As we have already discussed an ulcer is an open sore or break in the skin caused by neuropathy, poor circulation, foot deformities, poor wound healing etc.

Typical sites for ulcer formation:

• Areas subjected to weight bearing- ball of the foot, bottom of big toe and heel. We take two to three times our own body weight on the heel when it strikes the ground.
• Sides of the foot- due to improperly fitted shoes.
• Back of the heel- from lying in bed.
• Tips of the longest toes- usually first or second.
• Top surface of toes- due to skin rubbing against shoes
• Mid-foot- if there is loss of foot arch due to foot deformities.
• Ankle bones- as they are more prone to trauma.

Although overall a diabetic has an increased risk of developing foot ulcers than a non-diabetic, there are some other factors that further increase this risk in diabetics. Therefore, it is crucial to identify these factors and follow the preventive measures accordingly to avoid developing a foot ulcer.

Major risk factors for developing an ulcer are as follows:

• Neuropathy – the risk of developing neuropathy increases with longer duration of diabetes, older age and poor glucose control.
• Peripheral arterial disease – the risk increases with longer duration of diabetes, older age, male gender, high cholesterol, high blood pressure, smoking and being overweight.
• Structural foot deformities – such as bunions, hammertoes, tiptop toe deformity, loss of arches.
• Calluses – It may overlie an underlying diabetic foot ulcer. The callus tremendously increases pressure on the ulcer area. Therefore, it is important for you to get it removed by your healthcare provider and wear an appropriate orthotic device to decrease its formation.
• Ingrown nails/improperly cut toenails
• Previous foot ulceration/amputation
• Kidney or Eye disease in diabetics
• Poor glucose control
• Poorly fitted shoes
• Smoking

Your doctor will perform a comprehensive foot exam (mentioned in previous article) and place you in a risk category. This is called Diabetic Foot Risk Assessment. It is important for you to ask your doctor about your risk category and devise a preventive and screening plan accordingly.

• If your feet are in a low risk category, the recommended frequency of comprehensive foot exam/follow up is once a year.
• For moderate risk, follow up should be every 3-6 months.
• For high risk, follow up should be every 1-3 months.
• For an active ulcer, follow up is individualized. Contact your healthcare provider.

By following the foot care routine, the do’s and don’ts of diabetic foot and daily foot self-exams is the cornerstone for preventing diabetic foot ulcerations. (See previous articles) We know that the two most common causes of diabetic foot ulcer are poorly fitted shoes and improperly cut toe nails. So the importance of preventive measures and foot care routine cannot be stressed enough.

Contact your health care provider IMMEDIATELY. Sometimes despite preventive measures and regular foot care routine, diabetics still develop foot ulcers. But the good news is that healing is possible. It is extremely important that you seek medical help and avoid treating your ulcer at home.

The goal of your healthcare team is to help your ulcer heal as quickly as possible to minimize further complications such as infection or amputation. Faster the healing process, the less chance of developing an infection. A multidisciplinary approach, usually by podiatrists, medical specialists, vascular surgeons, dietitians, physiotherapists and diabetes educator in the management of diabetic foot ulcers significantly increases the chance of successful healing and preventing recurrence.

There are several key factors in appropriate management of a diabetic foot ulcer. Let’s discuss them one by one.

I.  Debridement:

It’s a process by which dead skin, tissue and callus surrounding the ulcer is removed until a healthy bleeding edge is revealed. Adequate wound debridement is an essential step as it helps the ulcer heal faster by removal of dead tissue. It also enables your healthcare provider to see the full extent of the ulcer. After debridement the wound may look deeper and bigger and it should be pink/red in color. There are many ways to do it.

• Surgical Debridement:
  Most common is by using a scalpel and scissors to remove the dead tissue and then washing out the ulcer. Your health care provider may use local or general anesthesia for the procedure depending on the extent of debridement.
• Enzymatic Debridement:
  Using special chemicals/enzymes on the ulcer that dissolve the dead tissue. It is usually slow and is ineffective if thick layer of dead tissue is present.
• Whirlpool Debridement/Hydrotherapy:
  Done by putting your foot in a whirlpool bath. Not very effective.
• Mechanical Debridement:
  Wet-to-dry dressing is applied to the wound where it sticks to the dead tissue, pulling it away when removed. This can be painful and can remove healthy tissue at the same time as dead tissue.
• Maggot Debridement therapy:
  Maggots are placed in the wound where they secrete enzymes that digest the dead tissue. Not very commonly used.

II.  Probing:

After debridement, probing of the ulcer is done using a blunt instrument to determine the extent of underlying soft tissue and bone involvement. If bone is encountered while probing, osteomyelitis (infection of the bone) is likely. Your healthcare provider may also take X-rays of your foot to evaluate for bone involvement. Three-phase bone scans and Radiolabelled Leukocyte Scans (See previous article) are expensive but more accurate in establishing a diagnosis.

III.  Wound Dressing:

Wound coverage with an appropriate dressing is absolutely essential in management of diabetic ulcers. The old school of thought of letting air get at the wound is now obsolete as it causes more harm to healing. Now we know that if wounds are kept covered and moist, they’ll heal faster. No single dressing is ideal for all types of wounds. Your health care provider may use different kinds of dressing during the healing process of your ulcer.

Generally speaking, an ideal dressing should be able to do the following:

• Be sterile and non-allergenic
• Non-adherent to the wound
• Easily removed with some debridement action
• Maintain a moist environment surrounding the wound area
• Able to absorb excess discharge without leakage to the surface
• Provide mechanical protection
• Protect against bacterial invasion

Types of dressings:

• Saline soaked Wet-to-Dry Dressing
  This is most commonly used first. A wet dressing is applied to the wound area and as it dries it absorbs wound discharge. Later on when the dressing is removed, some of the tissue comes off with it promoting healing.
• Hydrocolloid Dressings
  They are a good choice for dry wounds as they maintain a moist environment.
• Dressing that contain Calcium Alginates
  Calcium Alginates is an absorbent material. It is used for wounds that produce large amount of discharge.
• Growth Factors
  Growth Factors are substances that promote wound healing. Specifically used for healthy wounds that have a reasonable healing potential.
• Synthetic Skin Substitutes
  Useful in managing chronic diabetic foot ulcers. Not useful for ulcers that are infected.

IV.  Off-Loading

Keeping pressure off the wound area in called off-loading. Foot ulcers need rest in order to heal, especially those on the bottom of the foot. Walking on an ulcer can force it to become larger and increase chances of infection. Off-loading device decreases pressure and reduces irritation to the wound area, speeding up the healing process.

Off-Loading can be done with:

• Total contact cast
• Walking brace
• Special footwear
• Crutches
• Wheelchair

Your healthcare provider will work with you to select the device best suited to your lifestyle. It is important to wear these ALL THE TIME even if you are only taking a few steps. In the comfort of their homes, diabetics sometimes choose not to wear them for a few quick steps around the house. DON’T DO IT! Every unprotected step is a day of healing lost. This is why appropriate off-loading must be done in order for the ulcer to heal quickly.

V.  Infection management

Not all ulcers are infected. However, it’s important for you to recognize the signs of infection in a diabetic foot ulcer (See previous article). If you have signs of infection, your doctor will take cultures from your wound to see what type of infection you have and which antibiotics will work. Mild to moderate infections can be treated on outpatient basis. For severe infection, you’ll need to be hospitalized.

VI.  Analgesics/Pain meds:

Take your pain medication as advised to keep yourself comfortable

VII.  Vascular Reconstruction:

Poor circulation to the ulcerated area can cause delayed healing. Your healthcare provider will assess circulation in your feet using non-invasive tests, and may refer you to a vascular surgeon if the circulation is poor.

VIII. Hyperbaric Oxygen Therapy:

Rarely used in chronic non-healing diabetic foot ulcers.

IX. Negative Pressure Wound Therapy/Vacuum assisted closure therapy

A vacuum device is used to remove excess fluid from the wound. Excess fluid can cause delayed wound healing.

After the initial evaluation phase and debridement, diabetic foot ulcers are mostly managed in an outpatient setting. However, there are some problems where you may need to be hospitalized. These include:

• Ulcers that extend into deeper layers involving muscle and bone
• Infection spreading to the bone called osteomyelitis
• Infection spreading to the rest of the body
• Gangrene(death of the tissue) resulting in amputation
• Ulcers that need revascularization

You can help with self care by following these key elements for successful healing:

• Rest – Take plenty of it. Avoid exhaustion and hyper ventilation situations
• Elevation of affected foot to relieve pressure
• Good wound care- Keeping the dressing dry and clean, changing it regularly as advised by your doctor.
• Wear your off-loading device AT ALL TIMES- The ulcer will not heal if the pressure is not relieved. Wearing your off-loading device for every step will give you the best chance to heal your ulcer quickly.
• Eat a healthy and balanced diet as advised by your doctor
• Maintain your blood glucose in target range
• Keep your blood pressure and cholesterol under control
• Don’t smoke
• Recognize the signs and symptoms of wound infection

In conclusion, as a diabetic it is very important for you to learn as much as possible about routine diabetic foot care as it plays the biggest role in preventing foot ulcers.

Diabetes and Foot Care … read more:

• How diabetes effects my Feet?
• How to take care of my feet?
• Daily Foot Exam Checklist
• Prevention is better than cure! Do’s and Don’ts
• When to see your doctor?
• At the Doctor’s office 
• Diabetic Foot Infections 
• Diabetic Foot Ulcers
• Diabetic Foot Deformities  
• Exams and Tests for Diabetic Feet 
  
• What is Diabetic Neuropathy?
• Diabetic Shoes
  
• Diabetes and Alcohol Consumption  – Latest Release