Diabetic foot is one of the major burdens on the healthcare system, the patients themselves, and their relatives. According to statistics, worldwide, every 30 seconds there is one case of limb amputation due to diabetes, and most of these cases initially involve diabetic foot ulcers.
Between 2007 and 2014 in the US, the cost burden of caring for diabetic foot ulcers reached 9–13 billion USD. Europe is no exception, with the cost of treating diabetic foot ulcers in 2017 in this region reaching nearly 14 billion USD, a very large number compared to the total costs of wound care.
So, what is diabetic foot, why is it dangerous, and why does it place great pressure on the healthcare system? Are there any effective treatments and care methods to reduce pain and help patients’ wounds heal faster? All information will be provided in the article below, compiled by Urgo Medical under the consultation of specialized doctors.
I. What is diabetic foot? Causes and risk factors
Diabetic foot is a common chronic complication in diabetic patients, being the main cause leading to limb amputation, increasing treatment costs, and reducing patients’ quality of life.
1. What is diabetic foot?
Diabetic foot, also known as diabetic foot syndrome, is a term used to describe the condition of the foot in diabetic patients when the following are present:
– Infection.
– Ulcers and/or deep tissue destruction.
=> This condition is believed to be related to abnormal nerve function and peripheral arterial disease regardless of the severity in the foot.
According to the International Diabetes Federation, each year about 9.1 to 26.1 million people develop diabetic foot ulcers, and about 19–34% of diabetic patients will have at least one foot ulcer in their lifetime. It is also estimated that up to 40% of diabetic patients experience foot ulcer recurrence within one year of wound healing.
2. Causes and risk factors of diabetic foot ulcers
“Diabetic gangrene does not fall from the sky but is born on the ground,” said scientist Elliott Joslin over 80 years ago about diabetic foot.
Indeed! The foot does not ulcerate spontaneously, but always originates from the following main causes and risk factors:
2.1 Peripheral neuropathy caused by diabetes: Causes loss of protective sensation
According to research by Reiber and colleagues, 63% of diabetic foot ulcer cases are caused by a very common complication in diabetic patients, namely: Peripheral neuropathy combined with trauma leading to foot ulcers.
Patients who experience common injuries such as blisters from tight shoes, trauma from hard objects hitting the foot, burns… will cause small wounds. However, wounds in diabetic patients usually heal slowly and easily get infected. Meanwhile, peripheral neuropathy causes loss of protective sensation, so patients cannot recognize they are injured, leading to lack of care and wounds progressing from small to large, even causing infectious complications.
Specifically, the effects of peripheral neuropathy on sensory, autonomic, and motor nerves are as follows:
– Effect on sensory nerves => causes loss of protective sensation (unable to feel pain, heat, cold, etc.). This is the main risk factor commonly present in most diabetic feet, increasing ulcer risk up to 7 times compared to normal feet.
– Effect on motor nerves => causes foot deformities, abnormal clawing of toes, overly high or flat foot arches (such as claw foot or hammer toe) => increases abnormal pressure on bony prominences of the foot, creating new pressure points.
– Effect on autonomic nerves => reduces sweat secretion => causes dry skin, cracking, and calluses.
2.2 Peripheral arterial disease caused by diabetes: Causes vascular complications
The next risk factor causing diabetic foot ulcers is peripheral arterial disease, which contributes to ulcer development in 50% of cases.
This is also the main risk factor leading to lower limb amputation in diabetic patients. This is because the disease causes inadequate blood supply from arteries to the foot, resulting in delayed healing, easy bacterial invasion, and necrosis.
2.3 Trauma
As mentioned, trauma is one of the causes and risk factors that make diabetic feet susceptible to ulcers and infections. There are two types of trauma causing skin damage:
– External trauma: burns, tight shoes, stepping on sharp objects, accidents…
– Intrinsic foot factors: calluses, foot deformities, ingrown toenails…
Besides the three risk factors mentioned, other factors are associated with increased risk of diabetic foot ulcers, including:
- Poor vision
- Smoking
- Edema
- Diabetic kidney disease, patients undergoing dialysis
- Poor treatment compliance, improper foot care
- Social factors: living alone, low social status, low education level, limited access to healthcare services…
II. Treatment of diabetic foot ulcers
Timely treatment of diabetic foot ulcers is very important because if the ulcer is severely infected, it may lead to amputation to save the patient’s life.
Therefore, besides regularly checking and caring for feet to prevent ulcers in those without wounds, early detection and treatment of existing diabetic foot ulcers should be continuously performed.
According to information from Dr. Thai Van Hung, most clinical doctors treating diabetic foot care will base their treatment on the following basic principles:
1. Reduce pressure and protect diabetic foot ulcers
If the ulcer is caused by increased pressure on the foot, then offloading pressure is the key foundation in treatment. Methods include:
– Switching to shoes that fit the foot size properly.
– Using padding between toes.
– Using removable orthotic devices (casts, braces).
– Using orthotic devices depending on the ulcer’s location and type.
2. Restore tissue perfusion to improve ischemia
Revascularization is a method to restore circulation directly to at least one of the arteries in the foot. This is the most effective way to restore tissue perfusion and should be considered first in the following cases:
– Patients showing signs of ischemia in the foot, soft tissue infection, or extensive tissue loss.
– After 6 weeks of optimal management, diabetic foot ulcers remain unhealed regardless of previous vascular diagnostic results.
– Patients at high risk of amputation (above ankle amputation).
*Note: Patients deemed unlikely to succeed should avoid revascularization.
Currently, pharmacological methods to improve perfusion have not been proven beneficial for diabetic foot ulcer patients. Therefore, revascularization is considered the most promising method to restore tissue perfusion to the arteries supplying blood to the wound.
Additionally, other treatments can be considered to reduce cardiovascular risks, such as: controlling hypertension and lipid disorders, smoking cessation, or using antiplatelet drugs.
3. Treat infection of diabetic foot ulcers
Treatment of diabetic foot ulcers requires a combination of different methods.
3.1 Superficial foot ulcers with mild soft tissue infection
Doctors will clean, debride necrotic tissue and callused surrounding skin. They will also prescribe oral antibiotics targeting common bacteria.
3.2 Deep or extensive infected ulcers threatening the limb
For moderate to severe infected diabetic foot ulcers, doctors will determine if surgical intervention is necessary to:
– Debride necrotic tissues, including infected bone.
– Release compartment pressure and drain abscesses.
If the patient has peripheral arterial disease, revascularization will also be considered. Treatment is based on broad-spectrum intravenous antibiotics targeting:
– Common gram-negative and gram-positive bacteria.
– Anaerobic bacteria.
Based on clinical response to initial antibiotics, antibiogram results, and bacterial culture, doctors will adjust antibiotic regimens accordingly.
3.3 Metabolic control and treatment of comorbidities
– Control patients’ blood glucose to safe levels; insulin may be used if necessary.
– Combine treatment if the patient has edema or malnutrition.
3.4 Local care for diabetic foot ulcers
– To detect early signs of severe infection and dangerous complications in diabetic foot patients, healthcare staff or the patients and relatives themselves should regularly inspect the ulcer. Depending on ulcer severity, underlying diseases, exudate amount, presence of infection, and wound care methods used, inspection frequency may vary.
– Debride necrotic tissues and callused surrounding skin.
– Use dressings that control excessive exudate while maintaining a moist environment to promote healing.
– Consider negative pressure therapy to support postoperative wound healing & consider some adjunct therapies for non-infected diabetic foot ulcers that are slow healing after 4-6 weeks despite optimal clinical care:
- Use hyperbaric oxygen therapy for ischemic non-healing ulcers (even after revascularization).
- Use Sucrose Octasulfate (NOSF – Nano Oligo Saccharide Factor) impregnated dressings for diabetic foot wound care, based on recommendations from the International Working Group on the Diabetic Foot.
Currently in the Vietnamese market, the reputable NOSF-impregnated dressing is UrgoStart – a specialized dressing for diabetic foot ulcers. This is a famous French product applying the proprietary TLC-NOSF Technology invented by the URGO group with 3 outstanding advantages:
– Maintains a moist environment, stimulates fibroblast proliferation, shortens healing time by over 60 days.
– Painless dressing changes, easy to use, adhesive absorbent backing.
– Prevents maceration, absorbs low to moderate exudate.
Accordingly, UrgoStart is made of a polyurethane absorbent foam layer containing TLC-NOSF (NOSF is evenly distributed within the TLC layer) acting at the wound base, helping shorten healing time in diabetic foot ulcers with two distinct mechanisms:
– Inhibiting excess MMPs (Matrix Metalloproteinases) in chronic wounds: The effectiveness of NOSF is optimized when combined with the TLC layer. Upon contact with wound exudate, a gel forms, allowing the active substance to contact the wound base and inhibit excess MMP enzymes. This balances the wound to a physiological state suitable for healing.
– Optimizing moist environment balance, restoring vascular redistribution by reactivating vascular cell proliferation and migration.
Not only clinically proven effective in diabetic foot care, UrgoStart is also recommended by the International Working Group on the Diabetic Foot (IWGDF) & the UK’s National Institute for Health and Care Excellence (NICE).
III. How to care for patients with diabetic foot ulcers at home
To properly care for diabetic feet at home, reduce pain, and prevent infection, relatives and the patients themselves need to be guided by healthcare workers on self-care and ulcer prevention. This includes:
– How to self-care for foot ulcers.
– How to recognize and report new infections or symptoms indicating worsening infection, such as: increased blood sugar, changes in wound status, onset of fever…
– How to prevent ulcers on the opposite foot during bed rest.
Among these, dressing changes are one of the foot care skills that relatives or the patients themselves must master. Although most diabetic foot ulcer patients believe antibiotics help wounds heal faster, in reality, dressing changes are the key solution to controlling factors promoting healing.
If dressing changes are not done carefully, the ulcer may not improve and may become more severely infected, potentially causing osteomyelitis, sepsis, and amputation. Therefore, we need to master medically accurate dressing techniques to minimize common risks.
Below are the steps to assess & change dressings for diabetic foot ulcers:
1. Wound assessment using the T.I.M.E protocol
This is a common protocol used by doctors and nurses.
2. Dressing change procedure for diabetic foot care
Changing dressings for foot ulcers helps remove dirty dressings, eliminate necrotic tissue, and restore balanced environment, aiming to promote healing.
Step 1: Gently remove old dressing, avoid causing pain to the patient
Use dressings with good non-stick properties for painless changes, such as UrgoStart. If using regular dressings, wet the old dressing with saline to loosen it and reduce adhesion to the wound.
Step 2: Remove necrotic tissue from diabetic foot ulcers
The person performing this must be trained and sometimes requires surgical debridement in a fully equipped operating room. Patients should go to medical facilities to remove necrotic tissue or choose home wound care services.
At this step, besides removing necrotic tissue, the wound should be cleansed with different solutions. For wounds with granulation tissue, antiseptics should not be used; instead, 0.9% NaCl saline should be used to avoid damaging granulation tissue.
Step 3: Apply new dressing to the wound
Choose dressings appropriate to the wound condition. For diabetic foot ulcers, UrgoStart dressing is a suitable choice.
Notes for diabetic foot care
– Depending on the wound’s exudate level, dressing change frequency may vary. For heavily exuding, malodorous ulcers, change dressing 1-2 times/day. For wounds with low exudate, granulation tissue or epithelialization present, changes can be done every other day or less frequently.
– An acute inflammatory process includes 4 phases: Hemostasis => Inflammation => Proliferation => Remodeling. When changing dressings, chronic ulcers should be converted into acute wounds to repeat the healing phases, allowing faster healing without delay.
– To enhance venous return, venous ulcers require compression or elastic bandaging.
– Pressure offloading on ulcers is crucial, especially on pressure points. At home, this can be done using offloading boots, limiting walking, and elevating the foot.
– After dressing change, monitor the ulcer continuously to promptly detect complications such as severe pain, bleeding, fever…
– If the wound exudes heavily and saturates the dressing after change, replace the dressing immediately.
Besides these diabetic foot ulcer care techniques, patients also need antibiotic therapy to promote healing based on doctors’ prescriptions and a complete, scientific diabetic nutrition regimen.
REFERENCES
- Article “Diabetic Foot” – MSc. Dr. Huynh Quoc Hoi – 115 People’s Hospital.
- Article “Basic principles in diabetic foot care” – Specialist Dr. Thai Van Hung.
Prevention and management guidelines for diabetic foot by the International Working Group on the Diabetic Foot 2019 (IWGDF).
- Article “Diabetic Foot – Causes and factors delaying wound healing” – Specialist Dr. Dau Ly Na.
– Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med. 2017;376(24):2367–75.
– Walsh JW, Hoffstad OJ, Sullivan MO, Margolis DJ. Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med. 2016;33(11):1493–8.
– de Smet GHJ, Kroese LF, Menon AG, Jeekel J, van Pelt AWJ, Kleinrensink G-J, et al. Oxygen therapies and their effects on wound healing. Wound Repair Regen. 2017;25(4):591–608.
– Reiber GE, Vileikyte L, Boyko EJ, del Aguila M, Smith DG, Lavery LA, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999 Jan;22(1):157–62.
– Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36 Suppl 1:e3269.
- Article “How to change dressings for diabetic foot ulcers & post-treatment monitoring” – Dr. Nguyen Dinh Duc.
– Nguyen TPL, Edwards H, Do TND, Finlayson K. Effectiveness of a theory-based foot care education program (3STEPFUN) in improving foot self-care behaviours and foot risk factors for ulceration in people with type 2 diabetes. Diabetes Res Clin Pract. 2019 Jun;152:29–38.