Diabetic foot care
- Not all people with diabetes develop foot problems. In many cases serious problems can be prevented. Good control of sugar levels, an understanding of what can happen to feet and good diabetic foot care will all increase chances of a positive outcome in the long term.
- People with long standing diabetes are more likely to develop diabetic complications. This is even more so if their blood sugar levels have not been well controlled. People with diabetes can be more prone to infection and can also develop neuropathy (damaged nerves) or peripheral vascular disease (blocked arteries) of the legs and either can lead to foot ulceration. Infection and foot ulceration, alone or in combination, often lead to amputation. This happens to about 3000 people in Australia each year. Neuropathy and peripheral vascular disease can also cause distressing pain in the lower limbs.
Steps that can be taken to prevent or treat foot problems.
Good diabetic control is essential. However, by itself, it is often not enough. The next step involves determining the presence of risk factors each patient has for developing foot health complications.
A Podiatrist will complete diabetic risk assessments for each patient presenting with a history of diabetes. These may be completed at reasonable intervals to keep track of a patient's risk factor status. Those whose assessments reveal greater risk factors can then be channeled into an appropriate level of Podiatric foot care and education.
For people with diabetes who have not yet developed active infection or ulceration, the important thing is to grade the degree of risk and then to provide them with appropriate foot care education to minimize the risk of developing active foot problems.
A Podiatry Diabetes Risk Assessment should be carried out at least once a year. Those patients already categorised as high risk will be monitored on a more regular basis.
The assessment will look at these factors:
- Measurement of foot pulses
- Foot temperature check
- Monitoring foot sensation with a 5.07 Weinstein filament
- Vibration perception test
- Skin texture (dryness, maceration)
- Foot and leg skin colour (redness, bruising, blanching etc)
The results will be recorded and the patients risk status for foot problems determined. They will be reassessed and compared at appropriate intervals, relative to the patients risk level. If there is a significant change in any area, the Podiatrist will refer the patient on for appropriate medical attention and or testing. For example if the foot pulses were found to be weaker or not palpable, the patient may be referred on to a vascular specialist for more extensive screening.
- For people already with infection or ulceration, the important thing is to urgently treat the infection and heal the ulcer. It is necessary to distinguish between different types of ulceration, as the treatment required for that in neuropathic or vascular disease may be quite different.
Pain, must also be defined in origin, as vascular or neuropathic because the treatment is again quite different.
- Poor diabetic control increases infection and impairs wound healing. Although it is not possible to be absolutely clear cut, it is generally those with, very poor control (e.g. HbA1c greater than 10%), that is most at risk. Therefore even if diabetic control is not perfect it is worthwhile improving it to a level that is not "very bad". Remember also that even excellent diabetic control by itself will not completely prevent foot problems once severe neuropathy or peripheral vascular disease is established. Preventive and treatment strategies still need to be adhered to.
Are Type 1 or Type 2 diabetics more likely to develop foot problems?
- Children or young adults with Type 1 diabetes are at a low level risk of diabetes related foot problems in the early years as their nerves and blood vessels will not have been severely affected by diabetes. Normal sports and usual activities should be encouraged. There is no reason to stop any activity after being diagnosed with diabetes for fear that it might hurt the feet. As the duration of diabetes becomes longer (e.g. greater than 10-15 years) and the person becomes older (e.g. older than 40-50 years), progressively greater care is needed.
Some people with Type 2 diabetes may have had diabetes for a long time without knowing, making them predisposed to foot problems even soon after diagnosis. Circulation and nerve function are also not as good in older people.
Foot care for those at high risk of developing a foot ulcer
Every person with diabetes needs to be careful about their feet. However, those at higher risk because of neuropathy or peripheral vascular disease or other factors need to more vigilant.
Daily foot care should include:
Look at your feet - every day. Look at the top and bottom of your foot. Look and feel in between your toes and around the heel area. If you cannot see your feet easily, use a mirror or ask someone to help you.
What to look for:
- Cracks/breaks in skin
- Soggy skin
- Dry skin
- Swellings/swelling in only one foot or leg
- Corns and calluses
- Ingrown or sharp toenails
- Hot/cold spots
- Anything that does not seem normal or that was not there yesterday
Check for Corns and Callouses (hardened skin).
Corns and calluses can be a problem. They cause pressure and may lead to ulceration. Never trim back or cut a corn yourself. Do not use a corn pad, they contain acid and often burn the surrounding skin without having any impact on the corn. An ulcer may develop from this. Using a pumice stone can also be dangerous, if you cannot feel your feet. The only safe way to treat a corn or callous is to see a podiatrist.
Callous before and after removal
Nail care: Do not cut your nails too short. Cut your nails straight across but file the corners so that they are not sharp.. Always check your nails for sharp edges. To smooth sharp edges use a nail file. If you are unable to cut your nails, see a podiatrist. Patients with high risk diabetes should not cut their own toe nails at all.
Wash your feet every day using warm water and mild soap or soap replacement. Check the water with your elbow first to make sure it is not too hot. Dry your feet using a light coloured towel, especially between the toes. Look at the towel to make sure there is no blood or pus on it. If you can see any blood or pus, contact your doctor as soon as possible.
Soaking the feet is not recommended as daily foot care. However if the feet are soaked for any reason it should be no longer than 2-3 minutes as this makes the skin too soft and fragile. Adding some bath oil to your foot bath can help moisturize the skin. This is particularly helpful if you are unable to get down to your feet to rub cream in.
Note: Foot Spas can be dangerous for people with diabetes, especially those with neuropathy or vascular disease. Check with your podiatrist before using.
It is important to dry between your toes well. If the skin between your toes becomes white and soggy (macerated) apply some methylated spirits using a cotton bud. If the problem doesn't clear in a couple of days, see your doctor. You may need an anti-fungal cream.
Apply moisturizing cream to your feet daily to stop them getting dry and cracked. Do not put cream between the toes. Initially, Use the cream twice a day if your feet are very dry. Your podiatrist can advise the best cream for your skin type. Some of the problems we see due to poor foot care are:
- Maceration or sogginess between the toes which can lead to infection
- Very dry skin with cracks predisposing to infection
Footwear and foot Protection.
- Bare feet are not only at high risk of injury, but the pressure under the foot is increased when walking without the cushioning of shoes to protect the feet.
- Wear thick socks with well cushioned, closed shoes which are large enough to fit the foot and sock.
- Be careful about exposure to direct heat such as bar heaters or hot water bottles to warm the feet as these can cause burns in someone with diminished sensation. Wear thick socks to keep the feet warm.
- Summer can also be problematic. The sun and hot sand can cause burns in someone with diminished sensation. Be sure to apply sun block to the feet, or better still keep the feet covered when in the sun. Wear surf shoes or sandals when on the beach to protect the feet from hot sand and injury.
Wearing new shoes is one of the commonest precipitating causes of developing foot ulceration. Buy new shoes in the afternoon when the feet are at their largest. Have your feet properly measured and fitted, as shoe size not only changes as we get older but people with neuropathy can have a change in foot shape and size. Also, people with neuropathy tend to buy shoes that are too small as they cannot feel that the shoe is too tight.