August Letters to the Editor

   People Without Diabetes Also Need Foot Screening

   Dear Editor: My involvement in research studies concerned with healing and prevention of foot and leg ulcers prompted me to respond to the article entitled "Assessing Foot Care Knowledge in a Rural Population with Diabetes" (Ostomy/Wound Management, 2002;48[1]:50-56).

   Although the author successfully reiterated the importance of comprehensive foot care in people with diabetes, applicability of such issues to non-diabetic populations has not been made clear. Many diabetic patients suffer from various degrees of peripheral neuropathy and are unquestionably at high risk for development of foot ulcers; screening of older non-diabetic patients for silent development of similar conditions also cannot be ignored and must become an active component of astute clinical practice.

   A retrospective review1 determined that 38% of older non-diabetic patients beyond age 60 exhibit one or more major risk factors favorable for the development of foot ulcers or amputation. Astute clinical examination combined with brief, concise utilization of Semmes-Weinstein monofilaments (SWF) has been identified as the most sensitive indicator for determination of foot ulcer/amputation risk.2

   Professional literature2-4 strongly supports the use of SWF. Although inability to feel tactile stimulation produced by a 5.07 SWF is generally considered a powerful indicator for incipient peripheral neuropathy, progressive changes of SWF force have been identified over time.5 Evidence suggests an average SWF force reduction of 1.2 g after 500 use cycles produced by an Instron Dynamic Testing Instrument.5 Ledda et al6 developed a simple, easy-to-read self-care foot program especially designed for patients at risk for foot ulcer development. Their innovative action to provide each high-risk patient with a large hand-held mirror to foster ease of self-examination is seen as a proactive approach to preventive foot care and should be seriously considered by practitioners across the country. Keen assessment, prevention strategies, and patient education issues should be moved to the forefront. Practitioners are reminded to include non-diabetic older adults into screening modalities often reserved for high-risk diabetic patients. Changing the clinician's approach to the use of SWF should be considered and potential monofilament weakening should be anticipated. Once significant risk for development of foot ulcers has been established, providing appropriate educational material and a large hand-held examination mirror are resourceful ways to reduce the risk for development of foot ulcers and subsequent, often devastating, amputations.
- Ingeborg D. Schultz, BSN RN Graduate Student, Sinclair School of Nursing University of Missouri - Columbia Columbia, MO

Reply
    Ms. Schultz makes several valid points related to foot assessments in the elderly and other at-risk patients. People with diabetes suffer with lower extremity ulcers, but so do others with physiological maladies. Peripheral neuropathy certainly places patients with diabetes at high risk for foot ulcers, but other physiological conditions also can predispose people to foot ulcers. Any vascular condition that affects circulation in the lower extremities can create conditions favorable for wound development and impaired wound healing related to ischemia and tissue hypoxia.

   Ms. Schultz notes that Semmes-Weinstein monofilaments are useful in diagnosing neuropathy, as are other tests such as vibratory and thermal toe pressures. I am grateful to Ms. Schultz for pointing out other risk groups that need regular foot assessments and foot care instructions to prevent the consequences of living with chronic wounds.
- Janice A. Neil, RN, PhD

Healing Shingles With Moist Dressings

Dear Editor:
   We read with interest "Healing Shingles with Moist, Occlusive Dressings" (Ostomy/Wound Management, 2002;48[3]:24-27), and would like to confirm, as physician and patient, Dr. Lee's observations.

   On June 10, 2000, Dr. Bolton experienced a blister-like, itching lesion on his left breast. Three days later, his primary physician, Dr. Uthappa, diagnosed shingles and prescribed a course of famciclovir, 500 mg, twice daily, for 7 days. By this time, a series of lesions extended 10 cm x 18 cm from the left breast to the left scapula. The affected area was covered with numerous blisters with slight itching that worsened upon scratching. After covering the affected area with two 1-cm x 10-cm dressings (DuoDERM CGF® Extra Thin Dressings, ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ), the itching decreased and no further deterioration of the lesions was noted.

   Despite the patient's tendency to scratch the area unconsciously, the skin was not irritated through the dressing and none of the lesions became infected. Two weeks later, the dressings were removed and all the lesions were healed.
    - Russell Bolton, PhD (patient) and Machia Uthappa, MD

Reply
    I am glad that someone else has had the same type of experience as we have had with moist wound healing. We have found it useful for a variety of wound types and it appears to help shingles cases, as you have confirmed with your own personal experience. I recently used the dressing after a tennis-related scrape. I encourage Dr. Uthappa to use moist wound healing for other situations and to share those experiences in OWM.
    - S. Kwon Lee, MD, FACS

1. Plummer ES. Focused assessment in foot care in older adults. J Am Geriatr Soc. 1996;44:310-313.

2. Pham H, Armstrong DG, Harvey C, Karkless LB, Giurini JM, Veves A. Screening techniques to identify people at high risk for diabetic foot ulcerations. Diabetes Care. 2000;23:606-611.

3. Zangaro GA, Hull MM. Diabetic neuropathy: Pathophysiology and prevention of foot ulcers. Clinical Nurse Specialist. 1999;13:57-65.

4. Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med. 1998;158:289-292.

5. Yong R, Karas TJ, Smith KD, Petrov O. The durability of the Semmes-Weinstein 5.7 monofilament. J Foot Ankle Surg. 2000;39:61-63.

6. Ledda MA, Walker EA, Basch CE. Development and formative evaluation of a foot self-care program for African Americans with diabetes. The Diabetes Educator. 1997;23: 48-51