Diabetic Foot Ulcers

A diabetic foot ulcer (DFU) is an open sore or wound that typically occurs on the bottom of the foot in individuals with diabetes. These ulcers are a serious complication of diabetes, often resulting from a combination of nerve damage (neuropathy), poor circulation (peripheral artery disease – PAD), and trauma or pressure. Due to reduced sensation, ulcers may form and progress without causing pain, making early detection challenging. Diabetic foot ulcers require immediate medical attention from a podiatrist or specialised wound care team in Singapore to prevent severe infections, hospitalisation, and potential amputation.

Early recognition is vital. Look for these signs, particularly on pressure points (ball of foot, heel, toes):

• Any Break in the Skin: Even a small cut, blister, or scrape can develop into an ulcer.
• Visible Sore or Ulcer: An open wound, which may look like a crater. It might be shallow or deep.
• Drainage: Fluid (clear, yellowish, or pus-like) weeping from the wound, possibly staining socks or bedding.
• Unusual Odour: A foul smell can indicate infection.
• Redness and Swelling: Inflammation around the wound area.
• Warmth: Increased skin temperature around the ulcer compared to other areas can signal infection.
• Callus or Hard Skin: Ulcers often form underneath areas of callus; any drainage from a callus requires urgent investigation.
• Discoloration: Black or bluish tissue (eschar) around the ulcer may indicate tissue death (necrosis).
• Pain (or Lack Thereof): Importantly, due to diabetic neuropathy, many ulcers cause little or no pain, even if deep or infected. Do not rely on pain as an indicator of severity.

Any new wound, sore, or suspicious area on the foot of a person with diabetes should be assessed by a healthcare professional immediately.

Diabetic foot ulcers develop due to a combination of factors:

• Peripheral Neuropathy: Nerve damage leads to loss of protective sensation. This means minor trauma (like pressure from a shoe, stepping on an object, or a small cut) goes unnoticed, allowing skin breakdown and ulcer formation. Neuropathy also affects foot muscles, potentially causing deformities that create pressure points.
• Peripheral Artery Disease (PAD): Poor blood flow impairs the delivery of oxygen and nutrients essential for wound healing. Even minor wounds struggle to heal and are more prone to infection and tissue death.
• Foot Deformities: Conditions like bunions, hammertoes, or Charcot foot (a severe diabetic foot complication) create abnormal pressure areas highly susceptible to ulceration.
• Trauma: Acute injuries (cuts, punctures) or repetitive microtrauma (friction or pressure from ill-fitting shoes).
• Poor Glycemic Control: High blood sugar levels impair immune function and wound healing.
• History of Previous Ulcers or Amputation: Significantly increases the risk of future ulcers.
• Other Diabetic Complications: Kidney disease (nephropathy) or vision problems (retinopathy, making self-inspection difficult) increase risk.
• Calluses: Thickened skin indicates high-pressure areas where ulcers often develop underneath.

Improper Footwear: Shoes that are too tight, too loose, or have inadequate support.

• Infection: Ulcers provide an open portal for bacteria. Infections can range from localized (cellulitis) to deep tissue and bone infections (osteomyelitis).
• Abscess Formation: Collection of pus within tissues.
• Gangrene: Tissue death due to severe infection or lack of blood flow.
• Sepsis: A life-threatening condition where infection spreads throughout the bloodstream.
• Charcot Foot: In individuals with severe neuropathy, inflammation can lead to bone weakening, fractures, and severe foot deformity, further increasing ulcer risk.
• Amputation: Diabetic foot ulcers are the leading cause of non-traumatic lower limb amputations worldwide. Prompt and effective treatment significantly reduces this risk.

Prompt and accurate diagnosis is critical for guiding treatment. A podiatrist at Fine Podiatry Clinic will perform:

• Detailed Medical History: Including diabetes history, duration, control, previous ulcers/complications, medications, and symptoms.
• Wound Assessment:
  • Location, Size, and Depth: Measuring the ulcer dimensions.
  • Wound Bed Characteristics: Assessing tissue type (granulating, sloughing, necrotic).
  • Exudate (Drainage): Noting amount, colour, and odour.
  • Periwound Skin: Checking for redness, warmth, swelling, callus, or maceration.
  • Signs of Infection: Assessing for clinical signs of infection.
  • Probing: Gently probing the ulcer base with a sterile instrument to assess depth and check for undermining or bone contact (suggestive of osteomyelitis).
• Wound Classification: Using standardized systems (like Wagner or University of Texas) to grade the ulcer’s severity, which helps guide treatment and predict outcomes.
• Neurological Assessment: Testing sensation to confirm neuropathy.
• Vascular Assessment: Checking foot pulses and potentially performing non-invasive tests (like Ankle-Brachial Index or Doppler ultrasound) to evaluate blood flow. Referral for further vascular assessment may be needed.
• Imaging: X-rays may be ordered to check for bone infection (osteomyelitis), foreign bodies, or gas in the tissues. MRI is more sensitive for detecting osteomyelitis.

Laboratory Tests: Wound cultures may be taken if infection is suspected. Blood tests can help assess infection severity and overall health (e.g., blood glucose, kidney function).

Diabetic foot ulcer management requires professional medical care and should NEVER be attempted solely at home. Treatment is multi-faceted and focuses on creating an optimal healing environment:

• Offloading: This is paramount. Reducing pressure on the ulcerated area is essential for healing. This may involve:
  • Specialised footwear (post-op shoes, diabetic walkers).
  • Total contact casting (TCC) – considered the gold standard for offloading neuropathic ulcers.
  • Removable cast walkers or boots.
  • Crutches or wheelchairs in some cases.
• Debridement (Professional): Regular removal of dead (necrotic), damaged, or infected tissue, and surrounding callus from the ulcer base by a trained podiatrist or healthcare professional. This promotes healing and helps control infection. This should only be performed by a trained professional.
• Infection Control: If infection is present, treatment involves appropriate wound cleansing, antiseptic dressings, and often systemic antibiotics prescribed by a doctor based on severity and culture results. Severe infections may require hospitalisation.
• Moisture Balance (Dressings): Applying appropriate wound dressings selected by the podiatrist based on the ulcer characteristics (amount of drainage, presence of infection, tissue type) to maintain a moist wound environment conducive to healing. Dressing types vary widely and require professional judgment.
• Addressing Underlying Factors:
  • Vascular Assessment/Intervention: If poor blood flow (PAD) is identified, referral to a vascular specialist for possible procedures to improve circulation may be necessary.
  • Glycemic Control: Working closely with the patient’s primary doctor or endocrinologist to optimize blood sugar levels is crucial for healing.
• Advanced Therapies (Sometimes): In complex or non-healing ulcers, advanced treatments like negative pressure wound therapy, bio-engineered skin substitutes, or hyperbaric oxygen therapy might be considered under specialist care.
• Surgical Options: May be required for severe infections (drainage, debridement, amputation) or to correct foot deformities contributing to ulceration. Revascularization surgery may be needed for PAD.

Note: Treatment is often long-term, requiring frequent visits for debridement and dressing changes. Patient education and adherence are vital.

Prevention is the best strategy. Follow diabetic foot care guidelines diligently:

• Strict Daily Foot Inspection: Check every part of your feet daily. Report any changes immediately.
• Manage Blood Glucose: Maintain levels as close to target as possible.
• Wear Appropriate Footwear ALWAYS: Never go barefoot. Wear well-fitting, protective shoes and socks. Check shoes before putting them on.
• Proper Foot Hygiene: Wash and dry feet carefully daily. Moisturise, but not between toes.
• Professional Nail & Callus Care: Do not self-treat corns, calluses, or ingrown nails. See a podiatrist regularly for safe care.
• Regular Podiatric Check-ups: Attend all scheduled diabetic foot assessments (at least annually, more often if high-risk).
• Stop Smoking: Smoking severely impairs circulation.
• Immediate Professional Help: Seek immediate podiatric or medical care for ANY cut, blister, sore, or sign of infection on your feet. Do not wait.