Diabetes mellitus is a chronic, globally escalating concern, affecting individuals at progressively younger ages due to factors like poor diet and physical inactivity. Its early onset carries significant implications, leading to complications such as diabetic nephropathy, retinopathy, and diabetic foot ulcers.
These ulcers, affecting approximately 15% of diabetic patients, stem from underlying conditions including peripheral neuropathy, peripheral artery disease, low blood pressure, and excessive foot pressure, leading to skin and tissue breakdown, infections, slow-healing or non-healing ulcers, and the potential for toe, foot, or limb amputation. Timely, comprehensive care by specialists can prevent these ulcers from progressing to chronic stages requiring amputations.
Risk Factors for Diabetic Foot Ulcers:
- Poorly controlled blood sugar levels
- Age (especially among the elderly)
- Smoking
- Previous history of foot ulcers or amputations
- Elevated body mass index (BMI)
- Foot deformities, calluses, or thickened skin
- High blood pressure or cholesterol
- Complications stemming from peripheral artery disease.
Causes of Diabetic Foot Ulcers:
Peripheral neuropathy, resulting from prolonged high blood sugar levels, leading to sensory, motor, and autonomic nerve degeneration, resulting in numbness, loss of pain perception, and temperature sensitivity. This condition causes muscle atrophy in the feet, loss of balance, and foot deformities (Charcot's foot), disrupting proper weight distribution, and leading to persistent uneven pressure and slow-healing chronic ulcers.
Peripheral artery disease (PAD), secondary to high blood sugar levels damaging blood vessel walls, causing thickening and obstructing blood flow to body tissues, particularly the feet, impairing their ability to regenerate and heal ulcers.
Foot deformities, including flat feet that distribute pressure unevenly on the soles.
Foot injuries, with diabetic foot ulcers occurring due to peripheral neuropathy, resulting in an inability to sense pain when pierced by sharp objects.
Symptoms of Diabetic Foot Ulcers:
- Numbness, particularly in the fingers and toes
- Leg and nerve pain accompanied by a burning sensation
- Lack of awareness of cuts or sharp object penetrations
- Foot or ankle swelling
- Dry, cracked skin, particularly on the heels
- Foul-smelling ulcers.
- Blood tests to determine infection and inflammation levels
- Ankle-brachial index (ABI) to assess blood pressure ratios between the ankle and upper arm (brachial artery). Ratios below 0.9 suggest significant arterial narrowing, affecting blood supply to the legs and feet.
- Transcutaneous oxygen measurement (TCOM) to gauge tissue oxygen tension around the ulcer, assessing tissue hypoxia levels.
- Doppler ultrasound employing high-frequency sound waves to evaluate blood flow and identify blocked arteries and veins.
- X-rays to check foot bone alignment.
- CT angiogram for a detailed vascular anatomy to locate obstructive sites.
Treatment of Diabetic Foot Ulcers:
- Blood glucose management to prevent nerve damage, infection risk, and complications
- Ulcer care involving thorough debridement of dead tissue, disinfection, and application of topical antibacterials
- Antibiotics (oral or intravenous) to control infection
- Hyperbaric oxygen therapy (HBOT) employing 100% oxygen in a high-pressure chamber to elevate tissue oxygen levels and stimulate healing, reducing swelling, and promoting growth factor release and stem cell growth crucial for tissue repair and ulcer healing
- Custom orthotics and braces to reduce ulcer pressure, enhance walking comfort, and prevent injuries
- Balloon angioplasty as an interventional procedure to restore blood flow in PAD patients' legs or feet.
Prevention of Diabetic Foot Ulcers:
Preventive measures include lifestyle changes, glycaemic control, blood pressure management, smoking cessation, nail and skin care, and wearing appropriate footwear. Daily inspection of the feet is essential for individuals with diabetic neuropathy, especially in the web space between the toes.
Diabetic foot ulcers, a common yet severe complication, can be predominantly prevented with proper care and control. Early intervention by a multidisciplinary team of specialised healthcare professionals is paramount to averting chronic stages that may necessitate amputations.
Diabetes mellitus is a chronic disease causing growing global health concerns due to its increasing prevalence, affecting people at ever younger ages due to lifestyle factors like poor diet and lack of exercise. The early onset of diabetes has significant implications for long-term health. It can lead to several complications, such as diabetic nephropathy, retinopathy, and diabetic foot ulcers. These ulcers are a dire issue, impacting around 15% of diabetic patients. They result from underlying conditions like peripheral neuropathy, peripheral artery disease, low blood pressure, and excessive foot pressure, causing skin and tissue breakdown, infections, slow-healing or non-healing ulcers, and potential toe, foot, or limb amputation. Early, comprehensive care by specialists can prevent these ulcers from progressing to a chronic stage and requiring amputations.
Risk Factors for Diabetic Foot Ulcers
Several factors increase the risk of diabetic foot ulcers:
- Poorly controlled blood sugar levels
- Age (elderly individuals)
- Smoking
- Prior history of foot ulcers or amputations
- High body mass index (BMI)
- Foot deformities, calluses, or thick skin
- High blood pressure or high cholesterol
- Complications arising from peripheral artery disease.
Causes of Diabetic Foot Ulcers
These ulcers stem from:
- Peripheral neuropathy stems from long-standing high blood sugar, leading to degeneration of the sensory, motor, and autonomic nerves with symptoms of numbness, loss of pain, and hot and cold sensations. Peripheral neuropathy causes atrophy of small muscles in the feet, loss of balance, and foot deformity (Charcot’s foot) with disruption of proper weight distribution on the foot, resulting in persistent uneven pressure and chronic ulcers that are slow to heal.
- Peripheral artery disease (PAD) is secondary to high blood sugar levels damaging blood vessel walls, causing thickening and obstructing blood flow to the body’s tissue, especially the feet, impairing its ability to generate tissue to heal the ulcers.
- Foot deformities include flat feet that maldistribute pressure on the soles of the feet.
- Foot injury: diabetic foot ulcers due to peripheral neuropathy with an inability to appreciate pain when pierced by sharp objects.
Symptoms of Diabetic Foot Ulcers
- Numbness, particularly at the fingertips and toes
- Leg and nerve pain with a burning sensation
- Oblivious to being cut or pierced by sharp objects.
- Foot or ankle swelling
- Dry, cracked skin over the heels.
- Foul-smelling ulcers
Diagnostic investigations of a diabetic foot ulcer involve performing a thorough physical examination, reviewing the patient’s medical history and associated symptoms, and performing special tests to evaluate the severity of potential underlying causes.
- Blood tests are used to ascertain infection and the degree of inflammation.
- Ankle-brachial index (ABI) is a test to determine the ankle-to-upper arm (brachial artery) blood pressure ratio. A ratio of less than 0.9 suggests a significant narrowing of the arteries supplying blood to the legs and feet.
- TCOM (transcutaneous oxygen measurement) measures tissue oxygen tension around the ulcer to assess the degree of tissue hypoxia.
- Doppler ultrasound uses high-frequency sound waves to evaluate blood flow and locate blocked arteries and veins.
- X-rays to check the alignment of the foot bones.
- CT angiogram to delineate a detailed anatomy of the blood vessels to identify obstructive sites.
Treatment of Diabetic Foot Ulcers
Treatment aims to expedite healing and involves:
- Managing blood glucose: Keeping blood glucose levels within the target range is crucial to preventing and delaying nerve damage and reducing the risk of infections.
- Ulcer care and management: clean and disinfect the ulcer by intensive debridement of dead tissue, including applying topical antibacterials to aid healing and prevent re-infection.
- Antibiotics: Oral or intravenous antibiotics to control infection
- Hyperbaric oxygen therapy (HBOT): treat ulcers in a 100% oxygen, high atmospheric pressure chamber to increase tissue oxygen tension and promote healing. HBOT therapy reduces swelling and stimulates the release of growth factors and the growth of stem cells essential to tissue repair and ulcer healing.
- Custom orthotics and braces: Customised shoes and braces help to reduce pressure on the ulcer and ulcer occurrence, increase walking comfort, and decrease injury.
- Balloon angioplasty is an interventional procedure to restore blood flow to the legs or feet of PAD patients.
Prevention of Diabetic Foot Ulcers
Preventive measures include lifestyle changes, glycaemic control, blood pressure management, smoking cessation, nail and skin care, and wearing appropriate footwear. Daily inspection of the feet is essential for people with diabetic neuropathy, particularly in the web space between the toes.
Diabetic foot ulcers, a common and severe complication, can be largely prevented with proper care and control. Early intervention by a multidisciplinary team of specialised healthcare professionals is crucial to avoiding chronic stages that may necessitate amputations.
Author: Vacharaphan Asanumet, MD. Endocrinologist, MedPark Hospital Tel. +66 2023 3333.
Series Editor: Katalya Bruton, Healthcare Content Editor and Director, Dataconsult Ltd. Dataconsult’s Thailand Regional Forum at Sasin provides seminars and extensive documentation to update business on future trends in Thailand and the Mekong Region. Contact: info@dataconsult.co.th Tel: 662-233-5606/7
