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Diabetic foot ulcer and its treatment

By Dr Dipti Sarma
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Diabetes mellitus is a hyperglycaemic state occurring either due to decreased secretion of insulin or defective insulin activity or both. Presently, 382 million of the total world population is afflicted by diabetes. In India, approximately 61.2 million people are diabetic and this number is predicted to increase to 101.2 million people by 2030.

This deregulated metabolism in the body is linked to changes in multiple organ systems and results in a huge burden on the healthcare system. Along with multi-faceted complications of the body, diabetic foot ulcers occur as one of the serious defects in the peripheral vascular system. This causes inappropriate circulation and leads the feet being at high risk. The lifetime risk in a person with diabetes for occurrence of a foot ulcer could be as high as 25%. Peripheral vascular disease (PAD) is a condition characterised by atherosclerotic plaques producing stenosis and occlusion of the arteries in the lower extremity. Presentation of PAD in smokers is well-known. In diabetics, the pain sensation is blunted due to damage to nerves (known as neuropathy). Thus, a mild foot trauma may lead to severe non-healed ulcers and the patient may go on to develop physical immobility. The presence of lower limb ischemia is detected by symptoms and physical signs as well as abnormal changes seen in non-invasive vascular techniques. The common symptoms are cramps in the calf or foot during walking, pain in the arch of the foot or forefoot at rest or during the night with impaired peripheral arterial pulses, and loss of hair on the lower leg or foot with shiny skin, as well as colour changes in the foot in different positions.

In India, peripheral vascular disease (PVD) is underdiagnosed and undertreated. There are four actions recommended. These are: (i) To increase the awareness of PAD, and to improve the identification of the patient with PAD; (ii) Initiate a screening protocol for patients at high risk of PAD; (iii) Improve treatment rates among patients with symptomatic PAD; (iv) Increase the rates of early detection among asymptomatic populations.

ABI is a non-invasive, simple, inexpensive and bedside measurement to diagnose PAD. ABI stands for ankle brachial index which is the estimation of the ratio between the blood pressures of leg and arm. This clinical test can be done in a OPD setting with a BP machine by a doctor, nurse or a health educator. Transcutaneous oxygen pressure measurement (TCPO2) and toe pressure measurement follows as a second tier diagnostic tool in the detection of PAD. Heel is a part of the foot were the maximum body weight is transmitted. In a diabetic patient, the heel is more vulnerable to develop a ulcer as pressure pains are not perceived due to decreased blood flow or degeneration of nerve due to long-standing diabetes. Clinical presentation can range from skin fissures to infection of soft tissues of the foot. Heel ulcers often require surgery; however, non-extensive heel ulcers can be treated medically. Toe gangrene (blackish discoloration of skin) is the next common presentation. Toe gangrene can result in cholesterol deposit with clot formation, occlusion of small blood vessels supplying the toes secondary to infection or cholesterol deposits in the vessels and occludes the small vessels of the toe. This is an urgent condition which needs medical attention. Women are at 10.3 times more risk to develop ulceration than men.

Diabetes mellitus, high blood pressure and increase in bad cholesterol are often seen together and this association increases the risk of heart and kidney diseases. Adequate management of hypertension and serum lipid levels improves the outcome like brain stroke and heart attack (MI) in the elderly with PAD. In diabetic patients, use of lipid lowering agents and proper diet can improve good (HDL) cholesterol and lower bad cholesterol (LDL) which are risk factors for PAD.

Medical therapy: Exercise rehabilitation is currently viewed as the cornerstone therapy. A supervised exercise walking programme of at least three months of intermittent treadmill walking 3 times per week is recommended for a patient without foot ulcer and neuropathy. The second medical therapy uses anti-platelet drug, Pentoxifylline (improves blood flow), thrombolytic therapy (used to dissolve clot) or balloon angioplasty (for opening occluded vessels).

Surgery is advised in the form of bypass or removal of the occlusion by vascular surgeons. The indications for surgical therapy include severe symptoms in limb (pain, ulcer and gangrene) or intermittent claudication which have failed to respond to non-surgical therapies. A surgical bypass reroutes blood flow around a blocked blood vessel by creating a new pathway for blood flow using a graft.

Therapeutic footwear: Footwear with low foot pressure and height of shoe heel less than 1.9 cm is advocated for patients with high risk of PAD. Those patients who develop diabetic foot ulcers need to relieve pressure over the ulcer areas by using walkers, crutches and casts in the immediate period of active foot ulcer. Endocrinologist, podiatrician and vascular surgeon will take care of such patients. Therefore, active participation of NGOs is needed in order to increase the awareness of diabetic foot disease among the common people and thereby decreasing the mortality related to it and the economic burden on the affected family.

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Diabetic foot ulcer and its treatment

Diabetes mellitus is a hyperglycaemic state occurring either due to decreased secretion of insulin or defective insulin activity or both. Presently, 382 million of the total world population is afflicted by diabetes. In India, approximately 61.2 million people are diabetic and this number is predicted to increase to 101.2 million people by 2030.

This deregulated metabolism in the body is linked to changes in multiple organ systems and results in a huge burden on the healthcare system. Along with multi-faceted complications of the body, diabetic foot ulcers occur as one of the serious defects in the peripheral vascular system. This causes inappropriate circulation and leads the feet being at high risk. The lifetime risk in a person with diabetes for occurrence of a foot ulcer could be as high as 25%. Peripheral vascular disease (PAD) is a condition characterised by atherosclerotic plaques producing stenosis and occlusion of the arteries in the lower extremity. Presentation of PAD in smokers is well-known. In diabetics, the pain sensation is blunted due to damage to nerves (known as neuropathy). Thus, a mild foot trauma may lead to severe non-healed ulcers and the patient may go on to develop physical immobility. The presence of lower limb ischemia is detected by symptoms and physical signs as well as abnormal changes seen in non-invasive vascular techniques. The common symptoms are cramps in the calf or foot during walking, pain in the arch of the foot or forefoot at rest or during the night with impaired peripheral arterial pulses, and loss of hair on the lower leg or foot with shiny skin, as well as colour changes in the foot in different positions.

In India, peripheral vascular disease (PVD) is underdiagnosed and undertreated. There are four actions recommended. These are: (i) To increase the awareness of PAD, and to improve the identification of the patient with PAD; (ii) Initiate a screening protocol for patients at high risk of PAD; (iii) Improve treatment rates among patients with symptomatic PAD; (iv) Increase the rates of early detection among asymptomatic populations.

ABI is a non-invasive, simple, inexpensive and bedside measurement to diagnose PAD. ABI stands for ankle brachial index which is the estimation of the ratio between the blood pressures of leg and arm. This clinical test can be done in a OPD setting with a BP machine by a doctor, nurse or a health educator. Transcutaneous oxygen pressure measurement (TCPO2) and toe pressure measurement follows as a second tier diagnostic tool in the detection of PAD. Heel is a part of the foot were the maximum body weight is transmitted. In a diabetic patient, the heel is more vulnerable to develop a ulcer as pressure pains are not perceived due to decreased blood flow or degeneration of nerve due to long-standing diabetes. Clinical presentation can range from skin fissures to infection of soft tissues of the foot. Heel ulcers often require surgery; however, non-extensive heel ulcers can be treated medically. Toe gangrene (blackish discoloration of skin) is the next common presentation. Toe gangrene can result in cholesterol deposit with clot formation, occlusion of small blood vessels supplying the toes secondary to infection or cholesterol deposits in the vessels and occludes the small vessels of the toe. This is an urgent condition which needs medical attention. Women are at 10.3 times more risk to develop ulceration than men.

Diabetes mellitus, high blood pressure and increase in bad cholesterol are often seen together and this association increases the risk of heart and kidney diseases. Adequate management of hypertension and serum lipid levels improves the outcome like brain stroke and heart attack (MI) in the elderly with PAD. In diabetic patients, use of lipid lowering agents and proper diet can improve good (HDL) cholesterol and lower bad cholesterol (LDL) which are risk factors for PAD.

Medical therapy: Exercise rehabilitation is currently viewed as the cornerstone therapy. A supervised exercise walking programme of at least three months of intermittent treadmill walking 3 times per week is recommended for a patient without foot ulcer and neuropathy. The second medical therapy uses anti-platelet drug, Pentoxifylline (improves blood flow), thrombolytic therapy (used to dissolve clot) or balloon angioplasty (for opening occluded vessels).

Surgery is advised in the form of bypass or removal of the occlusion by vascular surgeons. The indications for surgical therapy include severe symptoms in limb (pain, ulcer and gangrene) or intermittent claudication which have failed to respond to non-surgical therapies. A surgical bypass reroutes blood flow around a blocked blood vessel by creating a new pathway for blood flow using a graft.

Therapeutic footwear: Footwear with low foot pressure and height of shoe heel less than 1.9 cm is advocated for patients with high risk of PAD. Those patients who develop diabetic foot ulcers need to relieve pressure over the ulcer areas by using walkers, crutches and casts in the immediate period of active foot ulcer. Endocrinologist, podiatrician and vascular surgeon will take care of such patients. Therefore, active participation of NGOs is needed in order to increase the awareness of diabetic foot disease among the common people and thereby decreasing the mortality related to it and the economic burden on the affected family.

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