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MANAGEMENT OF DIABETIC FOOT ULCER

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

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Content

  1. Introduction
  2. Assessment of Diabetic Foot Ulcer
  3. Classification of Diabetic Foot Ulcer
  4. Clinical Photos
  5. Management

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INTRODUCTION

  • Diabetic foot is a foot that exhibits any pathology that results directly from diabetes mellitus or any long-term (or "chronic") complication of diabetes mellitus (Jeffcoate & Harding, 2003).
  • Diabetic foot’ implies that the pathophysiological process of diabetes mellitus does something to the foot that puts it at increased risk for “tissue damage” and the resultant increase in morbidity and maybe amputation (Payne & Florkowski, 1998).

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INCIDENCE OF DIABETIC FOOT ULCER

  • Studies have indicated that diabetic patients have up to a 25% lifetime risk of developing a foot ulcer.
  • The annual incidence of diabetic foot ulcers is ~ 3% to as high as 10%. (Armstrong and Lavery, 1998).

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�PATHOPHYSIOLOGY OF DIABETIC FOOT ULCER�

  • Diabetic are prone to foot ulceration due to:
    • Neuropathy- leads to skin dryness and cracks, foot deformity and loss of protective sense in the foot
    • Microangiopathy/vascular disease- lead to poor blood supply to the toes and foot and then ulcerate easily
    • Immunopathy- Defects in leukocyte function (leukocyte phagocytosis, neutrophil dysfunction) and also deficient white cell chemotaxis and adherence

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�CLINICAL PRESENTATION�

  • Soft tissue infections (superficial to deep tissue infection e.g. cellulitis, necrotizing fasciitis, etc.)
  • Osteomyelitis (bone infection)
  • Septic arthritis (joint infection)
  • Gangrene (dry or wet)
  • Chronic non-healing ulcer
  • Combination of more than one of the above mentioned condition

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ASSESSMENT OF �DIABETIC FOOT ULCER

  • History:

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  • Examination:�Thorough and carefully look at the whole foot

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CLASSIFICATION OF �DIABETIC FOOT ULCER

  • Wagner Classification of Diabetic Foot Ulcer

Grade

Description

0

No ulcer in a high risk foot (callosities, deformity, skin dryness etc)

1

Superficial ulcer involving the partial or full skin thickness but not underlying tissues.

2

Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation.

3

Deep ulcer with cellulitis or abscess formation, often with osteomyelitis or joint sepsis.

4

Localized gangrene (portion of forefoot or heel).

5

Extensive gangrene involving the whole foot

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�FOOT AT RISK OF ULCERATION�

  • History of ulceration
  • Presence of neuropathy
  • Presence of peripheral vascular disease
  • Presence of foot deformity
  • Inappropriate footwear
  • Skin lesion
  • Nail pathology
  • Duration of diabetes
  • Prolonged standing or walking
  • Type of occupation

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MANAGEMENT OF �DIABETIC FOOT ULCER

  • Objective:
    • Control infection
    • Ulcer/wound management
    • Prevent amputation
    • Maintain pre-morbid foot/lower extremity function as much as possible
    • Prevent recurrent ulcer

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1. General Management

  • A multidisciplinary approach
  • Good diabetic control
  • Systemic antibiotics (according to CPG on Antibiotic Guideline and also culture and sensitivity of the infected tissue)
  • Optimized other co-morbid complications.
  • Advised stopped smoking

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2. Local Management

  • Wound/ulcer management: depending on severity of wound; vascularity and also presence of infection
  • Debride infected/necrotic tissue follow by wound management
  • May need repeated debridement
  • Amputation may be the treatment of choice
  • Minimize risk of infection
  • If indicated reestablished adequate blood supply (refer to chapter on arterial ulcer)
  • Off loading with contact cast etc
  • Good foot care and foot wear

Expect to see sign of healing after 2 weeks of treatment

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�DIABETIC FOOT-CARE�

  • Foot inspection- minimally once a day.
  • Use lukewarm (air suam), not hot water to wash feet.
  • Use gentle soap to bath/wash feet.
  • Apply moisturizer to avoid dry feet – be careful with the web space and not too much (causing skin maceration).
  • Proper nail cutting, avoid cutting too close/digging nail fold.
  • Wear clean, dry socks (NEVER use heating pad or hot water bottle) to keep foot warm.
  • Avoid walk barefooted.

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DIABETIC FOOT-CARE

  • Wear comfortable well fitting shoe (not too tight or too loose), evening is the best time to buy shoe. Shake out shoes and feel the inside before wearing.
  • Never treat corns or calluses themselves.
  • Good diabetic control.
  • Stop smoking.
  • Periodic foot examination by relevant personals.
  • Keep the blood flowing to feet (elevate, wiggers toes, moving ankle), avoid cross-leg or hanging leg/feet too long.

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TAKE HOME MESSAGES

  • Good glycemic control, regular foot assessment, including vascular and neurological assessment, to prevent diabetic foot ulcer.
  • The main underlying cause of DFU is chronic pressure – think of off loading.
  • Diabetic foot ulcer need multidisciplinary approach.

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REFERENCES

  • James Teh, Tony Berendt, Benjamin A Lipsky. Investigating suspected bone infection in the diabetic foot. BMJ 2009;339:b4690.
  •  Warren Clayton, Jr.Tom A. Elasy. A Review of the Pathophysiology, Classification, and Treatment of Foot Ulcers in Diabetic Patients. Clinical Diabetes Spring 2009 vol. 27 no. 252-58.
  •  Armstrong DG. And Lavery LA. Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. Am Fam. Physician. 1998 Mar 15; 57(6):1325-1332.
  •  Frykberg RG. Diabetic Foot Ulcers: Pathogenesis and Management. Am Fam. Physician. 2002 Nov 1; 66(9):1655-1663.

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THANK YOU

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