Medicine For Diabetic Foot Ulcer

When You Need More Treatment

If your wound doesnât heal in about a month or becomes an infection that spreads to the bone, you may need other treatments. These can include surgery and hyperbolic oxygen therapy, which involves breathing pure oxygen in a special room in order to help your body heal.

If your ulcer develops gangrene and your tissue dies, your doctor may have to amputate that area of your body.

Guidelines For The Use Of Adjuvant Agents In The Treatment Of Diabetic Ulcers

Preamble: Many agents have been suggested to be used as adjuvants to dressings and off-loading therapy in the treatment of diabetic ulcers. These adjuvant agents can be divided into topical agents to be applied to the ulcer, devices aimed at accelerating ulcer healing, and systemic drugs to treat the patient. Several of these agents have enough evidence to allow guidelines regarding their use.

Growth Factors For Treating Diabetic Foot Ulcers

What are diabetic foot ulcers?

People who suffer from diabetes mellitus can develop wounds on their feet and ankles. These diabetic foot ulcers can take a long time to heal, and affect quality of life for people with diabetes. In some people, failure of these ulcers to heal can contribute to the need for some level of amputation on the foot. Any treatments that encourage diabetic foot ulcers to heal will be valuable.

What are growth factors?

Growth factors are substances that occur naturally in the body. They promote growth of new cells and healing of wounds. Treatment of diabetic foot ulcers with growth factors may improve the healing of ulcers.

The purpose of this review

This Cochrane review tried to identify the benefits and harms of treating diabetic foot ulcers with growth factors in addition to providing standard care .

Findings of this review

The review authors searched the medical literature up to 3 March 2015, and identified 28 relevant medical trials, with a total of 2365 participants. The trials were performed in ten different countries, generally in out-patient settings. All the trials had low numbers of participants, which makes potential overestimation of benefits and underestimation of harms more likely. Half of the trials were sponsored by the pharmaceutical industry that produces these growth factors.

Shortcomings of the trials included in this review

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Clinical Presentation And Initial Evaluation

As in all medical conditions the initial evaluation of a patient with a diabetic foot ulcer begins with a detailed history. Important components of the history include length of time the ulcer has been present etiology of the wound any self or professional treatment prior ulcer, infection, or amputation history personal medical history allergies medications surgical history family history tobacco use alcohol abuse recreational drug use and a detailed review of systems to elicit the presence of macrovascular or microvascular disease .

On physical examination one may appreciate the classic appearance of the diabetic plantar foot ulcer . This is most commonly a partial or full thickness wound underlying a bony prominence or area of deformity. When chronic low grade elevated plantar pressures are present the skin forms reactive hypertrophic tissue, indicated by hyperkeratotic callus, the tell-tale sign of the neuropathic ulcer. The wound should be examined for size, undermining , general appearance, and the probe to bone test should be performed.

Figure 1.

Classic appearance of the diabetic foot ulcer. Note the characteristic red, granular base and hyperkeratotic rim under an area of increased pressure as well as the contralateral foot with prior amputation of the 3rd, 4th, and 5th rays.

Figure 2.

DFU with ischemic appearance demonstrating a yellow, fibrotic base and lack of healthy red granulation tissue.

Figure 3.

Figure 4.

How Does Hbot Help Your Diabetic Wounds Heal

Oxygen can only make its way through the blood within red blood cells. Since the circulation problems associated with diabetes slow the movement of red blood cells, important tissues become deprived of oxygen.

Without enough oxygen, cells struggle to produce the energy they need to block bacteria, synthesize new collagen, or regenerate and repair after injury. This is why diabetic wound healing slows until it comes to a full stop. Inhaling the concentrated flow of oxygen provided through regular HBOT treatments makes it possible to overcome oxygen deficiencies and stimulate a more effective healing process.

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What Should I Watch For

Take a moment each day to look at your feet. Find a well-lit area, perhaps under a lamp or in the bathroom, and look closely at your entire foot especially the tips of your toes and the bottoms of your feet. If you aren’t able to see your feet, ask a family member or caretaker to check them for you.

If you notice a callous, blister, drainage on your sock, an area of redness or a patch of skin that remains warmer than the surrounding areas long after you’ve removed your shoes, contact your doctor. Your doctor may clean the wound, remove any dead tissue, apply a clean bandage, treat any infection and advise you to stay off of your foot as long as possible. Left untreated, foot ulcers are a leading cause of foot amputations in people with diabetes.

Tips To Prevent Ulcers

Thereâs a lot you can do to lower your chance of having ulcers in the first place:

Keep your blood sugar in check. Good blood sugar control is the single best way to prevent small cuts and sores from becoming ulcers. If you have trouble managing your blood sugar, tell your doctor. They can work with you to make changes to your medication and lifestyle that will keep your blood sugar from getting too high. Even if your blood sugar level is fairly steady, itâs still important to see your doctor regularly. Thatâs especially key if you have neuropathy, because you may not feel damage to your skin and tissue.

Check your skin every day, and pay special attention to your feet. Look for blisters, cuts, cracks, sores, redness, white spots or areas, thick , discoloration, or other changes. Donât rely on pain even feeling more warmth or cold than usual can be a sign that you have an open wound on your skin, and itâs possible that you may feel nothing at all.

Ulcers are most likely to form on the ball of your foot or the bottom of your big toe, so be sure to check your feet every night. If you notice a problem, or you arenât sure if somethingâs normal, call your doctor.

Donât smoke.Smoking damages your blood vessels, decreases blood flow, and slows healing. Those things raise your risk of ulcers and amputation.

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Moist Wound Healing Environment

The presence or absence of drainage helps to determine what type of adjunct dressing the diabetic foot ulcer may require. By converting a chronic diabetic foot ulcer to an acute wound and maintaining a moist wound bed, the inflammation, infection and exudate are controlled while increasing epithelial advancement . This prevents retardation of cellular proliferation and angiogenesis by eliminating the excessive levels of matrix metalloproteinases, growth factors and cytokines present in the chronic wound. Applying a hydrocolloid or hydrogel may help to introduce moisture. If excessive drainage is present an absorbent dressing should be used, such as a calcium alginate or another absorbent fiber. Other dressing components have been found to increase healing in small studies such as the use of topical and oral -glucan . In another study, comparison of various dressing options demonstrated no statistical difference in ulcer healing but did note that the basic wound contact dressing, was more cost-effective in healing diabetic foot ulcers than a fibrous hydrocolloid dressing .

What Are Arterial Ulcers

A condition called peripheral arterial disease can reduce blood flow to your extremities. When this happens, your foot tissue may start to die. The ulcers that form from reduced blood flow are called arterial ulcers.

The word arterial means relating to arteries. Arteries are blood vessels that transport blood from your heart to the rest of your body, including your feet and toes. Anyone can get an arterial ulcer, but people who smoke or have diabetes, high blood pressure or high cholesterol are at higher risk.

Unlike neurotrophic ulcers, arterial ulcers can form on many parts of your body, including:

• On the tips of your toes.
• Between your toes .
• The bony parts of your feet and toes that rub against bed sheets, socks or shoes.

Arterial ulcers are:

• An unusual walk that puts too much pressure on one part of your foot or toe.
• Friction when your foot or toe rubs against the toe box of your shoe.

Although they dont cause ulcers, foot and toe ulcers are often found alongside toe conditions such as hammertoe, mallet toe and claw toe.

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Who Can Get A Diabetic Foot Ulcer

Anyone who has diabetes can develop a foot ulcer. Native Americans, African Americans, Hispanics and older men are more likely to develop ulcers. People who use insulin are at a higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and heart disease. Being overweight and using alcohol and tobacco also play a role in the development of foot ulcers.

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Diagnosis And Clinical Presentation

Diagnosing infection. Because all skin wounds contain microorganisms, infection must be diagnosed clinically, that is, by the presence of systemic signs , purulent secretions , or 2 local classical signs or symptoms of inflammation . In chronic wounds, additional signs suggesting infection may include delayed healing, abnormal coloration, friability, or foul odor. Infection should be suspected at the first appearance of a foot problem and at evidence of a systemic infection or of a metabolic disorder. Peripheral neuropathy or ischemia can either mask or mimic inflammation. Occasionally, inflammatory signs may be caused by other noninfectious disorders on the other hand, some uninflamed ulcers may be associated with underlying osteomyelitis . Signs of systemic toxicity are surprisingly uncommon in diabetic foot infections , even those that are limb threatening. Proper evaluation of a diabetic foot infection requires a methodical approach . Whenever infection is considered, this diagnosis should be pursued aggressively these infections can worsen quickly, sometimes in a few hours.

Clinical characteristics that help define the severity of an infection.

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Wash Your Foot With Hot Water

Make sure that the water is at a bearable temperature, otherwise, youll risk scalding the skin, and thats one more thing to worry about. As bacteria are not capable of surviving in very warm temperatures, washing your foot in hot water will surely cleanse them. Not only that, but the heat can also loosen the veins in your foot, regulating blood circulation.

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Diabetic Foot Ulcer Management Strategies

Effective treatment of DFUs starts with physical examination. Patients suspected of having the condition should be examined for signs of clinical presentation. Patients with peripheral vascular disease should immediately receive compression therapy to reduce their risk of developing DFUs. If an ulcer is found, the treatment focus should be on achieving rapid and complete wound healing. The wound should be regularly debrided to keep it free of non-viable tissue, and clinicians should select dressings that reduce bacterial load and provide an optimal healing environment.3

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Symptoms Of Diabetic Ulcers

Look for signs of bleeding or infection on or around the persons feet. Blood or discharge, an infectious odor, or sections with yellow discoloration can reveal that an infection has taken hold. If any areas have turned black, that indicates gangrene, or tissue death. The same rules apply if the infection is present in a different location, such as the hands, legs, or anywhere on the skin.

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Preventive Care And Treatment

Preventive measures against the risk of amputation include regular foot examination, evaluation of amputation risk, regular callus debridement, patient education, professionally fitted therapeutic footwear to reduce plantar pressure and accommodate foot deformities, and early detection and treatment of diabetic foot ulcers . Many studies that have assessed interventions to prevent and treat diabetic foot ulcers have had limited quality of supportive evidence because of problems in study design and methods . However, the treatment of foot ulcers typically is most effective with an interprofessional approach and includes measures to improve glycemic control, decrease mechanical pressure with off-loading, treat infection, ensure adequate lower-extremity arterial inflow and provide local wound care .

Treatment of the acute Charcot foot requires immobilization of the foot, typically for several months, in a total contact cast, removable walker boot or custom orthosis until consolidation occurs . Surgical stabilization may be indicated for Charcot arthropathy associated with marked instability, deformity or nonhealing ulcers. Although bisphosphonates have been considered for the treatment of Charcot arthropathy, further studies are necessary to fully evaluate these agents and other medical therapies in the routine treatment of Charcot arthropathy .

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Treatment Of The Foot Ulcer Depends On The Severity Of The Wound

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Are You At Risk For A Foot Ulcer

• Do you have a foot deformity? If so, you may have a higher than average risk of a foot ulcer.

• Do your shoes rub the wrong way? Poorly fitting shoes are a leading cause of foot ulcers.

• Can you feel your feet? Diabetes can cause nerve damage to the feet, making it difficult to feel cuts or scratches.

• Do you have high blood pressure? You may not realize it, but controlling your blood pressure could actually help protect your feet as well as your heart.

• Have you had a foot ulcer before? If so, youre at higher risk of having another one. Check your feet daily and call your doctor at the first sign of an injury.

• Do you go barefoot? Wearing shoes both inside and outside can help protect your feet from injury.

• Can you see your feet? People who are overweight or have diabetic eye disease should ask a family member or caretaker to examine their feet every day.

• Do you smoke? Ask your doctor for help quitting. Your feet will thank you.

Treatment Of Active Infection

Wound infection is a known predictor of poor wound healing and amputation. The appropriate recognition of infection and treatment with antibiotics in diabetic foot infection is imperative to improve outcomes. Conversely, inappropriately treating with antibiotics, often in the setting of fear of missing an infection, to reduce bacterial burden or prophylaxis is associated with several adverse effects, including antibacterial resistance. The IDSA has outlined specific guidelines for the treatment of diabetic foot infections. The IDSA recommends treatment of wounds with at least two signs or symptoms of inflammation or purulent secretion. It is recommended that, before antibiotic therapy, a deep tissue culture via biopsy or curettage after debridement be obtained. Swab specimens should be avoided, especially in inadequately debrided wounds. Antibiotic therapy should be targeted to aerobic Gram-positive cocci in mild to moderate infections. Severe infections should be treated with broad-spectrum empiric antibiotics pending cultures. IDSA recommends 1- to 2-week antibiotic course for mild infections and 23 weeks for moderate to severe infections, but antibiotics can usually be discontinued once clinical signs and symptoms of infections have resolved. To avoid antibacterial resistance and other adverse outcome of therapy, it is best practice that treatment of clinical diabetic foot infections be completed with narrow=spectrum antibiotics for the shortest duration possible.922

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