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Diabetic Foot Ulcer- Causes, Symptoms, Diagnosis, and Treatment

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Diabetic foot ulcer occurs in patients with high blood sugar levels leading to loss of the toe if left untreated. Read the article to know more.

Medically reviewed by

Dr. Nagaraj

Published At December 20, 2022
Reviewed AtJune 22, 2023

Introduction

Patients with diabetes mellitus are unable to produce enough insulin to control glucose (sugar) levels in the blood. Insulin, a hormone from the pancreas, regulates and maintains blood sugar levels. Its inadequate production leads to type 2 diabetes mellitus. Whereas resistance to insulin by the body leads to type 1 diabetes. People with diabetes always carry a high risk of complications if the glucose levels are not under control. Among the many complications, the most common is the foot ulcer that occurs in repeated trauma or pressure areas.

What Is Diabetic Foot Ulcer?

A diabetic foot ulcer usually occurs on the bottom of the foot as a wound. About 15 % of diabetic patients develop a foot ulcer and require hospitalization. The wound or sore, if poorly managed, can lead to the removal of the ulcer and the affected toe.

Who Is More Likely to Get a Diabetic Foot Ulcer?

The diabetic foot ulcer is more likely to develop in:

  • Patients with type 2 diabetes mellitus.

  • A patient with diabetes for more than ten years.

  • Poorly controlled diabetes.

  • Male patients.

  • Patient with a history of diabetic foot ulcer.

What Are the Causes of Diabetic Foot Ulcer?

The two leading causes of foot ulcers are peripheral neuropathy and peripheral arterial disease.

  1. Peripheral neuropathy refers to nerve damage due to high blood glucose levels. The nerve damage occurs in the extremities of the body and leads to loss of sensation of pain, pressure, and temperature. Finally, the area becomes numb, and the patient does not know even if there is any injury in that region. These injuries, which are left unnoticed, lead to the development of an ulcer.

  2. Peripheral arterial disease affects the blood vessels at the extremities of the body. The blood supply becomes restricted, and any wound in that region takes a long time to heal.

What Are the Symptoms of Diabetic Foot Ulcer?

The symptoms of diabetic foot ulcer include:

  • Numbness.

  • Redness.

  • Swelling.

  • Skin gets darkened.

  • Dry and cracked skin.

  • Sore or a wound on the foot.

  • A non-healing ulcer.

  • Difficulty in walking.

In advanced stages,

  • A foul smell is felt.

  • Discharge from the wound, which indicates the presence of an infection.

  • A callus (thick and hard skin formed due to friction or pressure) formation.

As mentioned above, any changes the patient feels must be consulted with the physician to prevent further complications.

What Are the Types of Diabetic Foot Ulcers?

  1. Neuropathic Ulcer - An ulcer that is formed due to peripheral neuropathy alone.

  2. Vascular Ulcer- An ulcer formed due to ischemia (restricted blood supply) without the involvement of nerve damage (neuropathy).

  3. Neurovascular Ulcer - An ulcer formed due to peripheral neuropathy and peripheral artery disease causing nerve damage and ischemia.

How to Find the Severity of Diabetic Foot Ulcers?

The extent and the condition of the ulcer depict its severity. The doctors use the Wagner grading system to find the severity of diabetic foot ulcers.

severity of diabetic foot ulcers.

The most severe stage is when the ulcer has reached grade 4 or 5. Removing the affected part is the only option available for treatment in these stages. Hence, the doctor is consulted at the initial stages to avoid such circumstances.

How to Diagnose a Diabetic Foot Ulcer?

The tests to diagnose the foot ulcer are:

  • X-Ray - To find the amount of bone involved in the ulcer.

  • Blood or Swab Test - To find the presence of any infection.

  • MRI (Magnetic Resonance Imaging) Scan - This shows the ulcer's soft tissue involvement and the presence of inflammation.

How to Treat a Diabetic Foot Ulcer?

The doctor makes a proper diagnosis after a series of tests. The aim of treatment should be to reduce the infection and promote healing. Diabetic patients are usually immunocompromised (decreased immunity to fight against infections). So, the wound is treated, and antibiotics are first given. The treatment for the ulcer includes:

  1. Optimizing Blood Sugar Levels - The cause of the foot ulcer is corrected. High blood sugar is the main factor in the formation of ulcers. So, the blood glucose levels are first brought down to a certain level.

  2. Debridement - This procedure refers to the removal of all the infected skin and tissues using a scalpel blade. The cleaned wound is then washed with an antiseptic solution.

  3. Relieving Pressure - The pressure in the ulcer area is reduced. A foot gear, brace, or using specialized castings, or a wheelchair helps in reducing the weight load that is put on the foot.

  4. Achilles Tendon Lengthening - It is a tendon on foot. This tendon is stretched to make the patient walk without bending the knee.

  5. Atherectomy - It is a minor surgery wherein the blocked blood vessel is cleared by inserting a catheter (a tube) to remove the clog from it.

What Are the Complications of a Diabetic Foot Ulcer?

  • Amputation is one of the most feared problems leading to the loss of a toe.

  • Gangrene of the foot.

  • Osteomyelitis (inflammation of the underlying bone and muscle).

  • A permanent deformity of the foot.

  • Sepsis is a life-threatening complication where the infection spreads across the whole body.

How to Prevent a Foot Ulcer?

Proper care is followed to prevent the formation of foot ulcers.

  • The feet are washed regularly with warm water. Moisturizing creams are applied on the feet to keep the skin soft without any callus formation.

  • The foot should be inspected by looking and feeling it regularly. Any changes noticed must be reported to the doctor immediately.

  • Do not go out barefoot. Always wear socks and shoes while going out. Socks should be made of cotton or any other material without tight elastics. Even in the house, footwear is used to prevent any injury.

  • Buy orthopedic shoes that are comfortable to wear.

  • The toenails must be cut carefully.

  • It is not advisable for the patient to remove the callus or any lesion by themselves. The specialist is consulted for the appropriate treatment.

  • Smoking is avoided. Smoking reduces blood circulation, and the amount of oxygen in the blood is also reduced. Hence, diabetic patients with smoking habits must quit as soon as possible.

  • The patient can continue activities like walking, bike driving, and swimming.

  • The feet are put up while sitting, and a few exercises recommended by the doctor are followed to improve the blood supply to the feet.

The instructions mentioned above are followed for a proper foot care routine. The doctor checks the feet every visit for any changes like numbness, callus, or other problems.

Conclusion

A diabetic foot ulcer is a complication that can be managed if the patient gets it checked at the right time. The patient has symptoms in the early stages which, when left unnoticed, can lead to the formation of an ulcer. Diabetic patients have low immunity and delayed wound healing which further puts them at risk of ulcer development. Hence, a proper foot care routine and regular check-ups by the doctor are followed to maintain a healthy and disease-free foot.

Frequently Asked Questions

1.

What Causes Diabetic Foot Ulcers?

Diabetic foot ulcers are caused by various factors, including
- Uncontrolled diabetic for an extended period.
- High glucose level.
- Lack of blood supply in the foot reduces the healing factor and increases the risk of infection.
- Abnormal foot pathology.
- Constant foot irritation due to friction or pressure.
- Trauma (Direct or indirect injury)
- Prolonged inflammation has a higher chance of causing ulcer formation.

2.

How Can a Diabetic Foot Ulcer Be Classified?

The code ICD-10 is broadly used for coding diagnoses. The most often-used diabetes codes, E10 and E11, are often described in section E. 
- E10 - insulin-dependent diabetes mellitus.
- E11- non-insulin-dependent diabetic mellitus.

3.

What Is the Code for an Infected Diabetic Foot Ulcer?

Based on ICD-10, the L97- code represents a foot ulcer associated with a diabetic condition. The infected foot ulcer results in constant pain, redness, warmth, swelling, and pus drainage and does not heal independently.

4.

What Is the Code for a Diabetic Foot Ulcer With Gangrene?

According to the WHO, type 2 diabetes mellitus with diabetic peripheral angiopathy and gangrene fall under the category of E11.52 for endocrine, nutritional, and metabolic illnesses.

5.

What Is the Code for a Diabetic Foot Ulcer With Osteomyelitis?

As long as "diabetes osteomyelitis" is listed as the primary diagnosis, the patient is still classified as an endocrine patient using ICD-10 Code E11.69.

6.

What Is a Diabetic Foot Ulcer?

A diabetic foot ulcer is an open wound that often develops on the bottom of the foot due to poor foot care, peripheral vascular disease, underlying neuropathy, and uncontrolled diabetes. These kinds of ulcers frequently experience pressure and recurrent stress. The progression of foot ulcers leads to foot osteomyelitis and lower extremity amputation.

7.

How Long Does It Take for the Healing of a Diabetic Foot Ulcer?

- Healing might take several months or just a few weeks, depending on various factors. 
The size and location of the wound
- Pressure from walking or standing
- Edema or swelling.
- Blood circulatioN
- Blood glucose levels.
- Wound care.
- The medicine was applied over the ulcer.

8.

What Is the Onset of a Diabetic Foot Ulcer?

When the nerves and blood vessels of the foot are damaged by high blood sugar, resulting in foot ulcers, the onset of a foot ulcer is characterized by drainage from the affected foot, with the early signs of swelling, itchiness, redness, and smells coming from one or both feet. The ulceration is more likely to develop on the heel and surface of the foot, which can push off when walking or running.

9.

What Are the Diagnostic Criteria for a Diabetic Foot Ulcer?

The diagnosis of a diabetic foot ulcer is based on physical examination, digital imaging (X-ray and MRI), and blood investigations. Where x-rays evaluate the bone loss and alignment of the foot; on the other hand, an MRI revealed inflammation of soft tissue. A blood test is also recommended for swelling, redness, and warmth in the affected foot.

10.

How Do Diabetic Foot Ulcers Appear?

A foot ulcer resembles a circular, red crater or trench-like appearance, surrounded by blistered, thicker skin. In severe cases, foot ulcers might expose tendons or bones. Other signs involve swelling, redness, discoloration, blisters, and drainage from an infected foot associated with a pungent odor.

11.

Which Doctor Can Handle Diabetic Foot Ulcers?

The diabetic foot ulcer is treated by a podiatrist, who works with feet, and a wound specialist, Who helps in the debridement of the affected foot; removal of affected skin and tissue. It is recommended to consult a podiatrist regularly for two to three months. It is advised to consult a doctor immediately when developing an ulcer on the foot or toe.

12.

How to Prevent Diabetic Foot Ulcers?

Most foot ulcers can be prevented by managing the blood glucose level. Other factors involved in prevention are exercise and a healthy lifestyle to control blood pressure, cholesterol, and triglyceride levels, and appropriate care for toes and toenails with shoes and shocks. Eventually, the regular appointment with a podiatrist.

13.

How to Recognize the Healing of Diabetic Foot Ulcer?

The healing factor is based on the size of the wound, location, pressure applied on the ulcer while walking or standing, blood circulation, swelling, blood glucose levels, and treatment for the ulcer.  The favorable healing factor reduces inflammation, swelling, redness, warmth, and drainage from a wound. Healing time can range from a week to months, depending on the severity of the ulcer.

14.

How Can Diabetic Foot Ulcers Develop?

Diabetic ulcers develop due to various factors, including poor blood circulation, long-term uncontrolled diabetes, foot trauma, and neuropathy. Diabetic neuropathy results in foot abnormalities, leading to increased skin pressure while walking and standing and frictional irritation. Rarely developed artery occlusive disease (blockage of a blood vessel).

15.

Describe a Diabetic Foot Ulcer?

A diabetic foot ulcer appears like an open wound that often develops on the bottom of the foot due to poor foot care, peripheral vascular disease, underlying neuropathy, and uncontrolled diabetes. These kinds of ulcers frequently experience pressure and recurrent stress. The progression of foot ulcers leads to foot osteomyelitis and lower extremity amputation.

16.

How to Evaluate the Measurement of Ulcers?

The measurement of an ulcer is based on the wound's length, breadth, and depth. The length is calculated from the patient's head to the toe, and the breadth is measured by the side-to-side proportion of the wound. A q-tip is often inserted with the tip of a finger into the deepest section of the incision to determine its depth.

17.

What Are the Treatments and Care for Diabetic Foot Ulcers?

- The treatment involves debridement, wound care, and different varieties of dressing. The care for wounds involves,
- Maintenance of blood glucose levels to promote healing.
- Avoid walking barefoot to reduce pressure on the healing site.
- Frequent cleaning of a wound with the help of dressing or bandage.
- Maintain blood pressure and body cholesterol which interferes with the healing mechanism.
- Quit smoking which has a negative impact on healing.

18.

How Will You Describe the Sensation of a Diabetic Foot Ulcer?

The common symptoms of diabetic foot ulcers are frictional skin irritation while walking, localized redness, swelling, warmth, persistent pain, discoloration, blisters, fever, chills, thickened layers of the skin or calluses, cuts, bleeding on the ground or a sock. However, neuropathic patients don't experience any kind of pain.
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Dr. Nagaraj
Dr. Nagaraj

Diabetology

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