Q) My grandfather is a diabetic and has a sore on his foot. His doctor seems to think it’s a big deal that has to be treated aggressively. Is that really necessary for just a sore?
A) As of 2016, there were 11 million Canadians who were living with type 1 diabetes (an auto-immune disorder that may start at any time, even in childhood), type 2 diabetes (a form of diabetes where the body isn’t able to respond to insulin as well as it used to, usually due to obesity related to lifestyle choices) or pre-diabetes.
In Canada, every three minutes another person is diagnosed with diabetes and there are quite frankly millions of us walking around right now that are diabetic but are still undiagnosed. While there are lots of complications related to diabetes such as heart attacks, pain from degraded nerves, loss of sight among others.
Foot ulcers is one of the others that is often neglected but really shouldn’t be. Foot ulcers in the diabetic population can lead to a cascade of complications that can potentially negatively impact the rest of their lives. 15-25% of all diabetics will at some point experience a foot ulcer (another word for a sore). Some of these sores may go on to develop an ulcer and potentially require hospitalization to help deal with the infection.
Worse, people with diabetes are somewhere between 15 to 40 times more likely to require lower-leg amputation than the general population and the majority of these amputations (85%) were the end result of a foot ulcer. That bears repeating….. 85% of lower-leg amputation started out as a foot ulcer. A lower-leg amputation is brutal. Not only does it impact the individual’s ability to get back to the daily activities of their “old” lives, there is a huge risk of psychological complications as well. There are also medical consequences from these operations to such an extent that the five-year mortality rate post surgery is 50%. This is a higher death rate than is seen with breast cancer in females or prostate cancer in males.
So what exactly is a foot ulcer? It is simply an open sore or wound that tends to be found in the areas of the foot which encounters repetitive trauma and pressure sensations as we move around. As such, they’re most often found under the big toe or on the balls of the feet. Often, the first sign of a foot ulcer is a stain on your socks formed by drainage that has leaked from the wound. Initially the impacted area will appear red, possibly swollen, irritated and there may be an odour to it. Treatment at this point is much easier than if the wound is allowed to progress.
The most easily recognizable sign of a serious foot ulcer is black tissue (known as eschar) that forms. Gangrene (a term that refers to tissue death due to infection) may appear and can be recognized by its pungent odour, pain and numbness. Foot ulcers are not always easy to spot. For many of us, looking at the bottom of our feet is a task that our bodies are no longer near flexible enough for us to accomplish on our own. As well, while for most of us a reddened area feels sore and will pique our attention, many diabetics suffer from neuropathy which will cause them to feel no pain until the sore is a challenge to treat. While all diabetics are at risk of a foot infection, some will be in greater peril than others. These include:
· poorly fitted or poor quality shoes
· poor hygiene (not washing regularly or thoroughly or not drying the feet well after washing)
· improper trimming of toenails
· alcohol consumption
· eye disease from diabetes
· heart disease
· kidney disease
· tobacco use (inhibits blood circulation)
Diabetic foot ulcers are also most common in older men as they often accumulate multiple risk factors. The goal of treatment is to obtain healing as fast as is possible in order to lower the risk of the wound developing an infection (sores do not start out infected). There are several activities involved with this:
· keep blood sugar levels in control (A1C less than 7)
· keep the sore clean by washing it daily and bandaged (to prevent bacteria from getting in)
· do not walk barefoot
Off Loading- for better healing, taking pressure off of the bottom of the foot is essential. This is known as off-loading. Patients may be fitted with special footwear, a brace, a unique cast or asked to move around with the aid of crutches or even a wheelchair.
Applying Medication and Dressings – The science of wound care has changed a lot over the last several decades. We no longer leave it open to let air get at it and dry it out. We know that all wounds heal faster and with a lower risk of infection if they are kept covered and moist.
We almost never use old standards such as peroxide or full-strength betadine as they kill many of the new skin cells that are trying to form. Good quality “non-stick” gauze dressings are applied over top the wound once it has been gently washed with saline and a medication has been applied. These medications range from antibiotics such as a prescription cream, Fucidin, or other prescription type creams to advanced products such as growth factors. Doctors may debride the wound, which involves removing dead skin or foreign objects from the wound.
There are now also specialized medicated bandages (such as ones that contain calcium alginates that inhibit bacterial growth) that wound-care specialists working for Public Health can suggest. Foot baths and enzyme treatments can also play a role in healing. A new study conducted in Sweden has shown that a gel made out of a cheap and safe beta-blocker (beta-blockers are drugs that have been used for decades to lower blood pressure, slow and control a heart rate..) helped achieve wound resolution at 12 weeks in 60% of patients who used it as opposed to 40% who applied a placebo. This is an amazing finding and provides hope that the next step we will talk about will not be necessary.
Surgery- the majority of non-infected foot ulcers do not require surgery however this is an option that can be exercised to help prevent the necessity of an amputation. Examples of surgical care can include the shaving or excision of bone(s) and the correction of various deformities such as hammertoes, bunions or other bony bumps.
It’s nice to have treatment options, but the key to diabetic foot ulcers is prevention, as it is with most medical conditions. Inspect your feet daily, wear seamless diabetic socks, keep your nails trimmed and seek care for any “reddened” area on the foot as soon as possible are the basic tenets of good foot care. For more information about this or any other health related questions, contact your pharmacist.