Diabetic Foot - Prevention and Management

Foot ulcers are a significant complication of Diabetes Mellitus and often precede lower-extremity amputation. The most frequent underlying causes are neuropathy, trauma, deformity, high plantar pressures, and peripheral arterial disease. DFU is seen more commonly in males than in females. People who have a history of smoking, uncontrolled hyperglycemia due to poor dietary control, physical inactivity, neuropathy, vascular disease, and deformity of foot have a higher risk of developing Diabetic Foot Ulcer. Diabetics who walk barefoot or wear improper, uncomfortable and/or ill-fitting footwear are at a much higher risk of developing a foot ulcer. 

As a majority of the times, the Diabetic patient isn’t aware about an evolving wound on his/her foot, the need for screening, assessment and education of patient and family members is important during each visit to a medical health professional. A known Diabetic must get a foot examination done at least once a year. 
Both feet need to be examined, after removal of their shoes, socks, bandages and dressings. A complete assessment needs to be done. Look for and record patient history, altered gait, skin discolourations, calluses, deformities, sensory deprivation, reflex and motor deficiencies, inflammation, limb ischemia, arthropathy, ulcerations and gangrene. Regular plantar pressure assessments help in early determination of risk of Diabetic Foot.

Prevention & Treatment

Proper Diabetes management requires maintenance of blood glucose levels to near normal by dietary control, regular exercise like walking, regularly taking prescribed medication in the given dose and visiting ones physician at regular intervals. Good foot hygeine, nail care and wearing well fitting and comfortable footwear is prehaps the best way to prevent Diabetic Foot. Illfitting footwear should be replaced. 

Pressure relief is the first step for both, preventive and curative therapy. Therapeutic shoes with pressure-relieving insoles or just pressure relieving insoles for proper plantar pressure distribution are essential for ulcer prevention and have been associated with significant reductions in their development.
In some cases, crutches or a wheelchair might also be recommended to totally off-load pressure from the foot.
Deformities that may impact the formation of high plantar pressure zones can also be managed with supportive or corrective footwear reducing their negative impact. In some other cases, elected podiatric surgery may be recommended. In case of edema, frequent foot elevation and rest is also recommended.

Diabetic foot ulcers are usually painless, punched-out ulcers in areas of thick callus ± superadded infection, pus, oedema, erythema, crepitus, malodour. They must be dealt with utmost care and urgency. The primary goal in the treatment of diabetic foot ulcers is to obtain wound closure. A mainstay of ulcer therapy is debridement of all necrotic, callus, and fibrous tissue.
Wound dressings and wound drainage help in lowering the potential fluid load and associated infection issues. Local and systemic antibiotics would be necessary to limit spread of the infection. Rest, elevation of the affected foot, and relief of pressure are essential components of treatment.

Ischaemia needs to be dealt with, particularly as a part of foot saving approach to treatment of severe ulcers. Micro vascular surgeries for revascularization and drugs that improve circulation may be necessary. The last resort to the treatment of diabetic ulcer is amputation. This is preceded by a morbid presentation of the ulcer. Post amputation, the choice of custom made orthotic is central to the management of the condition. The risk of repeat amputation is high. 

The negative impact of neuropathies can be partially managed by a vigilant patient and healthcare professional. Management of the Diabetic Foot Uforlcer is a multidisciplinary approach involving a diabetologist/endocrinologist, primary physician, surgeon, nurses, physiotherapist, social worker, patients care-giver, family and patient themselves. Every person has their own role in the management of the diabetic foot ulcer.
 

 1. International Diabetes Federation. Clinical Practice Recommendations on Diabetic Foot: A guideline for healthcare professionals : International Diabetes Fedaration, 2017

2. International Diabetes Federation. Foot Screening Pocket Chart, 2017

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