As much as a quarter of all diabetics will develop a foot ulcer in their lifetime, and many of these ulcers will become infected. See here for a discussion of 8 factors that increase the risk of a diabetic foot ulcer becoming infected. Foot ulcers cause great emotional, physical, productivity, and financial losses. In this post, I will discuss 10 strategies for prevention of foot infections in diabetics.
1- Get tested for diabetes. The most obvious risk for diabetic foot infections is being a diabetic. Duh…I know that’s what you are thinking, but many persons with diabetes are undiagnosed, and go undiagnosed for many years! Too often, a severe foot infection prompts someone to seek medical attention and only then, for the first time, they are finding out that they have diabetes. I have even had cases where, on the first presentation, amputation of several toes and even the entire foot, is necessary. Imagine going from “healthy” to having your foot amputated in a matter of days, because you never got a test for diabetes. It is extremely devastating.
2- Know whether or not you have neuropathy. Neuropathy is the condition where the nerves are damaged to the point where feeling is diminished (explained in more detail here, factor #6). The doctor can test for this with a simple “monofilament test” where points on your foot are touched with a special piece of nylon filament, to detect areas with decreased or absent sensation. Knowing that you have neuropathy should make you that much more vigilant about protecting your feet from trauma. Trauma can occur during an activity as “simple” as a long drive. I had a patient once who took a 3 hour roadtrip as the driver. The following day, he woke up to find a big blister on his right heel. This broke down becoming an ulcer within a few days. The ulcer was still present months later, by which time it had extended to the bone, with severe infection present. He underwent weeks and weeks of antibiotics and repeated surgeries to clean away the dead tissue and bone. All this from keeping his foot on the pedal of the car for too prolonged a period. (This patient also had circulation problems.)
3- Wear proper fitting shoes. They might not be the most beautiful shoes, but I think most people would prefer to have unflattering shoes on their own feet rather than to have beautiful shoes on prosthetic feet. For persons with serious deformities of the feet, a podiatrist or an orthotic specialist can design the best shoes, to reduce areas of high pressure and friction, and to accommodate foot deformities.
4- Inspect your feet at the end of every day. Yes. Every. Single. Day. Every day, because a wound can become infected within hours. Because you may not feel the pain from a blister or wound, you need to look for such injuries. If you cannot reach the feet, then use a mirror to visualize the soles of the feet. If your vision is not the best (eye disease is common in diabetes), use your hands to feel your feet for irregularities or wet areas. If you know how your feet feel, you would feel the difference when there is a wound (sort of like women doing breast self exams for breast cancer prevention, to get to know the feel of their normal breasts). If all else fails, hopefully there is a loved one you can depend on to inspect your feet for you every day.
5- Don’t let beauticians cut on your feet. When getting a pedicure, your cuticles should not be cut, and corns/calluses should not be filed down. These procedures are sometimes done too aggressively in beauty parlors, resulting in significant wounds. Additionally, tools used may not be sterile, and infection may develop in the wounds within days.
6- See a podiatrist at least once per year. Sometimes, I think podiatrists are a forgotten part of the diabetes care team. Too many diabetics have never been to a podiatrist which is a shame, considering that it is a service often covered by medical insurance plans. A podiatrist can examine the feet looking for deformities, areas prone to increased pressure, and the presence of neuropathy. Podiatrists can also safely remove calluses and thickened toenails, among other procedures. All diabetics should visit a podiatrist at least once per year, more often depending on the condition of the feet.
7- Get athletes foot treated. Athletes foot refers to the presence of a fungal infection between the toes and sometimes on the sides and soles of the feet. It is a common problem in diabetics and causes maceration (raw, moist skin) between the toes, and cracking of the skin at the sides and soles of the feet. Bacteria is then able to enter the raw cracks and infection may then follow. Athletes foot greatly increases the risk for diabetic foot infection. It is treated with anti fungal powders and creams, but anti fungal tablets may be given for more severe cases. Keeping the feet dry, especially between the toes, decreases the chance of getting athletes foot, along with keeping diabetes under control.
8- Fix poor circulation. Sometimes the arteries supplying the feet are so filled with plaque, that enough blood does not get through to keep the tissues healthy. Therefore wounds take forever to heal, literally. In some cases, a vascular surgeon may be able to clean out the arteries, or use a graft to join a healthy artery above the blockage, to a healthy artery below the blockage, thereby “bypassing” the blocked area.
9- Keep diabetes well controlled. The body doesn’t work as well when blood sugar (glucose) levels are high. Everything gets lazy including wound healing and infection fighting capabilities. One of the best markers of diabetes control is the glycated hemoglobin or A1c blood test. This is a measure of how well the diabetes has been controlled over the preceding 3 months. The desired number is less than 6.5% but most doctors would be pleased to see any number less than 7%. This is a better test to look at for determining overall diabetes control, rather than the daily blood sugar readings.
10- Stop smoking. Smoking does not go well with anything related to good health, but smoking and diabetes are a particularly bad combination. This is because both conditions result in damage to blood vessels and build up of cholesterol plaques. Cigarette smoking with diabetes therefore speeds up the development of poor circulation, thereby increasing the risk for diabetic foot ulcers. Diabetics who smoke have a higher risk of amputations because the poor circulation is often too far gone to be fixed with vascular surgery.
Diabetes is no doubt a complexed, multisystem disease. All patients with diabetes should be screened by their primary care provider for the presence of risk factors for foot ulceration and infection. Once risk factors are identified, interventions can be instituted to decease the chance of grave complications in the future, such as amputation.
In this age of limited time available for consultations with doctors, diabetics owe it to themselves, to obtain as much knowledge as possible about their disease, so that they can have meaningful discussions when they do get to see the doctor. A motivated, educated patient, is an empowered patient.