Diabetic Foot Disease

Diabetes is a chronic condition that is associated with many macrovascular and microvascular complications.

Diabetic foot disease is a severe complication of neuropathy and/or peripheral vascular disease and can lead to chronic infection, foot ulcers, gangrene, and lower-limb amputation. Every year, about 1% to 4% of people with diabetes develop a new foot ulcer.¹A foot ulcer is the initial event in more than 85% of amputations performed on those with diabetes.²Although the rate of foot and leg amputation has greatly declined over the past 2 decades, increasing awareness is essential because diabetes is the leading cause of lower-limb amputations in the United States.³

Not only does diabetic foot disease have an impact clinically and socially, but the economic burden is great. In the United States, medical costs for managing diabetic foot disease range from $9 billion to $13 billion.⁴The good news is that the condition can be prevented. Early recognition and treatment can greatly delay or prevent the complications of diabetic foot disease, and physicians can make a diagnosis during a simple foot exam. The hard part is getting patients to take off their shoes and socks. Do not hesitate to assist them in doing so.

The American Diabetes Association recently updated the standard for medical care in diabetes. Here is a summary of the guidelines regarding foot care for patients with diabetes⁵:

• Assess for foot deformities, check the skin, and perform a neurological assessment (10-g monofilament testing with at least 1 other assessment: pinprick, temperature, or vibration) and vascular assessment, including pulses in the feet and legs.
• Direct patients who smoke or who have histories of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or peripheral arterial disease to foot care specialists for preventive care.
• Inspect patients’ feet at every visit.
• Obtain a prior history of amputation, angioplasty or vascular surgery, Charcot foot, cigarette smoking, renal disease, retinopathy, and ulceration.
• Perform a comprehensive foot evaluation at least annually.
• Provide general preventive foot self-care education.
• Recommend specialized therapeutic footwear for high-risk patients.
• Refer patients for ankle-brachial index and vascular assessment if symptoms of claudication or decreased or absent pedal pulses are present.
• Use a multidisciplinary approach for individuals with foot ulcers and feet at high risk of disease (eg, patients undergoing dialysis and those with amputation, Charcot foot or prior ulcers).

There are some startling statistics that support the need for adhering to these recommendations and providing education to patients with diabetes. The lifetime risk of developing a foot ulcer for someone with diabetes is 25%,¹and diabetic neuropathy alone causes between 45% and 60% of diabetic foot ulcers.⁶Throughout the world, it is estimated that a leg is amputated because of diabetes every 30 seconds.⁷Therefore, prevention is key, with focused education on teaching patients with diabetes how to care for their feet. Here are some tips for them⁸:

• Check your feet every day. If you cannot see the bottom of your feet, use a mirror or ask someone for help.
• Do not smoke.
• Exercise.
• Keep blood flowing to your feet. Elevate them when sitting; wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day; and do not cross your legs for long periods.
• Look inside your shoes before wearing them. Make sure the lining is smooth and that no objects are hidden.
• Notify your health care provider about blisters; breaks or cuts in the skin; changes in color, sensitivity, or shape; ingrown nails; pain; red spots; and swelling.
• Protect your feet from extreme hot and cold temperatures.
• Rub a thin layer of lotion over the tops and bottoms of your feet, but not between your toes, to keep the skin soft.
• Trim your toenails straight across, and file the edges.
• Use a pumice stone on wet skin to treat calluses. If a callus becomes thick, see your health care provider for treatment. Do not attempt to cut, trim, or remove calluses with chemical agents on your own.
• Wash your feet every day, and dry them carefully, especially between the toes.
• Wear shoes and socks at all times. The shoes should be comfortable, fit well, and protect your feet.

Diabetic foot disease is real, but it can be prevented. Join the task force in reducing the clinical, economic, and social impacts of this severe complication for those with diabetes.

References

1. Wu SC, Driver VR, Wrobel JS, Armstrong DG. Foot ulcers in the diabetic patient, prevention and treatment.Vasc Health Risk Manag. 2007;3(1):65-76.
2. Brownrigg JR, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ. Evidence-based management of PAD & the diabetic foot.Eur J Vasc Endovasc Surg. 2013;45(6):673- 681. doi: 10.1016/j.ejvs.2013.02.014.
3. CDC report finds large decline in lower-limb amputations among U.S. adults after diagnosed diabetes [news release]. Atlanta, GA: CDC; January 24, 2012. cdc.gov/ media/releases/2012/p0124_lower_limb.html. Accessed August 21, 2018.
4. Raghav A, Khan ZA, Labala RK, Ahmad J, Noor S, Mishra BK. Financial burden of diabetic foot ulcers to world: a progressive topic to discuss always.Ther Adv Endocrinol Metab. 2018;9(1):29-31. doi: 10.1177/2042018817744513.
5. American Diabetes Association. Microvascular complications and foot care: standards of medical care in diabetes—2018.Diabetes Care. 2018;41(suppl 1):S105-S118. doi: 10.2337/dc18-S010.
6. Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer.World J Diabetes. 2015;6(1): 37-53. doi: 10.4239/wjd.v6.i1.37.
7. Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers.N Engl J Med. 2004;351(1):48-55. doi: 10.1056/NEJMcp032966.
8. Foot care. American Diabetes Association website. diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html. Updated October 10, 2014. Accessed August 21, 2018.

Kristen Marjama, DNP, APRN-BC, is a family nurse practitioner with more than 10 years of experience in the retail health industry. She is the manager of clinic education and professional development at Walmart Care Clinic in Fort Lauderdale, Florida.