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Monday, November 14, 2011

Causes of Diabetic Foot Complications and Its Management

Posted by Dr Prahallad Panda on 5:35 AM Comments

Diabetics very commonly experience foot problems in a variety of forms. Most of the expected complications can be averted by careful foot care. If complications do occur, proper care can ensure satisfactory outcome, if detected earlier. Self foot care is a good habit, so also essential.

A 54-year-old diabetic male with a long histor...Image via Wikipedia, Charcot Deformity and Plantar Ulcer

Diabetics especially if, in a uncontrolled state are prone for various types of foot complications;
Various causes are put forth for the complications;
  1. Poor circulation: prolonged high blood sugar can damage blood vessels, called macroangiopathy and microangiopathy that decreases blood flow to any organ including the foot. This poor circulation can impair nutrients reaching the skin and consequently weaken the skin; which contribute to the formation of ulcers and impaired wound healing. High levels of sugar in the bloodstream encourages bacterial and fungal infections to set in and complicate ulcers.
  2. Diabetic patients have poor immunity and their white blood cells (WBC) do not reach at the site of infection at right time and in right number; what is termed as impaired chemotaxis of WBCs.
  3. Nerve damage (neuropathy): Elevated blood glucose levels over time can damage the nerves of the foot, sensory ones first, decreasing a person's ability to feel pain and pressure. Without these sensations, accidental injuries to skin, soft tissue, bones and joints go unnoticed.
  4. Myopathy (Muscle Injury) along with neuropathy, over time can damage bones and joints dramatically to alter the shape of the foot, such as making foot flat (Collapsed arch) that creates fresh and unusual pressure points in foot; which are prone for injury and ulceration.
Foot examination;
People with type 1 diabetes for at least five years should have their feet examined at least once a year. People with type 2 diabetes should have their feet examined once per year.
During a foot exam, a healthcare provider should check for poor circulation, nerve damage through nerve conduction tests, skin changes, and bony deformities. An examination should include tests to reveal different motor reflexes mediated through nerve and muscle coordination and tests to analyze the ability to sense pressure, vibration, pin pricks, and changes in temperature.
Poor circulation —Some simple clues can point to circulatory problems. Poor pulses, cold feet, thin or blue skin, and lack of hair signal that the feet are not getting enough blood.
Nerve damage — Nerve damage may lead to unusual sensations in the feet and legs, including pain, burning, numbness, tingling, and fatigue. Patients should describe these symptoms if they occur, including the timing, if the feet, ankles, or calves are affected, and what measures relieve the symptoms.
Nerve damage may cause no symptoms as the foot and leg slowly lose sensation and become numb. This can be very dangerous because the person may be unaware that they have improperly fit shoes, a rock or other irritant in a shoe, or other problems that could cause damage.
Skin changes — Excessive skin dryness, scaling, and cracking may indicate that circulation to the skin is compromised. Other skin changes may include healed or new ulcers, calluses, and broken skin between the toes.
Deformities — The structure and appearance of the feet and foot joints can indicate diabetic complications. Nerve damage can lead to joint and other foot deformities. The toes may have a peculiar "claw toe" appearance, and the foot arch and other bones may appear collapsed. This destruction of the bones and joints is called Charcot arthropathy
Prevention of foot problems:
  • Controlling blood sugar level:
  • Quiting smoking — Smoking can worsen heart and vascular problems; and reduce circulation to the feet.
  • Foot care is important,
  1. Prevent injuries to foot--avoid walking barefoot, using a heating pad or hot water bottle on the feet; and stepping into the bathtub without testing the temperature.
  2. Use care when trimming the nails — toe nails need to be trimmed in a straight line outside the nail bed, not in a semicircular manner; which may encourage in-growing of the toe nails, a condition where corners of nail bury into the tissue below and may cause sepsis. File the nails to remove any sharp edges. Not to cut the cuticles nor open blisters; rather better to take help of a healthcare provider or podiatrist for seemingly minor problems.
  3. Washing and checking feet daily before going to bed —feet to be cleaned with lukewarm water and mild soap; dried with soft cloth and a kept soft by a moisturizing cream or lotion.
  4. Entire surface of both the feet is to be checked for skin breaks, blisters, swelling, or redness. Special care is to be taken to see the area between and underneath the toes where damages might be hidden; a mirror or a family member can be of great help in this regard.
  5. Choosing socks and shoes carefully — Cotton socks that fit loosely are better and should be changed every day. Select shoes that are snug but not tight, and break new shoes in slowly to prevent any blisters. Prefer for customized shoes if the feet are misshaped; which reduce the chances of developing foot ulcers in the future. Shoe inserts may also help cushion the step and decrease pressure on the soles of the feet.
The treatment of foot problems depends upon the presence and severity of foot ulcers.
  • Treatment of superficial ulcers (involving only the top layers of skin) usually needs cleaning; removal of dead skin and tissue (debridement) by a healthcare provider.
  • If the foot is infected, antibiotics will be required. The patient (or someone in his or her household) should clean the ulcer and apply a clean dressing twice daily. The patient should rest the foot having ulcer as much as possible. The foot should be kept elevated when sitting or lying down to reduce the swelling. The ulcer should be checked by a healthcare provider at least once a week to assess the progress.
  • Ulcers that extend into the deeper layers of the foot, involving muscle and bone, usually require hospitalization. More extensive laboratory testing and x-rays may be required to plan the treatment, Surgery may be necessary to remove infected bone or to place a cast on the foot to take pressure off the ulcer.
  • If part of the toes or foot become severely damaged, causing areas of dead tissue (gangrene), partial or complete amputation may be required. Amputation is reserved for patients who do not heal despite aggressive treatment, or whose health is threatened by the gangrene. Untreated gangrene can be life-threatening.
  • Some patients with severe foot ulcers and peripheral vascular disease (poor circulation) may require a procedure to restore blood flow to the foot.
New treatment options include;
  • Synthetic wound dressings,
  • Grafting of skin grown in a laboratory,
  • substances that stimulate healing and support the growth of infection-fighting cells,
  • electrical stimulation, and
  • exposure to elevated oxygen levels.
For people with diabetes, foot complications are an ever-present risk. However, it is possible to design a plan for keeping the feet as healthy as possible. While routine medical exams are important, everyday foot care plays the biggest role in preventing foot complications before they start.
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