DIABETIC FOOT CAN BE PREVENTABLE

 

One of the most important complication and scourge of diabetes is the involvement of lower limbs with Vasculopathy (Peripheral Vascular Disease), Peripheral Nerve Disease (Diabetic Neuropathy), Bone Disease and Infections especially in making diabetic foot ulcers (DFU) to foot amputations. Diabetic Foot care is an essential part of limb preservation as most foot problems are preventable through early identification and prompt treatment by skilled health professionals. Diabetic foot managers are combination of Physicians, Surgeons, Podiatrists and Ped-orthotists.

Among people living with Diabetes mellitus 20% are addressed for foot ulceration as a result of peripheral neuropathy (nerve damage), peripheral vascular disease (Blood vessel damage) or both with different presentations.

Knowledge of practice regarding different aspects of care regarding diabetic foot ulcer (DFU) reduces risk of diabetic foot complications and ultimately our Goal – Save Amputations.

Diabetic foot is a Public Health issue and global diabetic foot ulcer prevalence is 6.3% , pertinent to have knowledge about diabetes and foot ulcer prevention and should be promoted both in the community and health personal to reduce DFU complications.

The knowledge of Stratification of services which should be from no risk to high risk which means normal foot to ulcer to gangrene to amputations with modifiable factors and multidisciplinary services, foot ulcers are the most preventable ones.

Foot ulcers and amputations are the major causes morbidity, disability and emotional trauma with economy class. 20% diabetics will get foot problems. More than 50% of the patients undergoing amputations in India are diabetic which are preventable.

A trivial injury in the foot of an uncontrolled with long duration of diabetes may have

components of neuropathy, vasculopathy and Infection will lead to diabetic foot ulcer.

Common neuropathic signs & symptoms are Paresthesia, Hyperesthesia, Hypoesthesia, Radicular pains, burning sensations, sensation of pins and needles to “no” symptoms may lead to callus formation over pressure points. Ultimately changes the shape of the foot in form of Hammer toes, Pas caves, loss of planter arch and Charcot’s foot.

Symptoms of vasculopathy will produce intermittent claudication, cold feet, nocturnal pain, rest pain, pain relived with dependency, absent pulses, blanching on elevation, atrophy of subcutaneous fat, shiny appearance of skin, loss of hair on foot and toes, thickened nails and ultimately Gangrene.

Patients of long-standing duration of diabetes may present with any of the above sign and symptoms or no symptoms even with a trivial injury like shoe bite, hoer surgery, Rat/Insect Bites, Thermal Injury, Foreign Body Injury, Chemical Injury and vigorous massage may lead the patent to diabetic foot ulcer (DFU). Now to manage this diabetic foot ulcer (DFU), basic requirement is to control glycaemia, wound dressings, adequate therapeutic foot wear, debridement if necessary with antibiotic cover are the hall marks of management.

On the holistic approach we must consider systemic and local factors like Hypertension, CAD, Hyperlipidemia and Renal Insufficiency.

Long standing diabetes must be looked for diabetic neuropathy with motor sensory and autonomic changes. Peripheral arterial disease (vasculopathy) should be evaluated for Ischemia. Joint mobility any orthopedics problems, Charcot arthropathy, infection which may ultimately are the causes of ulceration.

Other risk factors like smoking, alcoholism and genetic predisposition also makes a difference

in outcomes.

Diabetic foot lesions are usually missed because of lack of awareness amongst diabetic

patients, because of sensory loss produces silent and painless ulcers.

Saving a diabetic foot needs regular foot inspection, prompt treatment of foot ulcers, Correction of vascular risk factors, good glycemic control, team work among medical personnel and patient education and patient involvement in the treatment.

Diabetic foot ulceration should be given parenteral antibiotics with compression stockings and bandages to reduce edema with aggressive glycemic control. Do not withhold antibiotics until the results of cultures are available. We should rely on our clinical judgment.

Antibiotic treatment is essential aspect of treating infected diabetic foot ulcers – ulcer must be regularly monitored. Depending on clinical response, frequent changes and long-term antibiotics may be required.

Dressing should be done by a trained person or treating doctor, strong solution like hydrogen peroxide, iodine, spirit should not be applied to the wound, sterile dressing material should be covered with six inches elastocrepe to prevent venous and lymphatic edema. The wound should not be must immersed in water. “Eusol Bath” which has no place in modern diabetic therapy, loose slough should be excised at the time of dressing with sterile scissors. Commonly used dressing material in diabetic foot lesion is dilute povidone iodine, hydrocolloid gel, dilute Savlon, Sterile Saline, Collagenase Ointment for loosening the adherent slough. Local antibiotic ointments are used in selected cases, metronidazole gel is useful in local anerobic infections, seven seas oil (fish oil) is used for dressings in diabetic foot lesions with poor blood supply. The oil acts as a local free radical scavenger enhancing local oxygen perfusion, use of talcum powder or any other in between the toes should be avoided. Moisturizers can be used fungal infection in between should be ruled out.

Reducing foot pressure in DFU is of utmost important with early diagnosis Charcot’s foot, treatment calluses, corrective foot wear with strictly non weight bearing walk. Wear shoes with good support, shoes with good arch support and cushioning to reduce pressure on feet avoid high heals or shoes with pointed toes as they cause unnecessary pressure on certain areas on your feet. Regular treatment of calluses, pressure source or even blisters. Keep your feet clean and dry. Wash your feet daily with mild soap and warm water, and dry them carefully, and specially between the toes. Moisturize your feet with a good moisturizer and avoid putting lotion between your toes. Get regular foot checkups with doctor or podiatrist regularly.

Specific foot wear should be individualize as needs of the patient. Patient participation in the management of diabetic foot lesions in very important. The routine foot care is vitally important to prevent the complications in diabetic foot lesions. The primary physician should instruct and encourage the patients to follow daily foot care. Do not walk barefoot. Walking barefoot increase the risk of injury. Remember that intact skin is the best protection. Do not do hot fermentation cold compresses or electric heater. This can cause burns or frostbite due to loss of protective sensation. Apply linolients like coconut oil, plain petroleum jelly to both the feet daily. Effective patient education can reduce the incidents of foot ulceration and amputation by over 50%. Certain foot deformities reduced, skin oxygenation and foot perfusion, poor vision, greater body mass and both sensory and autonomic neuropathy independently influence foot ulcer risk, thereby providing support for a multifactorial etiology for diabetic foot ulceration.

It is important to know that medication for hyper glycemia should be instituted as early as possible for control with level of fasting, post prandial sugars and glycosylated hemoglobin according to the WHO guidelines. Long-acting oral hypo glycemic agents plays a very important role which produces less glucose variability. Insulin should be initiated and optimize for better outcomes in moderate to severe infections and with other co-morbid conditions like coronary artery diseases (CAD), Hypertension and Chronic Kidney Disease.