BMJ: Diabetic foot

Summarised from BMJ Clinical Update Diabetic Foot by Mishra et al Mumbai and London 18 Nov 17

Foot disease troubles 6% of people who have diabetes and includes infection, ulceration or destruction of tissues of the foot. It can affect both social life and work. Up to 1.5% of diabetic people will end up with an amputation. Good foot care, screening and early treatment of ulceration is hoped to prevent a foot problem developing into a need for amputation. This article gives an update on the prevention and initial management of the diabetic foot that can be expected from primary care.

A combination of poor blood sugar control, foot neglect, lack of appropriate footwear, insufficient patient education and failure to find and treat pre-ulcerative lesions cause increasing foot damage and worsens the outlook.  Nerve and blood vessel damage make damage more likely to go unnoticed and more difficult to heal.

A careful examination of the feet by the patient or carer every day is a good idea. A careful examination by health professionals also detects problems early. Fungal infections, cracks and skin fissures, deformed nails, macerated web spaces, callouses, and deformities such as hammer toes, claw toes, and pes cavus increase the risk of ulceration.  Cold feet can suggest poor blood supply and warm feet can be an indicator of infection.

Monofilaments are often used to detect neuropathy at annual assessments. Pain after walking a certain distance and pain at rest suggest peripheral arterial disease.

Assessments every three to six months is needed for medium risk feet and every one or two months for high risk feet.

As neuropathy is difficult to reverse once established, prevention is key. Optimal glycaemic control is extremely important. Smoking cessation, maintaining a normal weight and continued exercise help the circulatory system.  Patients also know how to check their feet and who to get help from if they find problems. New shoes should be worn in gradually to prevent blisters.

Health care professionals need to send urgent cases to a specialised diabetic foot centre if at all possible. Such cases would include foot ulceration with fever or any signs of sepsis, ulceration with limb ischaemia, gangrene,  or suspected deep seated soft tissue or bone infection.

Ulcers are best washed in clean water or saline with a moist gauze dressing.  Anti-microbial agents can be cytotoxic  and can affect wound healing. Weight bearing on the area needs to be avoided. Tissue will be taken for bacterial culture and antibiotics prescribed due to local policies.

Referral within a day or two is needed for rest pain, an uncomplicated ulcer or an acute Charcot foot. (suspected fracture due to neuropathy).

Patients with rest pain and intermittent claudication need vascular referral.

Here are the top tips for patients:

Inspect your feet daily including between the toes and if you can’t do it yourself get someone else to do so

wash your feet in warm but not hot water daily and dry carefully especially between the toes

use oil or cream on dry feet but not between the toes

cut nails straight across and if necessary go to a podiatrist for this

Don’t do home treatments for corns and callouses

Check your shoes for objects or rough areas inside them and wear socks with them

avoid walking barefoot

get your feet examined regularly by a health care professional

notify the appropriate health care professional if you develop a blister, cut, scratch or sore on your feet