What is Diabetic Ulcer?
Diabetes is a condition where the body either doesn’t produce enough insulin (Type 1) or doesn’t use insulin properly (Type 2), resulting in high blood sugar levels. Type 1 diabetes often appears in younger individuals and is due to the body’s immune system incorrectly attacking the insulin-producing cells in the pancreas. This misdirected action results in a total lack of insulin and equates to only about 5-10% of all diabetes cases globally.
On the other hand, Type 2 diabetes, which accounts for a hefty 90-95% of global diabetes instances, occurs due to a combination of genetic and environmental reasons. These factors lead to resistance against insulin and decrease the effective function of insulin-producing cells in the pancreas, causing an insufficient insulin response. This type of diabetes can go unnoticed for many years.
The abnormal way the body handles glucose, or sugar, in these conditions can result in complications that affect the large blood vessels (macrovascular disease) – primarily impacting the heart and brain. It can also affect small blood vessels (microvascular), leading to kidney disease, eye damage, and nerve damage.
One serious issue people with diabetes might deal with is diabetic ulcers. These are sores that can form due to small injuries and can lead to a high level of illness if not addressed. Identifying and treating these small injuries early can help improve the overall health of individuals with diabetes and efficiently reduce the risk of these wounds developing into serious complications. In fact, up to 25% of individuals with either Type 1 or Type 2 diabetes may develop a diabetic foot ulcer at some point in their lives.
What Causes Diabetic Ulcer?
The progression of a diabetic foot can be broken down into six stages as identified by the 7th Practical Diabetes International Foot Conference:
- Stage 1: A normal foot with no risk factors
- Stage 2: A high-risk foot
- Stage 3: A foot with an ulcer
- Stage 4: A foot with cellulitis, a bacterial skin infection
- Stage 5: A foot with necrosis, or dead tissue
- Stage 6: A foot that is beyond saving
Three types of diabetic foot ulcers have been identified: neuropathic, neuroischaemic, and ischaemic. The majority of these ulcers result from small injuries that go unnoticed and untreated because they don’t cause any pain. This is due to sensory neuropathy, a condition where the nerves don’t send signals properly. Heart attack is a severe consequence of peripheral arterial disease that limits blood flow, but ischemia, or reduced blood flow, leading to diabetic foot ulcers is also a grave concern for patients and health care systems due to the chronic nature of the complication and difficulty in treatment.
Several risk factors can increase the chances of developing complications associated with diabetic foot:
- Peripheral motor neuropathy: Abnormal foot structure and movement resulting in higher pressure, calluses, and ulcers
- Peripheral sensory neuropathy: Loss of feeling, which can lead to unnoticed small injuries from increased pressure, heat, or mechanical stress
- Peripheral autonomic neuropathy: Decreased sweat, causing skin to become dry and cracked
- Neuro-osteoarthropathy deformities: Conditions like Charcot disease or limited joint mobility
- Vascular insufficiency: Poor blood flow affecting tissue health, healing of wounds, and neutrophil delivery
- Hyperglycemia and other metabolic issues: Impaired immune function and wound healing, along with excessive collagen cross-linking
Risk Factors and Frequency for Diabetic Ulcer
Across the globe, around 6.3% of people suffer from diabetic foot ulcers. North America has the highest occurrence of this condition, with a rate of 13%. Oceania has the lowest, at just 3%. Africa’s rate is 7.2%,which is slightly higher than Asia’s 5.5%. Diabetic foot ulcers are more common in men with diabetes, at a rate of 4.5%, compared to women, at 3.5%. People with type 2 diabetes tend to have a slightly higher occurrence of foot ulcers (6.4%) compared to those with type 1 diabetes (5.5%).
A 2016 study by Zhang and colleagues revealed certain characteristics that were more common in patients with diabetic foot ulcers. These patients typically were older (average age of 61.7), had diabetes for longer durations (typically 11.3 years), had a slightly lower body mass index (average of 23.8), a higher rate of smokers (29.1%), suffered from hypertension (63.4%), and had diabetic retinopathy (63.6%). These characteristics were compared to patients who did not develop foot ulcers.
- The worldwide prevalence of diabetic foot ulcers is 6.3%.
- North America has the highest rate at 13%, while Oceania has the lowest at 3%.
- Diabetic foot ulcers are more common in men (4.5%) than in women (3.5%).
- People with type 2 diabetes have a higher occurrence of foot ulcers (6.4%) than those with type 1 (5.5%).
- Characteristics often seen in patients with foot ulcers include: an older age (average 61.7), longer diabetic duration (11.3 years on average), lower body mass index (average 23.8), higher percentage of smokers (29.1%), hypertension (63.4%), and diabetic retinopathy (63.6%).
Signs and Symptoms of Diabetic Ulcer
When someone has a diabetic ulcer, doctors usually use both clinical and radiological assessments to evaluate their condition. This means they look at the person’s medical background and physical symptoms, as well as using imaging techniques.
First, the doctor would want to know about the patient’s diabetes type, what medications they’re on, any other health conditions they may have, and any symptoms of damage to nerves or blood supply issues. Nerve damage symptoms could be reduced or heightened sensation, tingling, uncomfortable sensations, and pain shooting down the body. Though most people with blood supply issues will not show any symptoms, some might experience pain when walking, continuous pain, or ulcers that don’t heal.
During the physical examination, the doctor will use a well-lit room to properly check the legs and feet. They will pay close attention to any ulcers, including their size, depth, how they look, and where they are on the foot. They’ll be looking out for signs of an infection, like changes in skin color, dead tissue, or draining wounds. Any other details like changes of nail color, formation of thickened skin areas, and foot deformities are also important. Deformities can occur when nerve damage causes an imbalance in the foot muscles. For example, deformities like hammer toe or claw toe, where certain joints in the toe bend abnormally, often occur in people with these problems. Charcot arthropathy, a breakdown of the joints and bones in the feet, is another typical deformity. The type of shoes someone wears can also contribute to a foot ulcer, so this is also part of the evaluation.
The doctor will also check on the cardiovascular system, including feeling for pulses in the knee, back of the ankle, and top of the foot, since problems like less leg hair or skin changes can suggest a lack of blood flow. If there’s a concern about vascular disease, a test called an ankle-brachial index (ABI) might be used. But in people with diabetes, this test might not be reliable due to hardened blood vessels. More reliable methods like measuring the blood pressure in the toes or the oxygen tension at the skin can be used instead.
Testing for Diabetic Ulcer
The severity of diabetic ulcers can be measured by the Wagner ulcer classification system, which considers the depth of the wound and any dead tissue.
So, according to the Wagner-Meggitt system, diabetes-related foot issues are classified as follows:
* Grade 0 – If you’re suffering from symptoms like foot pain only.
* Grade 1 – Ulcers that are surface-level, affecting only skin and fatty tissue underneath.
* Grade 2 – Deeper ulcers that reach down into ligaments, muscles, tendons, and so on.
* Grade 3 – Ulcer has spread to the bone.
* Grade 4 – Part of your foot is dead or dying (gangrene).
* Grade 5 – Your entire foot has gangrene.
Doctors use several tests to study diabetic ulcers:
CBC (a common blood test) and serum inflammatory markers (substances in the blood that rise in response to inflammation) will likely be done for basic checks.
Ultrasounds or X-Rays let doctors detect where the wound has spread and see if the soft tissue is involved.
If your doctor suspects bone inflammation (osteomyelitis), inflammation of the tendons (tendonitis), or joint inflammation, they might order an MRI. This imaging test gives a detailed view of these areas.
A probe-to-bone test can help determine if the ulcer is deep enough to have reached the bone.
A monofilament test is a simple way to check if you have lost any feeling in your feet. A significant loss of feeling may be a sign of nerve damage from diabetes, known as neuropathy.
Sometimes, a bone scan can be used, especially for deep wounds, to see if and how far the damage has spread.
A biopsy or a culture (taking a small sample of bone or infected tissue and studying it in a lab) can be done to identify the specific bacteria causing an infection. This test helps determine the most effective antibiotic for treatment.
Treatment Options for Diabetic Ulcer
Managing Diabetic Ulcers involves several steps, which can begin with education on foot care and maintaining proper blood sugar levels. This can also involve support from diabetic educators and social workers.
Good control of blood sugar is also crucial and is usually managed by a team comprising your primary care physician, podiatrist, and vascular specialist. The patient’s attitude towards medication, such as insulin, along with the severity of their condition, shapes the approach taken.
Lowering pressure on the ulcer site to prevent further injury or new wounds is also essential. This can be achieved using crutches, wheelchairs, and casts. Studies show that the healing process for the ulcer can be significantly improved with casts that stay in contact with the foot at all times, as opposed to removable casts.
Improving blood flow to the affected area can help the healing process too. The first step is usually to prescribe anti-blood clotting medication, but if the blood supply is really poor, surgical bypass might be needed. Preventing or controlling infection also plays a vital role in healing, which can be achieved using antibiotics and surgical cleaning of the wound.
The ulcer itself can be treated topically with dressing and debridement (removal of damaged tissue). For less severe ulcers, occlusive and semi-occlusive dressings, which keep out air and bacteria, are typically sufficient. However, if the ulcer is deep, a specialized dressing that contains ingredients like hyaluronic acid and collagen, plus surgical intervention to clean out the wound, can be required.
What else can Diabetic Ulcer be?
Venous ulcers are a type of wound that form due to long-term high pressure in veins, often due to faulty valves. This condition can cause vein damage and swelling in the lower limbs, leading to wound formation. They’re frequently found in the lower leg and near the inside ankle, and often look like a shallow sore with irregular edges, covered by a whitish, fibrous matter.
Diabetic dermopathy is another condition that causes skin appearances, especially for those with diabetes. They appear as painless, purple, round spots which can show up anywhere on the body, but are quite common on the legs. Usually, these spots don’t need any treatment.
Cancer can also present as skin sores. However, people with this condition typically also have other symptoms like fever, unexplained weight loss, and general discomfort. A biopsy, which involves taking a small tissue sample for examination under a microscope, can confirm the diagnosis.
Superficial Thrombophlebitis is a condition where there is inflammation and clot formation in surface veins. It typically causes pain, redness, and swelling in the affected area.
Leukocytoclastic vasculitis refers to an inflammation of blood vessels and nearby tissues due to immune complex deposits.
An inflammation caused by a buildup of uric acid crystals in the joints, known as gouty arthritis, may also lead to ulcers.
Infections can also lead to the formation of ulcers. These may occur due to a direct infection at the wound location, or as a result of an infection that has spread through the body.
Sickle cell disease is another condition that can result in painful leg ulcers, particularly near the ankles.
Lastly, certain medications such as warfarin, heparin, and hydroxyurea can cause ulcer formation.
What to expect with Diabetic Ulcer
The outlook for diabetic ulcers depends on multiple factors, including good control of diabetes, patient awareness, living a healthy lifestyle, and taking proper care of wounds. However, poor blood circulation, infections, long-lasting ulcers, and recurring ulcers can result in a challenging prognosis.
These indications help doctors determine the necessary steps and preventive measures to decrease the risk of severe complications like bone infections (osteomyelitis) and amputations.
Possible Complications When Diagnosed with Diabetic Ulcer
Diabetic ulcers can cause several problems and are often the reason why people with diabetes need to go to the hospital or experience difficulties in performing everyday activities.
Possible complications from diabetic ulcers include:
- Cellulitis, a skin infection
- Gangrene, which is dead tissue caused by an infection or lack of blood flow
- Sepsis, a serious infection that affects your whole body
- Abscess, which is a pocket of pus that forms at the infection site
- Ascending lymphangitis, an inflammation of the lymph vessels
- Osteomyelitis, a bone infection
- Limb ischemia, where there’s limited blood flow to your limbs
- Amputation, a removal of the limb because of severe infection or disease
Recovery from Diabetic Ulcer
Correct cleaning, washing and bandage changes are essential for preventing infection and supporting healing. For patients with diabetic foot ulcers, the use of special foot supports like casts and post-surgery shoes can help encourage better healing. It’s especially important for diabetic patients to get good after-surgery care due to certain risk factors. These can include reduced movement, lesser blood flow, poor nutrition, and loss of feeling.
Preventing Diabetic Ulcer
Teaching patients the correct way to care for their wounds and informing them about the possibility of the condition returning are essential steps to help them improve their quality of life. The main aims are to lessen the number of hospital visits and prolong the time period without ulcers. Keeping a close, long-term watch on the situation and regularly sharing information can heighten the effectiveness of the care given. Distributing easily understandable articles is paramount for effective communication. It’s also important to encourage health care providers to share useful information across various platforms.
