Diabetic foot ulcer is an open wound that occurs in the foot of diabetic patients. Without prompt diagnosis and appropriate treatment, this condition can cause severe complications. This is because, in diabetic patients wound healing is impaired and so the wounds can become deeper and can even spread to the bones. Diabetic foot ulcer is the main reason that leads to majority of the lower extremity amputations in diabetic patients. Getting treatment at the right time helps the foot ulcer to heal completely and moreover reduces the risk of losing your foot.

The main objectives of diabetic foot ulcer treatment are obtaining complete closure of the wound or ulcer, relieving pressure on the foot, removal of infection and management of ischemia. Prior to starting treatment it is important to determine if the ulcer is neuropathic (caused by peripheral neuropathy) or ischemic (caused by peripheral arterial disease). In order to improve the outcome, this condition also requires the assessment of experts from multiple medical disciplines such as a diabetologist, orthotist, podiatrist, vascular surgeon, neurologist and a nurse.

Wound Closure

The first step in diabetic foot ulcer treatment involves thorough cleansing of the wound and preparing it to heal and ultimately enable the closure of the wound. The various steps involved in attaining this goal includes

- Debridement – This is the process by which dead or infected tissue is repeatedly removed by surgery. In some cases the dead tissue may also be removed by using chemical debriding agents such as enzymes which dissolves the dead tissue. Proper debridement is essential to reduce the risk of infection.

- Wound dressings – The wounds are dressed in such a way as to provide a favorable environment that promotes tissue repair and enables proper healing. Hydrogels, hydrocolloids, alginates and foams are some of the elements used for preparing the wound dressings.

- Soft-tissue coverage of the wounds – The diabetic foot ulcers are usually covered with skin grafts taken from the patient’s own skin (autologous skin graft), taken from a cadaver (cadaveric skin graft) or by using bioengineered skin substitutes.

- Growth factors – These are actually proteins that encourage cell division and promote healing of wounds. Becaplermin (Regranex gel) and granulocyte colony-stimulating factor (G-CSF) are examples of such growth factors.

Offloading

Offloading is the technique of relieving the pressure on diabetic foot ulcers. The various approaches to offloading include the use of special shoes, casts, braces, crutches, wheelchairs, canes and insoles. It is also important to avoid the use of ill-fitting shoes. Rest and elevation of the affected foot also helps to promote healing of diabetic foot ulcers.

Removal of infection

The possibility of amputation of the limbs increases if there is infection of the diabetic foot ulcer. The following methods are usually employed for the management of diabetic foot ulcer infections

- Culture of the wound – The infected wound is cultured and the organisms causing the infection are identified

- Debridement – surgical removal of dead or infected tissues present in the wounds

- Treatment using antibiotics – All infections of diabetic foot ulcers would require treatment with antibiotics. Mild infections would require a 7-10 day course of antibiotic treatment whereas severe cases usually require an extended course of treatment.

- Surgery –If the infection has spread deeper into the bones, surgery for resection of the infected bone has to be done. In addition to surgery, 4 to 6 weeks of parenteral antibiotic therapy will also be required.

Management of Ischemia

If the diabetic foot ulcer is caused by peripheral vascular disease or ischemia, a vascular surgeon has to be consulted for further assessment. The treatment options for this condition includes

- Hyperbaric oxygen therapy

- Vascular surgery to re-establish adequate blood flow to the affected foot

- Angioplasty and stenting

Conclusion

Patients having diabetic foot ulcers should undergo urgent treatment to reduce the risk of infection, prevent the loss of his/her limbs, avoiding longer term treatment costs and improving quality of life. Therefore if an ulcer is noticed in the foot, make sure to seek medical care immediately. After a successful diabetic foot ulcer treatment, it is important to prevent the recurrence of a subsequent ulcer. Since the risk of amputation increases with each recurrence of the ulcer, preventing recurrence is a key objective in the management of patients who have had previous incidents of diabetic foot ulcers.

Foot ulcers are open skin wounds that are usually slow to heal. They are most commonly seen in patients with diabetes and can be caused by several reasons such as trauma to the foot, peripheral neuropathy, and peripheral vascular disease. If not diagnosed and treated in time, foot ulcers can lead to the amputation of the lower limbs and foot. There are several methods to treat foot ulcers and the primary objectives of all treatment methods are basically obtaining closure of the wound, relieving pressure on the foot, eradication of infection and management of ischemia. These methods usually involve wound cleaning, appropriate dressings, debridement, use of antibiotics and advice on appropriate footwear, and insoles.

Most foot ulcers in diabetic patients remain largely hidden as they appear very small on the surface but in actual case they may extend deeper even into the bones.  Depending on how deeply the ulcer has penetrated the layers of the skin, foot ulcers can be classified into four stages. These four foot ulcer stages are:

Stage 1 – Stage 1 ulcers are characterized by red skin over bony areas. The redness of the skin remains even after relieving the pressure over the area. You may also notice that the skin feel warm to touch.

Stage 2 – In stage 2, the skin over the affected area may develop cracks and blisters. The patients may have experienced loss of thicker layers of the skin, which involves the top two layers.

Stage 3 – At stage 3, patients develop broken skin that may look like a crater. There may sometimes be bloody drainage. The ulcer may have spread all the way into the bottom layers of the skin leading to full thickness skin loss that involves the tissue between the skin and muscles (subcutaneous tissue).

Stage 4 – This is most severe of all the stages. In this stage, the ulcer has spread deeper into the muscles, tendons, joints and bones causing a great deal of damage to the tissues in these areas. This stage often leads to infection in the bones, a condition known as osteomyelitis.

diabetic foot wound

Diabetic foot ulcers are classified into grades of 0 to 5 according to the Wagner wound classification system, which is the most widely used system. This system classifies the ulcers based on how deep they have penetrated the skin and occurrence of osteomyelitis, gangrene and tissue death.

The five grades of foot ulcer as per the Wagner system are as follows.

- Grade 1 – These are superficial ulcers that may extend over the partial or sometimes the full thickness of the skin.

- Grade 2 – In this case, the ulcers may spread over the ligaments, tendons, joints or the fibrous connective tissue that separate or holds together the muscles.

- Grade 3 – Grade 3 ulcers penetrate deep into the skin leading to bone infection (osteomyelitis) and/or joint sepsis.

- Grade 4 – Grade 4 ulcers involve decay of tissues in the forefoot or heel regions of the foot, a condition called gangrene.

- Grade 5 – This stage involves gangrene that has spread over a wide area.

These classifications into different foot ulcer stages or grades are highly beneficial as it helps in the proper examination coupled with prompt and appropriate treatment of the condition. This would help to bring down the risks of limb amputations to a great extent.

A foot ulcer is a common skin problem characterized by the development of open wounds or skin lesions on the foot that usually takes time to heal.  This condition is most commonly seen among patients having diabetes and can be caused by a number of reasons such as poor circulation, trauma, peripheral vascular disease and peripheral neuropathy. A person experiencing foot ulcer symptoms should not hesitate to consult a doctor for proper diagnosis and appropriate treatment because if left untreated, foot ulcers can cause several complications that may eventually lead to the amputation of the infected area of the foot.

A foot ulcer looks like a red depression or hole in the skin. They develop mostly on the sides or base of the foot or on the tip of a toe. The ulcer may be bordered by layer of thickened and coarse skin. In some cases the ulcer may spread deep into the foot tendons or bones. If the nerves in your foot are functioning properly, you will experience pain caused by the ulcers. However, people with damaged sensory nerves do not experience any pain whatsoever. Diabetic patients have poor blood circulation, especially to the lower extremity regions. This causes their feet to become numb and they do not feel any sores or pain. As a result, the foot ulcers are left untreated leading to several complications such as an infection of the bones or the blood stream.

How To Spot Foot Ulcer?

The primary foot ulcer symptoms include irritation of the skin, blistering and skin redness. In the advanced stages, the patient may develop open sores that drain fluid. These wounds become infected leading to inflammation and draining of pus. The following are some of the most common foot ulcer symptoms.

- Skin lacerations – As mentioned earlier, the initial symptoms of foot ulcer is the development of skin lesions that is usually surrounded by a thickened and coarse skin border.

- Skin discoloration – The skin at the infected area may be unusually discolored and may appear blue, red or black in color.

- Swelling or inflammation – Foot ulcer can cause damage to the surrounding tissues leading to inflammation and swelling. This causes the affected foot to appear enlarged and tender to touch.

- Pain or burning sensation – People suffering from foot ulcers may experience burning, itching or pain in the affected area, a condition that can be very uncomfortable. The pain in the foot can vary from mild to severe and may affect the normal daily activities of the patient. Due to the severe irritation, the patients may scratch the affected area leading to an infection.

- Fever – Another common foot ulcer symptom is fever that is usually mild in nature. Along with fever, the patient may also experience chills, headache or sweating.

- Drainage of pus – Foot ulcer, if not properly treated can lead to severe infections. At this stage, you may notice fluid or pus leaking from the open wound, giving out a foul odor. This may also be accompanied by pain or swelling of the affected area.

- Cold feet – Poor blood circulation in the feet can cause the feeling of coldness in the affected feet, making it difficult for the patient to move about.

- Increase in blood sugar levels

If any of the above mentioned foot ulcer symptoms are noticed, make sure to seek immediate medical care. With proper diagnosis and right treatment, further complications can be avoided. Proper foot hygiene and care, inspection of the foot on a daily basis, wearing the right shoes and management of minor wounds in the foot can help to prevent the development of foot ulcers.

Foot ulcer is a major problem that is characterized by the formation of open wounds on the foot. This condition is commonly seen in diabetic patients, which unfortunately in majority of the cases leads to lower extremity amputations. Foot ulcers are usually caused by factors such as trauma to the feet, peripheral neuropathy (a condition caused by diabetes in which the peripheral nerves are damaged leading to the malfunctioning of the motor, sensory and autonomic nerves) and peripheral vascular disease (a condition where the blood vessels to the lower parts of the body become narrow, leading to decreased blood supply to those areas).  Foot ulcers if left untreated can cause the development of debilitating infections which may ultimately lead to lower-limb amputations. Therefore, if you notice any of the associated signs or symptoms, it is important to get immediate foot ulcer treatment in order to facilitate healing and prevent further complications.

Foot ulcer treatment begins with a prompt evaluation of the condition. You should inform your doctor about any surgical procedures you have undergone in the past, medications, and any other medical conditions you may have. The doctor may also conduct a physical exam and perform tests. All these factors would help the doctor to arrive at an accurate diagnosis of your ulcer. The first step in the treatment involves thorough cleansing and dressing of the wound for obtaining wound closure. After a few weeks, there should be significant improvement in the wound bed.

If there is no noteworthy improvement in the condition after the first few weeks of wound care, the patient may have to undergo advanced therapies. Advanced foot ulcer treatment involves the use of several wound- healing techniques, some of which are listed below.

- Debridement – Surgical or sharp debridement is carried out by removing the dead and infected tissues from the wound bed by using surgical instruments such as scissors, curettes and scalpels. After the procedure, moist wound care dressings may be used.

- Debriding agents – This method uses enzymatic debriding agents that dissolves the dead tissues in the wound and facilitate healing. These are available in the form of ointments that can be applied once a day. Although they are very effective in removing the dead and infected tissues, they are not as fast as the surgical debridement process. In some cases, combination of the two treatment methods may be used.

- Pulse lavage therapy- This procedure uses a water-gun–like apparatus attached with a suction device to clean and debride the wound simultaneously.

- Hyperbaric oxygen therapy – In this procedure, the patient is made to lie in an acrylic tube filled with 100% oxygen under twice or thrice the normal atmospheric pressure. This treatment method helps to increase the oxygen level in the blood and also the oxygen supply to the tissues. This procedure that lasts for about 1.5 to 2 hours is to be done daily and requires an average of 20 to 30 sessions.

- Growth factor therapy – This therapy makes use of engineered human growth factors to promote healing. A topical gel that contains recombinant human platelet-derived growth factor (rhPDGF) is often used for foot ulcer treatment. The gel has to be applied daily with weekly monitoring of the progress of the condition. Becaplermin (Regranex gel) and granulocyte colony-stimulating factor (G-CSF) are other examples of growth factors.

- Soft tissue coverage of the wounds – In this foot ulcer treatment method, skin graft taken from the patient’s own skin or bioengineered tissues are used to cover the wounds.

- Energy therapies – This technique involves passing of energy into the wound to initiate the healing process. Energy therapies have to be performed at least three times a week for about 3 or 4 weeks or until the wound begins to heal. The various methods of energy therapies commonly used involve

- Passing of high-voltage pulsed electrical energy into the wound (electrical stimulation)

- Passing of high-energy acoustic waves into the wound (ultrasound)

- Using an ultrasound-created mist (MIST Therapy System)

- VAC therapy (Vacuum-assisted closure therapy) – VAC therapy uses negative-pressure therapy in which a polyurethane sponge attached to a plastic tube is applied on the wound bed. The plastic tube is attached to a pump that produces negative suction which helps to drain the wound. This is a portable device and can be attached to the waist belt.

Once the foot ulcer has been treated and the wound healed, it is important to take precautionary measures to prevent its recurrence. People with a history of prior diabetic foot ulcers are at a high risk for developing subsequent ulcers. Appropriate foot care, inspection of the foot on a regular basis and proper management of even minor wounds can help to prevent foot ulcers to a great extent. If foot ulcers develop despite following these preventive measures, immediate medical care should be sought for and foot ulcer treatment should be started promptly.