Diabetic Foot Ulcers Treatment in Pune: Benefits, Risks & More

A diabetic foot ulcer is an open wound or a sore that develops most commonly on the skin or bottom surface of a foot in a person with diabetes. People with diabetic foot ulcers are mostly hospitalized due to infection or other complications of the ulcers. Diabetic foot ulcers are one of the common reasons for nontraumatic lower limb amputation worldwide; hence, it is important to manage diabetic foot ulcers timely. Read on to learn more about the causes of diabetic foot ulcers, their diagnosis, and management.

A diabetic foot ulcer is an open wound or a sore in a diabetic person. In this, there is a loss of partial or full skin thickness. Diabetic foot ulcers are painless because there is a loss of sensation in the feet (this occurs due to the development of diabetic neuropathy, a complication of diabetes). 

Foot ulcers are one of the complications seen in people in whom diabetes it is not managed adequately by diet, exercise, or medications. These foot ulcers form because the skin tissue breaks down, exposing the deeper layers underneath it. Diabetic foot ulcers are most commonly found under your big toe, balls of your feet, over the plantar and bottom surface of the foot, etc., and they can even extend to the bones underneath the skin. Individuals with diabetes (type 1 and type 2 diabetes mellitus) have a risk of developing foot ulcers, but proper foot care is important to prevent their development. The treatment of diabetic ulcers depends on the cause of ulcers, and timely intervention can help prevent complications. 

Almost anyone with diabetes can develop foot ulcers. Diabetic foot ulcers are usually caused due to poor and decreased blood circulation, chronic and uncontrolled type 1 and type 2 diabetes, nerve damage (diabetic neuropathy), and foot or skin injury.

• As a complication of diabetic neuropathy, there is sensory dysfunction (you will not be able to feel any sensation) and autonomic dysfunction (your general well-being and balance will be affected) in the area. As a result, if there is an injury on the foot or lower extremity, you will not be feeling any pain, hence will not be aware of the wound. Over time, the infection sets in the wound, and the ulcer develops. 
• As a complication of angiopathy, decreased and poor blood flow to the ulcer area leads to peripheral vascular diseases (diseases related to blood vessels). Blood vessels can be damaged by chronic uncontrolled high blood sugar levels, leading to decreased blood flow to the limbs and feet (ischemia) or skin (angiopathy), resulting in poor healing of the wound.
• Peripheral Arterial Disease occurs when there is a blockage of one or more arteries one or more arteries supplying blood to the legs are feet due to plaque deposition in atherosclerosis (fat, cholesterol, and other substances being built up in the walls of the arteries). 
• Deformities of the foot like hammertoe (toe is bent at its middle joint) and Charcot's foot (disease affecting the bones, joints, and soft tissue of the foot)
• Foot trauma, ill-fitting shoes, and stepping on sharp objects can cause injuries in a diabetic person and lead to diabetic foot ulcers.
• Previous ulcerations are the common cause of the development of new diabetic foot ulcers (30% to 50% ).
• Other microvascular (diseases involving smaller blood vessels) complications of diabetes like diabetic retinopathy (damage to small blood vessels in the eye), diabetic nephropathy (damage to small blood vessels in the kidney), in individuals who are diabetic on dialysis (method to remove the waste fluids from the body which the kidney is unable to function).
• Diabetics who have received a transplant of kidney or pancreas.
• Use of cream to treat corns and calluses in the feet.

Diabetic foot ulcers are painless, and sometimes the symptoms will not appear until the ulcer becomes infected. 

• One of the first symptoms that you may observe is the staining of your socks. This may occur due to the drainage of the ulcer (leaking).
• Swelling, redness, and a bad odor from one or both feet will be present.
• A black tissue (eschar) may be formed around the ulcer due to the lack of blood flow.
• These symptoms, if persists for a longer duration, may lead to the formation of partial or complete gangrene (death of the tissue due to infection and lack of blood supply. If gangrene develops, pain, odorless discharge, and numbness will occur in the affected area.

If you are a diabetic and notice skin discoloration or an open wound that is not healing or any pain around a recent injury, contact your surgeon immediately.

Diagnosis of a diabetic ulcer is important for its treatment. Your surgeon will take a complete history of your disease and physically examine the ulcer. Some tests would be advised by your surgeon to arrive at the diagnosis. This will enable the surgeon to plan your treatment accordingly.

• The surgeon will examine the ulcer and its depth and look for infection, cellulitis, and gangrene development. The surgeon will perform a test to check for your heel tendon tightness and check the blood flow to the arteries by feeling the pulse.
• A Wagner Ulcer Classification scale (from 0 to 5) will be used by your surgeon to identify the complexity and severity of the diabetic foot ulcer 

0: no open lesions; may have healed lesion

1: superficial ulcer without penetration to deeper layers

2: deeper ulcer, reaching tendon, bone, or joint capsule

3: deeper tissues involved, with abscess, osteomyelitis, or tendonitis

4: gangrene in a portion of the forefoot or heel

5: extensive gangrenous involvement of the entire foot

• Blood tests to check for the presence of infections and anemia
• Blood sugar testing (random, fasting, and post-prandial) to check for the progression of diabetes. A glycosylated hemoglobin test (HbA1c) will be done to measure the 3-month blood glucose levels.
• Imaging tests like X-ray of the foot, ultrasound, MRI, and CT scan will be performed for injuries, the presence of osteomyelitis, etc.
• Bone scans will be advised. 
• Doppler ultrasonography for checking the blood vein in the blood vessels.
• Transcutaneous oxygen pressure measurement to assess for wound healing.
• Ankle-brachial and ischemic indexes for checking the percentage of calcification in the arteries

Treatment of diabetic foot ulcers is essential as if not treated may result in amputation of the limb or other serious complications.

The primary aim of the treatment is to enter the healing phase; the faster the healing, the fewer chances of developing infections. The treatment can be medical or surgical. 

Medical 

The treatment is divided into 5 parts:

1. Preventing the infection
2. Offloading - Taking the pressure off the affected area
3. Debridement- Removal of the dead skin and tissue
4. Medications applications to the ulcer
5. Managing sugar levels and other health issues

Preventing The Infection

Not all diabetic foot ulcers will get infected, but if it does, your surgeon with start with antibiotics, wound care, and hospitalization will be necessary. To avoid the infection, it is important to:

• Ensure that your blood sugars are under control.
• The ulcer should be debrided, cleaned, and bandaged daily.
• Do not walk barefoot. Wear the right shoes for walking.

Off-loading

For proper healing, it is recommended that the ulcers must be off-loaded (especially the ulcers present at the bottom of the foot). You will be advised to wear special footwear, a brace, a cast, or use a wheelchair or crutches, as they can remove pressure and irritation to the ulcer. This also helps in healing. 

Debridement

The ulcer should be debrided to remove any dead (necrotic) or infected tissue before applying medications. This allows the ulcer to heal properly.

Medications

The foremost objective in managing foot ulcers in diabetes is to heal the ulcer before it gets infected. Diabetic foot ulcer treatment needs antibiotics. To prevent infection, cleanse the wound of the debris. To enhance the healing process, topical medication application is applied before dressing.

Managing sugar levels and other ailments 

Keeping your blood sugar levels in check is of utmost importance during treating a diabetic foot ulcer. You should take your diabetic medications regularly, exercise and eat a well-balanced diabetic diet. If any associated health conditions like cardiac or high blood pressure are present with diabetes, ensure they are controlled to reduce the risk of complications.

Surgical

When conservative treatment fails, the doctor suggests a surgical procedure. Surgical management includes the excision of bones, correction of deformities like hammertoes, bunions, or bony projections, and amputation when tissue damage is irreversible.

Healing is a long process and may take weeks or even several months.

The starting of a diabetic foot ulcer is with an injury which then progresses to swelling, itching, and burning sensation. If not treated on time, some complications can develop like:

• Skin infection: This is more common in foot ulcers; it results in swelling around the wound, foul-smelling pus, fever, and chills. If the infection spreads from the skin to the deeper layer and to the bone, amputation of the foot may be required.
• Sepsis: This occurs when the infection reaches the bloodstream. It is a life-threatening condition as the immune system reacts and starts damaging its own organs, causing multi-organ failure.
• Abscess formation: When the ulcer gets infected, pus develops under the skin- an abscess.
• Deformities of the foot: Uncontrolled diabetes may damage the bones and joints of the foot. The bones can become fragile, dislocate or break even with little movements.
• Gangrene of the foot: This is when the tissue's death occurs due to infection or lack of blood supply to the ulcer. Discoloration of the skin, pus-filled discharge, and loss of sensation are the symptoms when gangrene develops.
• Amputation: When gangrene and neuropathy develop, the foot must be amputated (cut off from the body) to prevent the spread of infection.

The ideal way to treat a diabetic foot ulcer is to prevent its formation in the first place.

• Wash your feet daily and keep them dry
• Keep your toenails trimmed to prevent them from getting broken
• Moisturize your feet regularly
• If you wear socks, change your socks daily
• Wear proper, well-fitting, comfortable footwear. Wear special shoes that are designed for diabetics to wear.
• Keep your blood sugars in control and check them regularly
• Avoid alcohol and quit smoking
• Keep a check on your blood pressure 
• If a callus or corn is formed, visit your podiatrist for removal

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