Diabetic foot ulcers

Dr Maxwell Adeyemi  -
Dr Maxwell Adeyemi -


DIABETIC FOOT problems are common throughout the world, resulting in major economic consequences for the patients, their families and the society.

Foot ulcers are more likely to be of neuropathic (nerve damage) origin and therefore preventable in developing countries like ours which will experience the greatest rise in the prevalence of type 2 diabetes in the next 20 years.

People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet. Education and frequent follow-up of these patients are important.

When assessing the economic effects of diabetic foot disease, it is important to note that the rates of recurrence of foot ulcers are very high, being greater than 50 per cent after three years. Which means that people with foot ulcers have a higher rate of recurrent foot ulcers.

Costing should therefore include not only the immediate ulcer episode, but also social services, home care, lost work times, hospital care, loss of social life and even subsequent ulcer episodes.

A broader view of total resource use should include some estimate of quality of life and the final outcome: An integrated care approach with regular well-co-ordinated screening and education of patients at risk which require low expenditure and has the potential to reduce the cost of healthcare.

A considerable number of our diabetics are coming down with foot ulcers. We therefore need serious interventions aimed at educating patients on prevention and management strategies.

Many of those with ulcers do experience recurrence, and this needs to be addressed in a meaningful way to reduce the recurrence rates. As a matter of fact, if we are dressing the same foot ulcer for three-four months without healing, then something is wrong and we may need to review such wounds and a new approach may be needed.

Often times infections complicate foot ulcers. The combination of foot ulcers and infection can be limb- or life-threatening, and this calls for aggressive and prompt treatment with antimicrobials (antibiotics).

Another militating factor against wound-healing is the issue of “off-loading” – taking weight and pressure off the ulcer points. The success of off-loading depends on the patient’s adherence and compliance to instructions. So, alleviation of the mechanical load on ulcers should always be a part of the treatment plan. Many of our patients need to be educated on the vital importance of this for greater appreciation and compliance.

Wound-dressing is another important factor we need to look at closely. The use of appropriate wound-dressing materials, techniques and under conditions that minimise infections are crucial to wound management. So, there is need for a concerted effort in training and retraining of staff, and educating our patients on dressing modalities for better results.

All attempts should be made to prevent diabetic foot ulceration and treat existing ulcers by a multidisciplinary team in order to decrease amputations. Indeed, improvement in ulcers healing has been observed with primary healing rates of 65-85 per cent.

Prevention of foot ulcers is crucial to avoiding amputations. The best approach is to make use of a team of multidisciplinary professionals who are
committed to limb salvage. Centres that have instituted teams specifically for this purpose have subsequently reported dramatic reductions in low extremity amputations and improved rates of primary ulcer healing.

Patient education has a central role in treatment and should include instructions on foot hygiene, daily inspections, proper footwear and the importance of prompt treatment of new lesions.

Reasons for poorly healing ulcers/wounds

• Poor metabolic control: Effective glucose control is vital because high blood sugars impede wound-healing. It affects the immune response to healing and the ability to fight infections, as it impairs functioning of the immune response cells. It is also crucial for lipids and blood pressure to be controlled.

• Poor circulation: Inadequate blood flow as occasioned by macro vascular and micro vascular damage will also slow down the healing process.

• Nutrition: Poor nutrition also militates against effective wound-healing.

• Infection: If an ulcer is not healing well, it is important to look for infections and treat promptly. Ulcers may be painful, oozing and have offensive odours.

• Excessive dead tissues: Healing may also be negatively impacted by excessive dead tissues that need to be cleaned out (debrided) to allow exposure to healthy vascular bed and promote healing. These can be slough tissues or hard, dark and dry tissues known as eschar tissues.

• Off-loading: Taking pressure off the ulcer points is very important as continuous bruising and pressures make healing a challenge.

• Use of proper footwear: It is important that diabetics wear appropriate and protective footwear that minimises foot injuries.

• Dressing materials: The use of appropriate and wound-type relevant dressing materials is essential to wound-healing. While some wounds need moisturised dressings, others need dry dressings, some do well with gels and others may need ointments. It is also important to clean wounds properly so you don’t keep loading the wound sites with materials that eventually create a pile of debris, which makes them ineffective. If you have a poorly healing wound, you need to get help to evaluate why this is so.

• Anaemia: Low blood count or anaemia can also affect the progress of an ulcer as this slows down the healing process.

• Kidney disease: Patients with various stages of kidney failure also experience significant retardation in wound healing.

It is therefore important to critically assess the ulcers and make an individual analysis of each patient with regard to the ulcers so that a customised management plan can be instituted, depending on the status of each patient.

Contact Dr Maxwell on 3631807 or 7575411


"Diabetic foot ulcers"

More in this section