Medical Care for Adult Diabetes and Foot Ulcers
Maintaining Your Health on Mackinac
By Yvan Silva, M.D.

Diabetes mellitus is a widespread condition requiring stringent control of blood sugar to prevent an array of complications that can ensue. Careful control with diet and medication, combined with frequent testing of blood sugar, is the mainstay for all diabetics. One of the ominous complications is peripheral neuropathy of the lower extremities, gradual nerve damage leading to loss of sensation and to deformities of the feet.

Diabetic foot ulcers are wounds or sores that are likely to occur in diabetics and are linked to poor blood sugar control. Loss of neural sensation contributes to formation of ulcers. Ulcers that are left untreated and do not heal can become infected, and in extreme cases can lead to the need for amputation in lifethreatening infections. Degenerative changes in the feet and pressure phenomena on calluses and hammer toes can cause pressure on the soles, leading to ulcers.

The lifetime risk of developing foot ulcers in people living with diabetes is estimated to be about 15 percent. Vascular disease of the lower extremities, peripheral neuropathy, foot ulcers and infections, and lower extremity amputation are twice more common in diabetics than non-diabetics; limb amputation occurs 10 to 30 times more frequently in diabetics than in the general population. Eight of 10 lower extremity amputations in non-accident cases occur in diabetics and about 85 percent of those follow complicated, infected foot ulceration.

Injury to the feet can occur from repetitive minor trauma such as prolonged walking or major injuries from stepping on sharp objects, scrapes and cuts, burns or scalds in hot water; inappropriate cutting of toenails into the integument and wearing ill-fitting shoes can also lead to injuries that are not easily appreciated because of neuropathy. Poor blood flow to the extremities is another common situation in diabetes and this slows the usual processes of wound healing, thus increasing the risk of infection and amputation.

Prevention is an essential component in the management of diabetes, for all possible threats. Careful control of diabetes and proper foot care can often prevent foot ulcers. Blood sugar control prevents peripheral neuropathy and stops or slows it from worsening. Diabetic individuals should check their feet regularly, daily for cuts and sores, especially between the toes. When direct inspection is difficult, a mirror can be used. Any continuing abnormal area should be directed for examination by a physician. It is important to keep feet clean and dry, especially in the areas between the toes. Before placing the feet in water, it's important to check the temperature with the hand, since the feet may not recognize the degree of heat.

Serious problems can ensue with the improper care of the toenails. These should be cut to conform to the curve of the toe. Nail edges should be filed down when they're sharp. When there is evidence of loss of sensation in the feet, regular toenail care should be provided by a specialist in foot care (the specialty of podiatry), who will evaluate and manage this important function.

Footwear should be chosen with the utmost of care. There should be no pressure or friction on the feet and worn footwear should be replaced regularly. People with neuropathy should not walk barefoot. Socks, made from materials like cotton, that prevent accumulation of sweat are better than others.

Preventing foot complications should well begin with the assessment of risk in each individual. Previous ulceration, structural abnormalities of the feet, bunions, calluses, dry skin, fungal infections, and other problems should be evaluated, as well as inspection of footwear for signs of friction or pressure. There are specific tests for evaluating neuropathy, for sensation, vibration, and for plantar pressure and tests for evaluating vascular disease in the lower extremities. These set the baseline, when needed, for follow-up and prevention. Recent studies have shown that patient education is very important in that it improves knowledge and action and may help to reduce the incidence of ulcers, infections, and amputations.

Blood sugar control, in studies where this was optimized, showed an appreciable reduction

in the occurrence of neuropathy than when it was not. Several studies in smokers have shown moderately variable results, but cessation of smoking is always recommended. Regular foot examinations, custom footwear, surgical treatment of calluses and bunions, and care by foot specialists with a team approach to management, inclusive of vascular specialists, are making this widespread public health problem more manageable.

In conclusion, diabetes is associated with a markedly increased risk for foot ulceration and the possible sequels, which include limb loss. The risks have been shown to be reduced by appropriate patient education, screening evaluations, and testing and appropriate interventions, medical and surgical. It is important for patients and physicians to work closely to reduce the incidence of foot ulceration and the serious consequences that may ensue.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.