Introduction
Diabetic foot ulcers (DFUs) are one of the many complications of diabetes, affecting around one-third of patients world-wide (Voelker, 2023). Voelker (2023) adds that approximately half of DFUs get infected, with around 20% of the infections leading to foot amputations.
Living with this risk can be difficult as it negatively impacts someone's quality of life. It can contribute to mortality, increase healthcare costs, and impact someone's social and psychological well-being (Jodheea-Jutton et al., 2022). This is why being informed about DFUs, their causes, prevention, and treatment can help diabetic patients reduce the chances of developing such injuries and their resulting complications.
What are Diabetic Foot Ulcers (DFUs)?
According to the International Working Group on the Diabetic Foot (IWGDF) (2020), a DFU is the breakdown of foot tissue in a person with or who previously had diabetes. It often occurs with neuropathy — peripheral nerve damage, or peripheral artery disease (PAD) — a condition that impairs blood flow (Van Netten et al., 2020; Voelker, 2023).
Potential Causes
Neuropathy can prevent someone from noticing injuries or trauma to the feet resulting in ulceration (Ko & Liao, 2023). Nerve damage can also lead to foot deformities and dry skin, resulting in calluses that can eventually develop into ulcers from repetitive stress (Voelker, 2023).
Additionally, around 50% of people with DFUs have PAD, which reduces blood flow to the legs (Voelker, 2023). According to Ko and Liao (2023), reduced blood flow can prevent the body from fighting against infections and thus impair wound healing. Tissue necrosis — tissue death, and osteomyelitis — infection of the bone can occur due to impaired healing which may require amputations to treat them (2023).
Prevention
The Centers for Disease Control and Prevention (CDC) (2023) and the American Diabetes Association (ADA) (n.d.) recommend proper foot care for diabetic patients to help manage and prevent DFUs which involves:
Washing with warm water
Drying thoroughly, especially between the toes, to prevent infection
Moisturizing but avoiding between the toes
Trimming toenails
Wearing well-fitted shoes that do not rub.
Wearing footwear indoors to prevent injury
Checking footwear for sharp objects before wearing
Self-examining the feet to look for redness, blisters, cuts, swelling, and calluses
Choosing exercises or activities that avoid excessive pressure on the feet
Getting regular foot check-ups with the doctor
Nerve damage can occur due to uncontrolled blood sugar levels, age, high blood pressure, high cholesterol, etc. (CDC, 2023). Therefore, the CDC (2023) recommends diabetic patients follow a healthy eating plan, take prescribed medications, be physically active, and avoid smoking to help manage diabetes and reduce the risk of developing DFUs.
Treatment
Some treatment methods used for DFUs include wound care, wound debridement, and wound off-loading (Everett & Mathioudakis (2018); Jodheea-Jutton (2022)).
Wound care involves cleaning DFUs with normal saline and can be accompanied by wound dressings to create the right environment for wound healing (Everett & Mathioudakis (2018); Jodheea-Jutton (2022)). They explain that wound dressings can be hydrogels, hydrocolloids, alginates, and foams, depending on the specific ulcer. They also describe that wound dressings should maintain a moist environment, absorb excess exudate, be non-toxic, allow gas exchange, and protect the wound against foreign particles for effective wound healing.
Wound debridement involves removing dead, damaged, or infected tissue by surgical (sharp) or non-surgical methods (abrasions or chemicals) (Everett & Mathioudakis (2018); Jodheea-Jutton (2022); Van Netten et al., 2020). This helps the remaining healthy tissue to heal by promoting tissue formation, reducing pressure, and preventing bacterial growth (Everett & Mathioudakis, 2018; Jodheea-Jutton (2022)).
Wound off-loading involves reducing foot pressure through casting, bracing, footwear, or walking aids (Wang et al., 2022). Wang et al. (2022) state that a total contact cast (TCC) is a recommended non-removable device for off-loading. It immobilizes the area below the knee, protecting the foot from injury, relieving pressure, and promoting tissue repair. Other options such as removable knee-high offloading devices and felted foam footwear are also mentioned, which can produce similar results.
After 3 months of treatment, 30 to 40% of DFUs heal (Voelker, 2023). Even when healed, Voelker (2023) recommends people get their feet examined by the doctor every 1 to 3 months. Around 40% of people see DFUs recurring after 1 year and 65% in 5 years (2023). This not only makes prevention and early detection important, but also strengthens the need for research to improve the management of diabetes and reduce the development of DFUs.
Conclusion
Diabetic foot ulcers (DFUs) can lead to severe problems such as amputations, reducing the quality of life for diabetic patients. There are ways to help prevent the development of DFUs for example with early detection through regular check-ups and self-examination. Treatments for DFUs can include multiple steps, such as wearing appropriate wound dressings or removing damaged tissue. Continued research on better methods to prevent or treat diabetes, DFUs, and their complications can help make a positive impact on a diabetic patient's life.
References
American Diabetes Association. (n.d.). Foot Complications. Diabetes. https://diabetes.org/about-diabetes/complications/foot-complications
Centers for Disease Control and Prevention. (2023, April 11). Diabetes and Your Feet. CDC. https://www.cdc.gov/diabetes/library/features/healthy-feet.html
Everett, E., & Mathioudakis, N. (2018). Update on management of diabetic foot ulcers. Annals of the New York Academy of Sciences, 1411(1), 153–165. https://doi.org/10.1111/nyas.13569
Jodheea-Jutton, A., Hindocha, S., & Bhaw-Luximon, A. (2022). Health economics of diabetic foot ulcer and recent trends to accelerate treatment. The Foot, 52, 101909. https://doi.org/10.1016/j.foot.2022.101909
Ko, A., & Liao, C. (2023). Hydrogel wound dressings for diabetic foot ulcer treatment: Status‐quo, challenges, and future perspectives. BMEMat, 1(3). https://doi.org/10.1002/bmm2.12037
Van Netten, J. J., Bus, S. A., Apelqvist, J., Lipsky, B. A., Hinchliffe, R. J., Game, F., Rayman, G., Lazzarini, P. A., Forsythe, R. O., Peters, E. J. G., Senneville, É., Vas, P., Monteiro-Soares, M., & Schaper, N. C. (2020). Definitions and criteria for diabetic foot disease. Diabetes/Metabolism Research and Reviews, 36(S1), 1–6. Definitions and criteria for diabetic foot disease - PubMed (nih.gov)
Voelker, R. “What Are Diabetic Foot Ulcers?” JAMA, vol. 330, no. 23, 2023, pp. 2314. https://doi.org/10.1001/jama.2023.17291.
Wang, X., Yuan, C.-X., Xu, B., & Yu, Z. (2022). Diabetic foot ulcers: Classification, risk factors and management. World Journal of Diabetes, 13(12), 1049–1065. https://doi.org/10.4239/wjd.v13.i12.1049