead or infected tissue with a scalpel. While this will actually make the ulcer larger in size and cause bleeding, it also exposes the healthy skin underneath for faster and cleaner healing.
2. Oral or intravenous antibiotics. Your doctor may send a sample of skin or fluid for bacterial culture and, if the area is infected, start you on antibiotics.
3. Hospitalization for surgery or infection control.
4. Wound care center referral for regular monitoring and care of the ulcer.
5. Hyperbaric oxygen therapy, the medical use of oxygen at a level higher than atmospheric pressure, applied to drastically increase partial pressure of oxygen in the tissues of the body and consequently raise the blood’s capacity to transport oxygen. The Cochrane Review Panel has concluded in 2004 that this therapy reduced the risk of amputation for patients with diabetic ulcers, and may improve the healing at one year.
6. Special paddings or shoes to minimize pressure or impact of walking and between the feet and footwear.
7. Vascular surgery and infectious disease consultation.
It is crucial to follow up with your doctor as scheduled, as diabetic ulcers can worsen very quickly and need to be closely monitored.
Surgery is necessary for deep infections. Even after the successful management and healing of an ulcer, the recurrence rate is 66% and the amputation rate hovers around 12%. Half of all non-traumatic amputations stemmed from diabetic foot complications, and the chance of needing an amputation for the other limb within 5 years is as high as 50%.
How to Prevent Diabetic Ulcers?
Poor diet or stress was long thought to be a cause of ulcers, but the affliction was definitively linked to the H. pylori bacteria in the 1980s. In addition, researchers also believed that lifestyle can determine which people develop ulcers. Therefore, healthy dietary habits supplemented by a steady intake of vitamin B12 and C — both valuable in fending off the bacteria — will go a long way in preventing diabetic ulcers.
Avoid risk factors linked to peripheral neuropathy, the primary cause of diabetic ulcers: Consumption of alcohol, overweight, poor nutrition, exposure to chemical toxins, use of certain drugs and medicated pads (especially to treat corns, calluses, or warts on the feet), and physical injury to the nerves.
Inspect your feet daily, including the parts between the toes, for any breaks in the skin, blisters, or red irritations. Use a mirror to see the bottoms of your feet or ask someone else to do this.
Trim your toenails carefully and regularly. Cut around the contour of the toes and never into the corners.
Don’t go barefoot, as the pressure of movement is more significant on bare feet than feet in proper-fitting, cushioned footwear.
Test bath water with your fingers instead of stepping right in it. If your feet lack sensation, they may get burned if the water is too hot!
Active people are less likely to develop ulcers of any type. Men who walked or ran at least 10 miles a week were 62% less prone to the condition than their inactive peers. Exercise helps the body deal with the physical effects of mental stress and enhances immune system’s function. You might, however, want to consider decreasing the pressure on your feet with non-weight bearing exercise such as cycling or swimming.