The Diabetic Foot Ulcer And Its Treatment

One of the most common complication of diabetes mellitus is FOOT ULCER.Food ulcers are occurring up to 15 % of all diabetic patients.The associated healthcare costs are enormous.It has been estimated around $28,000 during the 2 years after the diagnose.Studies have shown that 6% to 34% of patients with a diabetic foot ulcer will ultimately progress to the AMPUTATION.The cost associated with it is even more formidable.The tragedy is that such morbidity and costs result from lesions that may be prevented by the institution of ,and compliance with,diabetic foot care policies.

MAIN CAUSES OF DIABETIC FOOT:

The main cause of foot ulceration is neuropathy,small peripheral vascular disease and abnormal foot biomechanics.Neuropathy itself is the chronic complication of uncontrolled diabetes which causes devastating neurological disorders.The poor glycemic control results in the involvement of sensory and motor systems as well as autonomic nervous system.Sensory system involvement makes the patient unable to sense the injury on feet caused by objects together with decreased pain sensations.

All factors are frequently compounded by bacterial infectio with organisms such as staphylococcus aureus and streptococcus pyogenes often accompanied with anaerobes such as bacteroides species.Neuropathy is thought to be the main factor in overall one half of ulcers with trauma occurring as a result of loss of pain sensation.Minimal trauma to the feet like foreign body in shoes,ill fitting shoes,walking on barefoot on hot surface may lead to devastating effects.Excessive pressures on the toe and heel ,predisposes to the formation of callus which can breakdown and lead to the ulceration.Indeed callus is the important predictor of ulceration.Such excess pressure is generated by motor nerve damage altering the posture of the foot,limited joint moibility and local deformalities including charcots arthropathy (hereditary sensorimotor neuropathy that results in progressive weakness and wasting of mucles of legs and thighs and loss of sensation).

Autonomic nerve damage leads to reduced sweating and a dry skin which may lead to crack or split more easily allowing the ingress of bacterial infection.

Atherosclerotic disease of peripheral vessels is very common in diabetic patient and another important factor in foot ulceration.Ulcers purely due to ischemia is rare but common to co exist with neuropathy.Previous amputation and foot deformity together with previous foot ulceration,poor footcare advice and advanced age are also the important risk factors for the development of diabetic foot ulcer.

SIGNS AND SYMPTOMS :

When ulcers get infected ,they show the signs of inflammation,that are redness on the site of ulcer,warmth and tenderness.On close examination you will see foul smeling,green or yellowish color pus discharge which is mostly blood stained.Deep seated infections and osteomyelitis that is involvement of bone are important to diagnose.If the bone is felt by probing a ulcer,osteomyelitis can be assumed.Depp infection is suggested by deep sinuses,tissues damage with discharge and crepitus on palpating the foot.
TREATMENTS:

Debridement and removal of slough and necrotic eschar is vital to promote healing.Surgical debridement may occasionally be necessary for an extensive lesion.Reflief of pressure is a basic principle of all neuropathic ulcers using methods as an insole encased in either a temporary shoe or plaster cast (total contact cast or scotchcast foot).Dressings should be absorbent enough to deal with the wound exudatuion.A moist wound environment may be preferable to encourage granulation tissue.Infection must be treated when presenr but may be difficult to determine as may be the causative organism.

Antibiotic regimens: In the absence of deep infections,monotherapy with a broad spectrum antibiotic,such as co amoxiclav is appropriate.Deep ulceration require initial intravenous administration of antibiotic,such as ampicillin, flucloxacillin, and metronidazole,changing to oral administration when infection seems to be responding. Clindamycin isuseful when there is the bone involvement or osteomyelitis.

Routine radiography may be helpful in showing the presence of gas or evidence of osteomyelitis .It often reveals calcification of the small vessels of the foot.Osteomyelitis is also confirmed by MRI or white cell scanning.In all cases vascular assessment should be made and amputation may be necessary it there is extensive gangrene or spreading of necrosis in a toxic patient.Revascularization may be possible for neuroischemic ulcers.

Many new and experimental treatments for diabetic foot ulcers have emerged in recent years.Dermagradft ,Smith and Newphew (cutured human dermis) and Alprigraph,Novartis (Graftskin) (bilayere bioenginerred skin substitute) have been shown to shorten healing time and to produce a significantly greater proportion of healed ulcers.Platelet derived growth factors (becaplermin) has been used to heal small low grade ulcers.Hyperbaric oxygen has been shown to accelerate the rate of healing and increase the number of wounds completely healed.Debridement with with maggots is simple and effecteive for cleaning chronic wounds and initiating granulation.None of these techniques has become an accepted standard therapy for the treatment of diabetic foot ulcers and further assessments of efficacy and cost effectiveness are required.

PREVENTIONS:

Prevention podiatric should be given to all patients especially at risk.Comprehensive screening programs and treatment programs have been shown to reduce the risk of amputation.Simple measures such as debridement of callus and the fitting of appropriate shoes,often with the help of an orthotist,may be all that is necessary to prevent one of the most devastating and feared complications of diabetes,amputation.

Self hygiene and foot care is very important but not the self treatment.Consultation with a State Registered Chiropodist / Podiatrist or your family doctor is recommended, they will evaluate the particular form of ulcer and choose the appropriate treatment plan.Using foot balms and lotions especially after bath and wearing proper fitting shoes are excellent measures.Even the minor crack and cut should be carefully treated to prevent the dangerous outcomes of foot ulcer