Diabetic Foot Ulcers: Keys to Prevention From the American Diabetes Association

Foot ulcers develop in about 15% of patients who have diabetes mellitus.¹ A major cause of morbidity and mortality, foot ulcers and resultant amputations impose a heavy emotional and physical burden on patients.

Updated recommendations from the American Diabetes Association focus on identifying and managing risk factors before foot ulcers develop and amputation becomes necessary.² Highlights of the recommendations follow.

WHICH PATIENTS ARE AT GREATEST RISK?

Preventive foot care is crucial for patients with diabetes. Those at higher risk for ulcers or amputations include men and patients with a history of diabetes of more than 10 years; poor glucose control; or cardiovascular, retinal, or renal complications. Conditions that heighten the risk of amputation include:

• Peripheral neuropathy with loss of protective sensation.

• Altered biomechanics (in the presence of neuropathy); examples are evidence of increased pressure (such as erythema or hemorrhage under a callus) and bony deformity.

• Peripheral vascular disease (decreased or absent pedal pulses).

• History of foot ulcers or amputation.

• Severe nail pathology.

WHEN TO PERFORM FOOT EXAMINATIONS

Examine the feet of all patients with diabetes each year. Assess protective sensation, foot structure and biomechanics, vascular status, and skin integrity (Table). Patients with one or more existing high-risk conditions need more frequent evaluations, and those with neuropathy (Figure) require a visual inspection at every visit.

PREVENTING AND MANAGING HIGH-RISK CONDITIONS

A significant predictor of foot ulcers and subsequent amputation is distal symmetric polyneuropathy. Maintaining near-normal glycemic levels can delay the onset of neuropathy. In addition, smoking cessation can reduce the risk of vascular disease.

Patients with neuropathy or signs of increased plantar pressure need fitted walking or athletic shoes that cushion and redistribute pressure. Caution patients with neuropathy to break in new footwear gradually to avoid blisters and ulcers. Extra-wide or extra-deep shoes may be necessary for patients with moderate bony deformities, such as hammertoes, prominent metatarsal heads, or bunions. Commercially available footwear may not be appropriate for more extreme deformities, such as Charcot foot; these patients require custom-molded shoes.

Further vascular assessment is recommended for patients with symptoms of claudication. Consider exercise therapy and surgical options for these patients.

Determine the underlying pathology of any previous foot ulcers and provide appropriate management. Treat such minor skin conditions as dryness and tinea pedis to prevent the development of more serious complications. Refer patients with callus to a foot-care specialist for debridement.

PATIENT EDUCATION

Assess the patient's current knowledge, risk factors, and foot-care practices. For patients at high risk for foot problems, emphasize the importance of daily foot monitoring, proper foot care (including nails and skin), appropriate footgear, and the ramifications of the loss of protective sensation. For those at low risk, instruction on appropriate foot care and footwear is usually sufficient.

Also, evaluate the patient's ability-both mental and physical-to independently conduct proper foot care. Patients with physical, visual, or cognitive problems will require assistance from a family member or caregiver to maintain a foot-care regimen.

References:

REFERENCES:1. Sanders LJ. Diabetes mellitus. Prevention of amputation. J Am Podiatr Med Assoc. 1994;84:322-328.
2. Mayfield JA, Reiber GE, Sanders LJ, et al. Preventive foot care in people with diabetes. Diabetes Care. 2003;26(suppl 1):S78-S79.