Diabetic foot ulcers

What it takes to heal

A diabetic foot ulcer is a break/hole through the body’s outer protective layer, the skin. The most important factors in their forming include:

  • Reduced ability to feel pain due to diabetic neuropathy.
  • Diminished blood flow to the lower extremities.
  • Excessive pressure at the ulcer site. This may cause a blister or callus to form. The skin below then begins to break down.

Additional factors include:

  • Abnormal blood sugars.
  • Reduced functioning of the immune system.
  • Nutritional imbalances.

Recognizing the role that each of the above factors play also tells us what is necessary to heal these wounds. If the right environment is created, ulcers will heal quickly and uneventfully. Each of the steps in treatment is aimed at creating that environment.

Diabetic foot ulcers must be kept clean and pressure free. If there is adequate blood flow, these wounds will generally close nicely and rapidly. When they do not respond, we need to reevaluate which of these factors is missing.

Clean – Bacteria love the unhealthy tissue that forms in and around an ulcer. Callus also creates a source of pressure that in turn injures the tissue below. Cleaning the ulcer may involve simply washing the wound daily. Various types of dressings are often used to help wick drainage and debris from the wound. Your doctor may also sharply debride the wound. This includes physically cutting away any unhealthy tissue and callus that has formed in and around the wound slowing the healing process.

If the ulcer and bacteria have penetrated to deeper tissues such as bone, treatment becomes much more difficult. Antibiotics can sometimes penetrate bone but more often, the infected bone must be removed.

Topical medications are sometimes used and may include antibacterial agents or tissue growth promoting agents.

Pressure free – Reducing pressure at an ulcer site is critical. Common sense suggests that keeping a wound pressure free is necessary for healing. Unfortunately, because those with neuropathy feel little or no pain from the wound, they often walk on their open ulcer without thinking about how much damage they are doing. The result is a nonhealing, infected wound.

Various means of reducing pressure are available. These include:

  • Padding around the wound
  • Altered shoes and insoles
  • Specially designed surgical shoes or boots
  • Cast
  • Crutches
  • Wheelchair

The means chosen to unweight the wound will depend on the seriousness and location of the ulcer. Whatever means is utlized, it is important that it is always used when weight-bearing. Not some of the time or most of the time but always — even when you get up to go to the bathroom. Just a very brief period of excess pressure is often enough to reverse several days of healing.

Adequate blood flow – Like a plant without water, without adequate blood flow a wound will suffer. Circulation brings nutrients and the body’s antibacterial fighting capabilities to the site of injury. Further, while it takes a certain amount of blood flow to maintain our tissues, it takes even more to heal them when they are wounded.

For the uninjured foot, exercise is the best way to maintain circulation. Walk, walk and then walk some more.

When the circulation is clearly inadequate, it is usually evident to your doctor by the color, temperature and texture of your skin along with the ability to feel your foot pulses. When your circulation is questionable, your doctor may suggest that you obtain the opinion of a vascular surgeon.

Blood sugars – Controlling blood sugars is often difficult in the presence of infection. Conversely, elevated blood sugars make it more difficult for your body to fight infection. If you are having difficulty in this regard, you need to contact the physician with whom you ordinarily work with your diabetes.

Diet – Maintaining proper nutrition is especially important when you are trying to heal a wound and/or infection.

Team effort – The healing of diabetic foot ulcers is a team effort. Your doctor may provide recommendations but their role is really that of coach. You are the player. Your doctor cannot do it for you. Medications need to be taken on time, dressings changed as prescribed and devices need to be worn at virtually all times that you are weight-bearing. Any adverse changes in the wound (redness, swelling, drainage or odor) must be reported to your doctor immediately. Together, with the right healing environment, these wounds can remain a minor annoyance and not become a limb threatening problem.