Care of the Diabetic Foot

Diabetes is a chronic condition that can cause a number of serious complications. Problems with the feet are one of the most common.Most foot problems that people with diabetes face arise from two serious complications of the disease: nerve damage and poor circulation. The lack of feeling and poor blood flow can allow a small blister to progress to a serious infection in a matter of days. Chronic nerve damage (neuropathy) can cause dry and cracked skin, which provides an opportunity for bacteria to enter and cause infection.

Infection of the Foot

People with diabetes, especially those with very high blood glucose levels, have poorer defence against infection. Minor cuts and abrasions to the foot that we all get from time to time can turn into infection. So protect the feet with appropriate footwear. If there is a foot ulcer, the break in skin would also make infection much more likely to occur.

It is essential to distinguish between localized versus generalized foot infection because they require different intensity of treatment.

Localized foot infection is recognized by redness, heat and swelling confined to an area. Note the foot as a whole is not swollen. Oral antibiotics for a few days can usually eliminate the infection.Localized foot infection associated with a neuropathic ulcer. Due to the neuropathy, the patient may not feel any pain or discomfort. Oral antibiotics are usually satisfactory but may need to be continued until the ulcer has healed.

 Generalized foot infection. Note the whole foot is red and swollen. Oral antibiotics in higher dosage can be tried but if there is no rapid response (eg. within 24 hours), intravenous antibiotics and sometimes surgical intervention are urgently required because there is likely to be infected tissue deep inside the foot.

Foot infection complicated by osteomyelitis. In the presence of a foot ulcer there is a risk of the underlying bones being involved. X-ray may show bone destruction. Once there is osteomyelitis, a much higher dose of antibiotics and for a longer period (eg. several months) is often required to eradicate the infection. Quite often, intravenous antibiotic therapy is required. Sometimes the infected bones need to be surgically removed to help the foot heal.

Osteomyelitis in the early phase does not show up on X-ray but can be detected as a hot spot on a technetium bone scan, confirmed by a similar uptake in a white cell bone scan. MRI scan has emerged as the most sensitive and specific test for osteomyelitis and should be performed if the diagnosis is in doubt. If an ulcer is big (> 2cm) or so deep that bone can be probed at the bottom of the ulcer, one should suspect that osteomyelitis is present.

Many patients are hesitant to take antibiotics and many doctors are hesitant to prescribe antibiotics. However, when infection is present in the foot of a person with diabetes, antibiotic treatment is required. Many feet are lost unnecessarily due to failure to treat the infection.

The consequences can range from hospitalization for antibiotics to amputation of a toe or foot. For people with diabetes, careful, daily inspection of the feet is essential to overall health and the prevention of damaging foot problems.

 General Care of the Diabetic Foot

• Never walk barefoot. The nerve damage decreases sensation so you may not notice that little pebbles or objects have gotten stuck in your foot. This can lead to a massive infection. Always wearing shoes or slippers reduces this risk.
• Wash your feet every day with mild soap and warm water. Test the water temperature with your hand first. Do not soak your feet. When drying them, pat each foot with a towel rather than rubbing vigorously. Be careful drying between your toes.
• Use lotion to keep the skin of your feet soft and moist. This prevents dry skin cracks and decreases the risk of infection. Do not put lotion between the toes.
• Trim your toe nails straight across. Avoid cutting the corners. Use a nail file or emery board. If you find an ingrown toenail, see your doctor. Good medical care is important in preventing infections.
• Do not use antiseptic solutions, drugstore medications, heating pads, or sharp instruments on your feet. Do not put your feet on radiators or in front of the fireplace.
• Always keep your feet warm. Wear loose socks to bed. Do not get your feet wet in snow or rain. Wear warm socks and shoes in winter.
• Do NOT smoke. Smoking damages blood vessels and decreases the ability of the body to deliver oxygen. In combination with diabetes, it significantly increases your risk of amputation — not only of the feet, but can include the hands, as well.

Shoewear

• Choose and wear your shoes carefully. A poor fitting shoe can cause an ulcer and lead to an infection.
• Buy new shoes late in the day when your feet are larger. Buy shoes that are comfortable without a "breaking in" period.
• Check how your shoe fits in width, length, back, bottom of heel, and sole. Have your feet measured every time you buy new shoes. Your foot will change shape over the years and you may not be the same shoe size you were 5 years ago.
• Avoid pointed-toe styles and high heels. Try to get shoes made with leather upper material and deep toe boxes.
• Wear new shoes for only 2 hours or less at a time. Do not wear the same pair every day.
• Inspect the inside of each shoe before putting it on. Do not lace your shoes too tightly or loosely.
• Avoid long walks without taking a break, removing your shoes and socks and checking for signs of pressure (redness) or ulcers.