According to one estimate, the diabetic population in the Indian subcontinent is the highest in the world. Sedentary lifestyle, lack of exercise, avoidance of regular daily morning walk, and no control over diet are some of the reasons. In diabetic patients, the leg becomes the commonest casualty of the disease.
Quite often a diabetic patient takes no notice of small scratches, small blisters or injuries to the leg. However, the small scratch turns into an ulcer if not treated properly in time. Normally, in a non-diabetic person leg ulcers heal well after repeated dressings and antibiotics applications. But in diabetic patients these foot ulcers generally do not respond to such treatment. Because of ignorance of this fact, a diabetic patient does not take his leg ulcer seriously and this results in a serious and complicated condition. Lack of timely care causes later loss of money, time, and even the leg. Therefore, always remember that a diabetic patient must take a leg or foot ulcer very seriously and instead of consulting a general or an orthopaedic surgeon should consult a vascular or a cardiovascular surgeon.
A diabetic patient must understand that inadequate blood supply to lower limb and loss of sensitivity of leg skin are the two most important factors which cause complications in leg ulcer. In diabetic patients due to diabetic neuropathy, the sensitivity of leg and foot skin is considerably decreased. Because of reduced skin sensitivity, a diabetic patient never feels the sensation of pain, which a normal non-diabetic person otherwise feels in case of pressure abrasion and a superficial simple injury. If a diabetic patient does not pay attention at this stage, the small abrasion later turns into a big ulcer. Diabetic neuropathy also causes weakness and partial paralysis of muscles of the foot resulting in constriction of the muscles. Bones of the foot become more prominent and bulgy, and therefore are subjected to undue pressure and the end result is that a superficial ulcer in the foot becomes deep. One more reason for development of pus and gangrene in foot ulcer of a diabetic person is inadequate blood supply to the foot due to narrowing of arteries of lower limb, which carry pure blood to feet. In such a situation where blood supply to the foot as well as sensitivity of the skin of the foot are reduced, any kind of infection, even a minor one, caught by the foot ulcer spreads very fast and reaches to a dangerous proportion.
If a diabetic patient develops a small superficial foot ulcer, he must consult a vascular or a cardiovascular surgeon and receive treatment under his supervision. Generally, these ulcers most of the time do not respond to simple antibiotics and dressing. For the treatment of such ulcers in a diabetic patient, the proper assessment of blood supply to the foot is of utmost importance. The cause of inadequate blood supply to the foot is generally narrowing of the lower limb arteries (blood pipes) due to deposition of fat, calcium and cholesterol in the inner wall of the artery. Due to deposition of these undesirable elements in the arterial wall, the arteries get narrowed. That is why the investigation of lower limb arteries is a must for the successful treatment of foot ulcers. For this, special investigations like Doppler Study, Multislide CT Angio, MR Angio, and Digital Subtraction Angiography are required. These specialised investigations determine the treatment strategy to be undertaken later to restore the blood supply to the feet. On the basis of Angiography results, modern treatments like Arterial Bypass Surgery, Angioplasty Stenting, Subintimal Angioplasty are undertaken to augment the blood flow to the lower limbs. To decide the treatment strategy for an individual patient, consideration of status of diseased arteries has to be taken into account. Therefore, one should always go to a hospital where 24-hrs availability of a full-time vascular surgeon is there and facility for Angiography, Bypass Surgery, and Angioplasty is available.
Quite often it has been seen in our country that a diabetic patient who is suffering from foot ulcers generally goes to a small clinic or hospital and gets his ulcer cleaned and dressed daily. Due to inadequate blood supply to the foot, this method of daily cleaning and dressing neither heal the small ulcer nor prevents it from developing into a large deep ulcer, and ultimately this leads to infection and gangrene. At this juncture we are left with no other choice except amputation of foot. Our family physicians and general physicians do not seem to be very serious about the management of foot ulcer in their diabetic patients. They try to get the ulcer healed with simple antibiotics and dressings. During the treatment of diabetic foot ulcer, proper care of the ulcer and prevention from infection are the most important components. In no condition, pus should be allowed to stay back. One should avoid solution like Betadine or Hydrogen Peroxide for dressing purposes. Special kinds of medicines for blood thinning are used to keep the blood diluted. In some patients, latest medicines like Collagen or P.D.G.F. dressing are required. Sometimes, special medicines like prostaglandins are administered intravenously, which help in the healing of ulcers indirectly. In special circumstances, use of ‘Skin Grafting and Myocutaneous Flaps’ facilitates the ulcer healing.
How to prevent foot ulcers in diabetic patients
1. Must get your legs and foot checked up by a vascular or a cardiovascular surgeon for evaluation of leg arteries and blood supply, even if you have no complaints. If at any moment, blood circulation to your feet starts decreasing, the doctor can formulate preventive as well as corrective strategies in time before it is too late.
2. Must keep your blood sugar under control either by insulin injection or oral anti-diabetic drugs under strict guidance of a diabetologist or your own local physician. Keep in constant touch with your physician and seek his regular advice about your diet, your food preferences and exercise.
3. Must never walk barefoot, even inside your house. Never expose your feet and toes to outside injuries and to extreme cold during winters. Keep your feet warm and covered with socks. Do not apply heat. Use of silicon insoles inside the shoes is very helpful in preventing development of ulcer.
4. Must keep your feet dry and clean. Never allow moisture or water to stay inside the space between the toes. Avoid wet and sweaty socks. Change your socks twice a day especially during monsoon and summer seasons.
5. Must clean your feet, toes and toe-spaces twice daily with methylated spirit and then sprinkle Neosporin powder on the toes and inside the space between the toes.
6. Must inspect daily your feet. Look for any abrasion, blisters, any raw area and thickened skin. Consult your vascular/ cardiovascular surgeon and seek his advice. Never ignore and sit idle, in case of any injury to feet, or any development of ulcer or red patches over your feet.
7. Must avoid tight and uncomfortable shoes. Discard immediately the shoes which bite your feet. Shoes must be soft, very comfortable, well-cushioned and not exerting any pressure on your feet, especially bony prominences. Do not save money on shoes; go for a good brand. Use of special diabetic silicon insole inside the shoe is beneficial.
8. Must never smoke. Tobacco in any form (Pann Masaala with Zarda, Khaini, Chaini, Mainpuri Tambakhoo and tobacco-mixed toothpaste) is injurious to your diabetic feet.
9. Must keep your weight under check. Obesity is very harmful for your legs and feet. Avoid oily and cholesterol-rich food. High level of blood cholesterol will clog your arteries and significantly reduce blood flow to your feet and leg. Get your blood cholesterol checked-up every six months and seek advice in this regard from your surgeon.
10. Must do daily morning walk for 5-6 km. It will increase blood circulation in your legs and feet. In special case, like, in presence of ulcer, use of Pneumatic Walker is very helpful in keeping the regular blood flow to the feet as they are scientifically designed.
11. Must never shave off any corn (thickened skin) that develops on your feet. Do not cut your nails deep; it may lead to painless minor injury which is harmful especially in a diabetic person.
The writer is Senior Consultant at Department of Cardiothoracic & Vascular Surgery at Indraprastha Apollo Hospital, New Delhi. [email protected]