Digging in With Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) are the most common lower extremity complication of diabetic patients, and can lead to devastating consequences if not managed quickly and effectively.¹ It is estimated that DFUs will affect about 15% to 35% of people with diabetes during their lifetime and will contribute to about 20% of hospital admissions among patients with diabetes.² The International Diabetes Federation reports that 9.1 to 26.1 million people will develop a DFU annually.³ They have a 2.5-fold increased risk of death compared with patients with diabetes who do not have foot wounds.³ The 5-year survival rate following presentation of a DFU is 50% to 60%, and the presence of a DFU is an independent predictor of mortality at 10 years.⁴

Risk factors for the development of DFUs include poor blood glucose control, peripheral neuropathy, peripheral arterial disease, foot deformities, and stress and friction on foot surfaces from improperly fitted shoes.² Other risk factors include male sex, having diabetes for more than 10 years, history of prior foot ulceration or amputation, and limited mobility.²

The most common cause of a DFU is repetitive stress or trauma over an area of the foot with sensory, autonomic, and/or motor neuropathy.¹ Sensory neuropathy is the loss of the protective sensation of the foot, motor neuropathy is secondary to foot deformities, and autonomic neuropathy is a decrease in sweating with resulting dry skin.¹ All of these contribute to dry, cracked skin, callus formation, subcutaneous hemorrhages, and ultimately, ulcer development.¹

Infection is a common complication of DFUs, with an overall incidence of between 25-60%.⁵ Infection is less likely in wounds that resolve in less than 3 months at 32%, and go up to 56% for wounds present from 3 to 12 months.⁵ A DFU with the greatest risk of developing an infection includes ulcers that have been present greater than 3 months, deep ulcers, patients with peripheral neuropathy, patients with foot deformities, and patients with a history of previous foot ulcers.⁵ Patients who develop an infection have a 155-fold increased risk of amputation compared with those who do not.⁵ About 50% to 70% of all lower limb amputations are due to a DFU.² After amputation, mortality exceeds 70% at 5 years and is twice as high at 10 years for a patient who has had a foot ulcer versus a patient who has not had one.¹

Standard of care practices for the management of DFUs include the following: sharp debridement to remove necrotic and devitalized tissue and callus; dressings that provide exudate control and a moist wound environment; offloading and pressure redistribution to relieve plantar shear stress and pressure, including appropriate footwear; vascular assessment with ABI or duplex ultrasound; infection control using deep tissue culture after debridement for wounds with at least 2 signs or symptoms of infection (erythema, warmth, pain, induration, purulent drainage) and treatment with narrow-spectrum antibiotics for the shortest duration possible; and optimal blood glucose control.³ Patient education is another important aspect of managing a DFU, as they will need to take ownership of their own illness and work together with their healthcare team to prevent further complications. It is imperative to provide education regarding proper diet and blood sugar control, appropriate footwear, offloading, proper follow-up appointments with specialists as required, and self-inspection of their feet.

Despite our best efforts, recurrence is common. About 40% of patients with diabetes with a resolved DFU have a recurrence within 1 year, almost 60% recur within 3 years, and 65% within 5 years.¹ Offloading has been identified as the best independent intervention to prevent initial and recurrent DFUs⁴; therefore educating patients on proper offloading techniques is imperative. Return demonstrations to ensure they are offloading effectively, along with professional foot care on a regular basis and proper diet to maintain blood sugar control are all ways to help improve the quality of life and long-term survival rates for patients with diabetes and with DFUs.

References

1          Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367–2375. doi:10.1056/NEJMra1615439

2.         Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer. World J Diabetes. 2015;6(1):37–53. doi:10.4239/wjd.v6.i1.37

3.         Everett E, Mathioudakis N. Update on management of diabetic foot ulcers. Ann N Y Acad Sci. 2018;1411(1):153–165. doi:10.1111/nyas.13569

4.         Jeffcoate WJ, Vileikyte L, Boyko EJ, Armstrong DG, Boulton AJM. Current challenges and opportunities in the prevention and management of diabetic foot ulcers. Diabetes Care. 2018;41(4):645–652. doi:10.2337/dc17-1836

5.         Jia L, Parker CN, Parker TJ, et al; Diabetic Foot Working Group, Queensland Statewide Diabetes Clinical Network (Australia). Incidence and risk factors for developing infection in patients presenting with uninfected diabetic foot ulcers. PloS One. 2017;12(5):e0177916. doi:10.1371/journal.pone.0177916

Dana R. Windsor, MSN, FNP-C treats patients in Kansas and Missouri as an Advanced Wound Specialist with Wound Care Plus, LLC.  Her extensive 15-year-career supporting patients has been marked by her passion for educating patients and staff about wound prevention and treatment.  Empowering clients to heal themselves while equipping staff with knowledge and tools to keep clients healthy, aligns with Dana’s top goal of always providing healing and comfort to clients during their most vulnerable times.  As a wound specialist with Wound Care Plus, Dana employs innovative products and cutting-edge technology to treat clients with wound or skin issues, both in person or via Tele Wound Care. Danabrings advanced wound care and clinical excellence, supported by evidenced-based medicine, to clients and caregivers alike with a passion that truly shows.