Diabetic foot ulcers (DFUs) may affect up to 25% of people with diabetes at some point in their lifetime. Once a person has developed a DFU, there is a 50% chance the ulcer will become infected.¹ DFUs are also among the leading causes of amputation.² Wound care specialists encounter DFUs regularly in the clinic, and these wounds can be very difficult to treat because of the underlying metabolic insufficiency. This blog provides a guide to current best practices with regard to DFUs and prevention.

Diabetic Foot Ulcer Etiology

DFUs are lesions affecting the lower extremity integument, soft tissue, or bone.¹ These ulcers can become infected as a result of poor wound healing in patients with diabetes, thereby causing a cascade that may lead to amputation.

DFUs result from the microvascular changes that take place internally in someone who has diabetes (eg, nephropathy, neuropathy³). Often, the ulcer forms because of improper foot care and an extended time between wound onset and patient awareness.¹

Individuals with diabetes mellitus often have neuropathy that makes it difficult to accurately sense touch, proprioception, and even pain. With the reduced touch signals, these patients may not be aware that an injury to the skin of the lower extremities has occurred. To compound this issue, they may not be able to feel the pain that so often accompanies wounds of this nature. Thus, they develop a DFU, which has not been treated in a timely manner and will have difficulty healing. This is why prevention is key for DFUs.

Diabetic Foot Ulcer Prevention

Prevention of DFUs often goes hand in hand with intervention. The ultimate goal is to allow the ulcer to heal properly and avoid future complications such as amputation.

Glycemic control. Individuals with diabetes must monitor their blood glucose closely to prevent hypoglycemic or hyperglycemic episodes. These events can have long-term consequences, including a DFU.

The human body requires balanced blood glucose to heal appropriately. Recent literature suggests that a hemoglobin A1c (HbA1c) value between 7.0% and 8.0% is optimal for facilitation of ulcer healing.⁴ However, this is dependent on the individual’s glycemic control at baseline. Additionally, an individual who has a DFU, an HbA1C of over 8.0%, and a fasting blood glucose greater than 126 mg/dL is more likely to have a lower extremity amputation.⁵

Other studies also indicate that strict glycemic control after a DFU has formed can lead to better healing rates. This was true for DFUs that did not respond to conventional care.6 Better glycemic control leads to improved healing and prevention.

Proper footwear. As discussed earlier, individuals with diabetes may not be able to feel the touch or pain of a sharp object or pressure point on their foot. Therefore, proper footwear is essential to preventing ulceration initially. Proper footwear includes:

• Sufficient coverage of the foot
• Appropriate sizing of footwear

Individuals with diabetes are encouraged to have their feet measured before purchasing any shoes.⁷ Wearing proper footwear also reduces the chance of infection should an ulcer develop.⁸ The footwear protects the foot from outside elements. However, many patients with diabetic neuropathy may choose not to wear footwear for different reasons. Some prefer to be barefoot at baseline, whereas others may use direct contact with the ground to compensate for the muted sensation. Whatever the reason, it is important to talk with patients who have diabetes about the importance of proper footwear to avoid future complications.⁹

Offloading. Once a DFU has formed, treatment must include offloading of the wound to promote healing. Depending on the location of the ulcer, an individual may need to use one of the following devices¹⁰:

• Walker
• Half-shoe
• Orthotic
• Total contact casting

For DFUs without signs of ischemia or uncontrolled infection, the gold standard offloading device is a non-removable knee-high offloading device such as a total contact cast.. Because it is not removable, the device increases adherence to medical advice, thus improving wound healing.¹¹ The goal of each of these devices is to allow functional weight bearing for mobility while decreasing pressure on the ulcer itself.

Frequent foot checks. Recent literature suggests an association between longer wait times between ulcer onset and seeking medical treatment and increased severity of the ulcer.¹² Daily foot checks alert the individual with diabetes to any areas of skin irritation, breakdown, or injury that might lead to a DFU.¹³ It is suggested also that individuals with diabetes be seen by a podiatrist at least annually if they do not have a history of infection, or at least monthly if they do have a history of diabetic foot infection.¹⁴ These checks by medical professionals can help identify high-risk patients and refer them for additional education or follow-up.

Skin care. Having a skin care routine is essential for patients with diabetes. Experts recommend the following¹³:

• Performing daily foot checks to inspect for cuts, scratches, blisters, and ingrown toenails
• Washing the feet with mild soap and water
• Avoiding hot water because of impaired sensation and microvascular complications
• Moisturizing after washing to maintain skin integrity and reduce risk of skin injury leading to infection

However, moisturizers and creams should not be applied between the toes because of the risk for fungal infections.¹⁴ Keeping the skin clean, dry, and appropriately moisturized helps prevent skin breakdown and infections that can lead to DFUs.

Patient education. With all the foregoing information, there is a common theme: patient buy-in. If the individual with diabetes does not know or understand what they can do to prevent DFUs, then the ulcers are more likely to occur. Studies have supported the importance of transitional care programs focused on patient education on these prevention techniques.¹⁵

Studies have found that patient education should include not only conversations about what should be done, but also visual demonstrations or videos to reinforce the information.¹⁶ Patients with DFUs are also more likely to have a lower education level,¹⁷ so information needs to be presented in an accessible way. This can be achieved through a multidisciplinary approach.¹⁸

Ultimately, prevention is up to the patient. However, clinicians need to equip patients with the knowledge to reduce their risk of developing DFUs.

Conclusion

DFUs cost between $9 and 13 billion in the United States each year, in addition to the cost of diabetes management without an ulcer. Prevention is key for these ulcers, especially given that diabetes affects the body’s ability to heal after injury.¹⁹ Using the information provided here, clinicians can better care for and educate patients with diabetes on how to prevent and manage DFUs.

References

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