Diabetic Foot
Diabetic Foot is the most significant and devastating complication of lower limb in people with prolong diabetes develop in the background of neuropathy and vasculopathy and can be presented as aery of foot condition
- Non healing ulcer
- Infection
- Gangrene
- Neuropathic bone and joint; Charcot disease
This is a vicious cycle of neuropathy and vasculopathy, the journey starts from the development of neuropathy. Every 2nd diabetics develop neuropathy in their life time and risk of developing impaired blood supply at tissue level is 2-8 times higher in diabetic population.
Neuropathy affects all functions of nerve:
- Loss of protective sensation like pain, pressure, heat and cold sensation increase the possibility of injury.
- Loss of muscle power, atrophy and paralysis mostly affecting small muscles of the foot which are the balancing force between upper and lower muscle of foot leading to deformity formation. Increase the risk of callus formation.
- Loss of sweating and tone of blood vessels lead to dry skin and swelling.
Abnormal pressure points are ignored as they remain painless in a neuropathic foot. With time fad pad between skin and bone at this area disappears and normal skin get replaced with thick dead skin. These are callus which ultimately peels off and ulcer forms. This ulcer do not get a chance to heal due to existing poor tissue circulation and oxygenation.
Peripheral arterial disease is 2–8 times more common in patients with diabetes. Starting at an earlier age, progressing more rapidly, and usually being more severe than in the general population. Major injury or even minor injuries, especially when complicated by infection, increase the demand for blood in the foot, and an inadequate blood supply may result in foot ulceration, potentially leading to limb amputation.
The prevalence of diabetic foot ulceration in the diabetic population is 4–10%; the condition is more frequent in older patients. It is estimated that about 5% of all patients with diabetes present with a history of foot ulceration, while the lifetime risk of diabetic patients developing this complication is 15%. The majority (60–80%) of foot ulcers will heal, while 10–15% of them will remain active, and 14–24% of them will finally lead to limb amputation within a period of 6–18 months after the first evaluation. Ulcers with good circulation usually takes 20 weeks to heal whereas in the presence of impaired blood supply it takes longer and will more often will lead to amputation. Ninety percent of hospital admissions for diabetic foot ulcers are related to peripheral neuropathy and infection. More than 90% non-traumatic amputations are due to DM.
The risk of foot ulceration and limb amputation increases with age and the duration of diabetes. The prevention of diabetic foot is crucial, considering the negative impact on ones quality of life and associated huge economic burden on the healthcare system.
In 2021 74.2 million people are living with diabetes in India, second highest of the world and will be remain so till 2045. It is predicted to increase by 69% by 2045 to reach 152 million. India accounts for 1 in 7 of all adults living with diabetes worldwide. Over 1 in 2 (51.2%) adults living with diabetes are undiagnosed.
All these are indirect data as our healthcare system does not have any protocol based dedicated treatment facility of diabetic foot. And there is no actual data of how many diabetic foot are being treated in different facilities on actual. But if the available scientific data of incidence of neuropathy and ulcer formation is extrapolated with current prevalence of diabetic population in India then the number is huge. Current diabetic population is 74.2 million in India and scientifically evident prevalence of neuropathy among diabetic in their lifetime is 50%. The prevalence of diabetic foot ulceration in the diabetic population is 4–10%; the condition is more frequent in older patients. It is estimated that about 5% of all patients with diabetes present with a history of foot ulceration, while the lifetime risk of diabetic patients developing this complication is 15%. The majority (60–80%) of foot ulcers will heal, while 10–15% of them will remain active, and 14–24% of them will finally lead to limb amputation within a period of 6–18 months after the first evaluation.
According to IDF 2021 data only 10.1 billion USD was spent on diabetes in the SEA Region. India constitute 90% of population of SEA Region. This expenditure representing 1% of the total spent worldwide, despite the region being home to 16.8% of people with diabetes worldwide.
Check your feet every day: In diabetes your feet sensation can get diminished and you may not feel any pain even if there is any cut or injury. Checking your feet every day will help you spot problems early before they get worse. A good way to remember checking every day is to check each evening when you take off your shoes or just before going to bed. Check not only top of the feet but also the bottom of feet and between the toes. If you cannot bend enough to examine yourself use a mirror or ask any of your family member to check for you.
What will you look for?
- Cuts, swelling, blisters or maceration
- Changes in your skin temperature like warmth (sign of infection) or colder (sign of loss of blood supply) than normal skin area
- Changes in your skin colour like pale (sign of reduced circulation), red (sign of infection) or blue (sign of gangrene)
- Changes in your nail like ingrowing toe nail (corner of nail buried within skin), thickening or yellow discoloration (sign of fungal infection).
Wash your feet every day: Washing will help you to remove dry scally skin and dirt from your feet and help keep your feet healthy. Remember the following while washing your feet:
- Use warm (not hot) water for washing
- Don’t use hard soap for washing
- Don’t soak your feet for long
- Dry your feet completely then apply lotion to the top and bottom but not between your toe clefts, use talcum powder.
Keep your feet moist: Due to nerve damage in diabetes skin of foot area does not produces any sweat and becomes dry. Dry skin develops cracks which allows bugs to invade and cause infection. To prevent skin cracks use moisturiser over top and bottom of your feet every day but avoid toe clefts.
Keep your toe clefts dry: Usually toe cleft remain moist which can cause maceration. Moist macerated skin is ideal site for fungal infection. Avoid using moisturiser between toes clefts rather use talcum powder after washing to keep it dry.
Care for corns and calluses: Gently rub corns and calluses with pumice stone only in one direction after bath and shower to keep it smooth and thin. Do not cut it with blade or use any over the counter corn removal products by yourselves, it may cause skin damage and infection. If it is too thick, ask your foot care doctor for removal.
Care for toe nail: Trim your toenails, when needed, after you wash and dry your feet. Using toenail clippers, trim your toenails straight across. Do not cut into the corners of your toenail. Gently smooth each nail with an emery board or non-sharp nail file. Trimming this way helps prevent cutting your skin and keeps the nails from growing into your skin.
Never go barefoot: Always wear shoes and socks or covered slip in slippers, even inside home to avoid injury. Never wear flip-flop or open slippers. Check that there aren’t any pebbles or other objects inside your shoes every time you are wearing and that the lining is smooth.
Protect your feet from heat and cold: use sunscreen on exposed skin and don’t walk bare foot at beach. In cold weather wear a warm woollen socks rather than warming your feet near a heater, fireplace or hot bag.
Wear shoes that fit well: For the best fit, try on new shoes at the end of the day when your feet tend to be largest. Break in your new shoes slowly—wear them for an hour or two a day at first until they’re completely comfortable. Always wear cotton seamless socks with your shoes.
Keep the blood flowing:
- Always put your feet up when sitting, it reduces swelling
- Wiggle your toes for a few minutes throughout the day, move your ankle up and down in and out to help blood flow in your feet and legs
- Do not wear tight socks or elastic stockings. Do not try to hold up loose socks with rubber bands.
- Stop smoking.
Choose feet-friendly activities: Be more physically active and choose activities that are easy on your feet like walking, dancing, yoga or stretching, riding a bike, or swimming. Check with your doctor about which activities are best for you and any you should avoid.