Diabetic foot ulcer
Tackling one of the most serious complications of diabetes.
Diabetic foot ulcer is a common and serious complication of both type 1 and type 2 diabetes mellitus
Because of the reduced blood supply to the lower limb, diabetic foot ulcers are prone to necrosis, infection, and involvement of deep tissues, including bone
Approaches to the management of diabetic foot ulcer include debridement, protection from trauma, treatment of infection, control of exudate, and promotion of healing
Patients with type 1 or type 2 diabetes mellitus have a lifetime risk of a foot ulcer of up to 25%
These findings show how important it is to manage diabetic foot ulcer appropriately, quickly, and effectively
Aetiology
The causes of diabetic foot ulceration are a combination of chronic narrowing of small arterioles that supply oxygen to the tissues, diabetic arteriolosclerosis, which results in tissue ischaemia, and high venous pressure, resulting in tissue oedema and hypoxia
Patients with diabetes develop specific risk factors that lead to foot ulcers, including loss of sensation due to diabetic neuropathy, prior skin damage or ulcers, foot deformity or other causes of pressure, external trauma, infection, and chronic ischaemia due to peripheral artery disease
Clinical and economic burden
Globally, an estimated 422 million adults were living with diabetes in 2014, compared with 108 million in 1980
Rates of lower limb amputation, due to diabetic foot ulcer, are typically ten to 20 times those of non-diabetic populations
In the US, Medicare claims data showed that between 2006 and 2008, patients with a diabetic foot ulcer were seen by their outpatient healthcare provider about 14 times per year and were hospitalised about 1.5 times per year. The US claims data also showed that the cost of care for each claimant with a diabetic foot ulcer was about USD 33,000 for all Medicare services per year
Effects on patient quality of life
Studies have shown that patients with diabetes who have a healed foot ulcer have a greater health-related quality of life (HRQoL) when compared with patients with chronic, non-healed diabetic foot ulcers when evaluated using standard questionnaires
Management
Successful treatment and diagnosis of patients with diabetic foot ulcers involves a holistic approach that includes the patients physical, psychological and social health and the status of the wound
The management of diabetic foot ulcer begins with assessment, grading, and classifying the ulcer based on clinical evaluation of the extent and depth of the ulcer and the presence of infection, which determine the nature and intensity of treatment
- 10 g Monofilament for testing the sensory neuropathy and should be applied at various sites along the plantar aspect of the foot.
- Tuning fork standard 128Hz is used to test the ability to feel vibrations, a biothesiometer is a device that also assess the perception of vibration
In patients with peripheral neuropathy, it is important to offload at risk areas of the foot in order to redistribute pressures evenly
To ensure holistic assessment and treatment of diabetic foot ulcers, the wound should be classified according to a validated clinical tool. The University of Texas (UT) system was the first diabetic foot ulcer classification to be validated and consists of three grades of ulcer and four stages
The European Wound Management Association (EWMA) states that the emphasis in wound care for diabetic foot ulcers should be on radical and repeated debridement, bacterial control and frequent inspection and careful moisture balance to prevent maceration
While it may seem logical that effective glucose control could promote healing of diabetic foot ulcers, there is no evidence in the published literature to support this assumption
Risk of infection
Chronic non-healing ulcers of the foot are susceptible to infection, which can lead to serious complications, including osteomyelitis and septicaemia
When a diagnosis of ulcer infection is made, treatment is based on the clinical stage of infection, and X-ray imaging is usually performed to exclude or confirm osteomyelitis
According to the Infectious Disease Society of America (IDSA) guidelines, infection is present if there is obvious purulent drainage and/or the presence of two or more signs of inflammation (erythema, pain, tenderness, warmth, or induration
The role of dressings in the management of diabetic foot ulcers
Following debridement, the diabetic foot ulcershould be kept clean and moist but free of excess exudate, with dressings selected based upon the ulcer characteristics, such as the extent of exudate, or necrotic tissue
By using a dressing that create a moist wound healing a natural process to soften and remove devitalised tissue will occur, this process is called autolytic debridement. Care must be taken not to use a moisture donating dressing as this can predispose to maceration. In addition, the application of moisture-retentive dressings in the presence of ischaemia and/or dry gangrene is notrecommended
It is important to incorporate strategies to prevent trauma and minimise wound-related pain during dressing changes
Other advanced treatments for diabetic foot ulcers
Adjunctive therapies may improve ulcer healing, such as negative pressure wound therapy (NPWT), the use of custom-fit semipermeable polymeric membrane dressings, cultured human dermal grafts, and application of growth factors
All ulcers subjected to sustained or frequent pressure and stress, including pressure-related heel ulcers or medial and lateral foot ulcersor repetitive moderate pressure (plantar foot ulcers) benefit from pressure reduction, which is accomplished with mechanical offloading. Offloading devices include total contact casts, cast walkers, shoe modifications, and other devices to assist in mobility
Patient education of self - care
Effective foot care should be a partnership between patients, carers and healthcare professionals. Educating patients about proper foot care and periodic foot examinations are effective interventions to prevent ulceration
The Exufiber® Effect
It is time for change
Highly exuding wounds are challenging to treat. Clinicians may see exudate pooling, slough and delayed healing due to the presence of biofilm. Patients may feel pain, embarrassment and anxiety from leakage. That is why we are looking at gelling fibres differently. Providing a wound healing solution that clinicians want to see and that patients can feel.
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