f you suffer from diabetes, then you should know that amongst other things, you must take good care of your feet. Diabetic foot disease is a common complication associated with diabetes, and a large proportion of people who suffer from this problem experience a great amount of distress from the problem.
The reason why foot problems can occur is because diabetes can lead to changes in the skin of your feet.
While normal amount of damage, wear and tear will rarely cause any problems, those with diabetes often find that the slightest amount of trauma to their feet can lead to the formation of ulcers or infections. These can take a long time to heal.
If you are concerned about your diabetes and your feet, then this article should give you a good understanding of what you must be doing to prevent it from happening.
What Causes Diabetic Foot?
Let’s start from the very beginning. What exactly is diabetic foot and what causes it?
In simple terms, diabetes that affects the skin and soft tissues in the feet is called ‘diabetic foot’. There are number reasons why the feet may be involved in diabetes, and some of the common ones include –
1. Reduced blood supply to the skin and soft tissues due to disease in the small blood vessels due to diabetes. This reduced blood supply means that the cells that help rebuild tissue are unable to reach the affected site.
In addition to this, any antibiotics given will also not reach the affected area in sufficient concentrations to kill any bacteria that are present.
Ulcers that develop from reduced circulation of oxygen rich blood to the foot are called arterial ulcers.
2. Loss of sensation, also called diabetic neuropathy. Diabetic neuropathy can reduce your ability to experience pain, cold and heat, increasing the chances of injury from these.
For example, individuals may not realise they have stepped on a thorn or a sharp object as they don’t feel pain. You might be walking around with a sharp stone in your shoe all day without even knowing it.
Ulcers that develop from loss of sensation are called neurotropic ulcers.
3. Skin changes – The skin of your feet may become dry, making it prone to breaks and cracks. The dry skin is because the nerves that control oil secretion in the feet are not working at their full capacity, thus drying the skin out.
Any injury to the foot becomes a portal of entry for bacteria.
These bacteria ‘feed’ on the sugar in the blood, making them proliferate at a rapid rate. This worsens the infection quickly.
What Sort Of Problems Can I Encounter If Diabetes Affects My Feet?
COMMON FOOT PROBLEMS IN DIABETES
1. Cracks and breaks in the skin of the foot
2. Callus formation
3. Foot ulcers
4. Infections such as cellulitis and osteomyelitis
As a general rule, foot infections in individuals with diabetes tend to be more severe and take longer to heal as compared to those who do not have diabetes.
In addition to this, people with diabetic foot disease are often affected from a physical, emotional and social perspective. It can place a significant financial burden on those who require repeated courses of antibiotics and sometimes surgical treatments.
Outdoor activities may need to be restricted due to infection risks, impacting the patient’s quality of life tremendously.
Is Diabetic Foot Disease A Common Problem?
Diabetic foot infections are the most common type of skeletal or soft tissue complication of diabetes.
However, the lack of sufficient knowledge and poor education of patients regarding diabetes and foot care means that a large majority of cases are not reported.
In fact, the general lack of awareness regarding diabetes and how it can affect the feet is an important risk factor in the development of diabetic foot infections.
Clinical studies have shown that in India, only 44% of patients with diabetes actually self inspect their foot on a regular basis! Education plays an important role in increasing this number.
Very rarely do people die from diabetic foot alone, though some patients with soft tissue necrosis from diabetes may succumb to it.
It is therefore of prime importance that you take care of your feet.
Stages Of Diabetic Foot
While a detailed description of the stages of diabetic foot is out of the scope of this article, we thought it appropriate to briefly describe how diabetes can affect the health of your feet.
Stage I – In this stage, there are no risks factors present and the foot is completely normal. You will not experience any symptoms in the stage.
Stage II – In this stage, you may have one or two risk factors present. In addition to high blood sugars, there may be evidence of reduced blood supply (ischaemia) and nerve damage (neuropathy).
You may experience symptoms such as pain in the calf muscles or in the legs when walking which is due to reduced blood circulation to the leg.
Stage II foot is considered a high risk foot. The risk increases if there is evidence of callus formation or ulcers have formed on the foot in the past.
Stage III – In this stage, you may have either a neuropathic ulcer or a neuro-ischaemic ulcer.
A neuropathic ulcer is one where either excessive heat or some form of trauma has resulted in a blood collection forming within the callus and tissues. This leads to tissue necrosis and death of the skin. Skin death is what leads to the formation of an ulcer.
In a neuro ischaemic ulcer, a reduction in the blood supply to a particular part of the foot is what causes and death of the tissues and ulcer formation. It is often seen and the tip of the post and just beneath the nails. It starts off as an area of redness that eventually forms a blister which then converts over a period of time into an ulcer.
Stage IV – This stage is one where the ulcer on the foot gets infected and spreads up the soft tissues within the foot and the leg. This type of infection is called cellulitis and requires urgent medical attention. The management of cellulitis involves the use of intravenous antibiotics and aggressive sugar control.
Stage V – In this stage, the skin and soft tissues have absolutely no blood supply and become gangrenous. The process begins with the development of an arterial ulcer. Necrosis of the foot ensues and this is complicated by the development of a serious infection. Emergency treatment is required.
Stage VI – This is the worst case scenario in a diabetic foot and the extensive necrosis and infection of the foot is life-threatening. Individuals with this level of diabetic foot involvement suffer a great deal of pain which cannot be managed with medical therapy alone. Often, amputation of the affected area is recommended.
What Are The Causes Of Diabetic Foot?
There are a number of different risk factors that increase your chances of developing foot problems if you suffer from diabetes.
Poorly fitting shoes is one of the most common risk factors. Tight shoes of footwear can rub against the tips of the toes and lead to damage of the skin and ulcer formation. Individuals who have a flat foot or bunions may require special footwear.
Diabetic neuropathy i.e. damage to the nerve fibers from diabetes is another recognised cause. The loss of sensation leads to an inability to recognise any trauma that the foot may suffer.
As a result, even minor scrapes or injuries can lead to serious infections. These infections can only get worse as the blood vessels that supply the affected area are also impacted by diabetes.
If you have diabetes and are a smoker, you are increasing your risk of developing a foot infection greatly. Smoking is a well-known risk factor in the development of peripheral arterial disease. In other words, it can damage the blood vessels that supply oxygen and nutrients to the skin and soft tissues in the foot.
Finally, infections of the foot such as fungal infections, bacterial infections and ingrown toenails can all lead to diabetic foot disease.
Symptoms of Diabetic Foot
You may or may not experience pain when you have a diabetic foot. Redness may indicate the presence of infection and may be associated with the formation of pus or the development of an ulcer. Swelling of the foot also accompanies inflammation and infection.
In addition to the infections, those who have reduced circulation to the foot may experience a phenomenon called ‘claudication’. Claudication is a condition that causes pain in the foot and calf muscles when walking that is relieved by rest. It is caused because the working muscles do not get the right amount of blood that they require when under stress.
Claudication pain is similar to the pain one experiences when they have a heart attack from reduced blood supply to the heart muscle.
The presence of diabetic neuropathy and reduced circulation can lead to changes in the skin on the feet. The loss of hair and the development of shiny, hard skin on the legs is a sign of diabetic foot disease.
If you do suffer from a diabetic foot, it is important that you keep an eye out for the presence of any new infections. If you develop a fever or notice the formation of pus or redness in a particular area of your foot or leg, get in touch with your doctor as soon as possible. You may have an infection that requires hospitalisation and antibiotic therapy.
Investigating Foot Disease In Diabetes
Evaluation of patients and diabetic foot disease is often done in a step-wise manner.
Firstly, a simple blood test can determine the blood sugar level (random) and an average blood glucose level (glycosylated haemoglobin).
Diagnosing an infection requires the presence of redness of the skin, pus and some degree of swelling and warmth. In other words, if you have a diabetic foot infection, you will find that the area is warm to the touch, appears red and ‘angry’ and may be painful. However, pain may not be present if diabetic neuropathy is present.
There are different ways to investigate foot disease in diabetes.
Firstly, an evaluation is conducted to determine whether the diseases affecting the health of an individual. In other words, is there a fever? Is there dehydration? Is the patient confused? All these may be signs of a serious infection.
Next, any possible deformities of the foot are noted. This means the bone structure and the integrity of the skin is analysed to see if there is any cause for this infection to develop.
Following this, an assessment is made of the blood circulation to the foot. This can be assessed by the doctor by feeling the pulses and assessing the venous circulation. Any swelling of the foot or reduced blood circulation can only make the infection worse.
Finally, a detailed assessment of the wound itself is conducted. The presence of healthy pink tissue (called granulation tissue) in the middle of the infection indicates that the wound is likely to heal.
However, if there is plenty of stick white pus (called slough) present, removal of these dead tissues may be required. A detailed analysis of whether the underlying bone is affected may be performed through clinical examination and x-ray imaging.
Keeping into account all the above, it is possible to determine how severe the infection is. For example, if there is involvement of the skin, deeper tissues and the bone, then the disease is a lot more serious when compared to someone whose skin is a little red with no underlying infection.
Once the severity of the infection has been determined, treatment strategies can be employed to ensure that the ulcer heals quickly and without complications.
Preventing Diabetic Foot Disease
There are a number of different steps that you can take to prevent foot disease in diabetes. In a nutshell, changing one’s lifestyle, controlling the blood pressure, controlling the blood cholesterol and sugar levels and stopping smoking are the most important steps.
Nail and skin care
Every individual who has diabetes must examine their feet on a daily basis.
In particular, it is important take a look in between the toes. This is because this area is very prone to fungal infections.
Also make sure you examine the under surface of your feet. If you are not able to bend your legs or bend down to view the feet then use a mirror. If your vision is impaired due to diabetes, then ask a friend or family member to take a look.
Make sure you wash and dry your feet at least once-a-day. Concentrate particularly on the spaces in between the toes. Warm water that does not exceed 37°C must be used. As diabetes can affect the sensitivity of your hand, you may be unable to gauge the temperature of the water. Instead, use your elbow or forearm to estimate the temperature of the water. This is a very important step to prevent heat burns of the hands and feet.
In the winter months, do not place an air heater or hot packs on any part of the skin, particularly if you have diabetic neuropathy. This can cause burns.
Wear comfortable shoes. When at home or when going outside, make sure you are always wearing footwear. These days specialist diabetic footwear are available that are comfortable and can prevent injury to the feet. Always make sure you wear socks when you wear your shoes.
Prior to wearing shoes, take a look at the inside of ensure that there are no sharp objects such as pins or stones in the shoes.
Diabetic neuropathy can affect the oil and sweat secretions in the feet. This can make the feet quite dry and prone to cracking. Make sure you apply a good quality moisturiser twice a day to keep the skin soft and supple.
Women who have diabetes should avoid manicures and pedicures as much as possible. If you do wish to undergo a pedicure, make sure the nails are cut straight across rather than in a rounded fashion.
Treat your feet with the utmost care. Make sure you undergo a comprehensive foot exam at least once a year. This includes an examination of the circulation of the feet along with neurological tests that determine how well the nerves in the feet are functioning.
Treatment of Diabetic Foot Disease
There are different ways that foot disease in diabetes can be treated, depending on the type of foot disease.
Venous ulcers are often accompanied by leg swelling i.e. edema.
Reducing leg swelling can be easily achieved by keeping the legs elevated when sitting. When sleeping at night, keep a pillow underneath you legs.
Wearing compression stockings is also very useful. Clinical studies have shown that wearing these stockings on a regular basis can not only help heal the ulcer, they can also prevent new ones from forming. This is because these stockings help improve the blood supply to the ulcers, promoting healing.
If there is a great deal of swelling, your doctor may prescribe you a diuretic medication. In addition, other drugs that improve blood circulation may be prescribed. Follow the advice your doctor gives you.
The loss of sensation of the feet increases the risk of development of ulcers from injury. The best way to prevent this is through strict blood sugar control.
If a neurotropic ulcer develops, then every step must be taken to prevent infections from developing. Sometimes, a treatment called ‘total contact casting’ is used. This involves wearing a foot cast at all times to prevent pressure and injury to the existing ulcer. This helps it heal a lot faster.
Surgical treatment of neurotropic ulcer is sometimes needed. This includes a treatment called ‘wound debridement’, where dead tissue is removed so that healthy tissue can grow.
If infections develop, then antibiotics may be needed.
These develop due to reduced flow of blood that is rich in oxygen and nutrients to the skin (Arterial blood). Surgical treatment is usually needed to manage this.
Untreated arterial ulcers can turn into gangrene and require amputation.
Diabetes can affect your foot. Make sure you take the right steps to prevent ulcers and infections by keeping your blood sugars controlled through diet, exercise and medication.
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