The Right Steps for Diabetes & PAD

After a long day of walking in a new pair of shoes, Brenda Ross became concerned when she noticed an open sore on the inner side of her foot. As someone with diabetes, she knew that she was at risk for serious complications from foot-related problems. Curiously, Brenda's open sore was not painful, even though the skin around it was red and raw. Though her foot didn't hurt, she knew to call her doctor and an appointment was made for later that day.

Brenda had been diagnosed with diabetes more than ten years ago and had been carefully managing her condition with attention to her diet, regular exercise, and medication. Her doctor regularly checked her feet and had mentioned that she needed to pay special attention to foot problems. When she saw her doctor, he examined the sore and checked her blood sugar. He explained that the remarkable lack of pain was not because the sore was not a serious problem. Rather, the lack of pain was due to diabetes-related nerve damage, or "neuropathy."

Although circulation problems from peripheral arterial disease (PAD) can affect any individual, those with diabetes have a higher risk of complications because of the increased possibility of nerve disease or damage. About 60 to 70 percent of people with diabetes develop some neuropathy, which may contribute to foot problems and the risk of amputation.

Although pain is not something people want to experience, the sensation of pain is essential in recognizing potential injuries. Without pain sensation in the feet and toes, it is easy to sustain a foot injury without feeling it. Diabetics with neuropathy may fail to recognize an injury until it is too late. For example, people have been seriously burned by electric blankets or heating pads because they could not feel the heat.

Brenda's problem was not unusual. Apparently, her new shoes did not fit as well as they should have. Neuropathy had caused her to lose her feeling of pain, allowing the shoes to rub a raw spot at the side of her foot, at the base of her big toe.

It is especially important for people with diabetes to carefully check their feet each day. Shoes should be checked to make sure they don't contain stones, staples, rough spots, or other sharp or lumpy objects that could cause an injury. Special shoes or orthotics may be needed to accommodate the feet if there is any type of deformity. New shoes should be broken in with great care. People with deformed feet and toes should never try to force them into regular shoes.

Skin needs good care, as dryness, cracking, and infections may be a result of changes that occur with diabetes. Feet should be washed and dried daily, and the remaining skin moisture should be sealed in with a thin coat of a lubricant, such as plain petroleum jelly, unscented hand cream, or other such products. Oils or creams should not be applied between the toes, as the extra moisture may lead to infection. Soaking the feet is not useful and may be harmful.

Small calluses may be treated with a pumice stone and lotion, but thick calluses may need to be trimmed by a trained health care provider. "Bathroom surgery" is never a good idea. Never try to cut your own calluses or corns, as this may lead to a skin ulcers or infection. Also, a health care provider should be seen whenever cuts or breaks in the skin occur, or when ingrown nails, changes in color, shape, or sensation are noticed. People with diabetes need regular and complete foot examinations and they can help remind their provider that a foot exam is needed by removing their socks and shoes while waiting for a physical examination.

Any break in the skin has the potential to lead to the development of an ulcer. An ulcer is an open sore. These can be superficial or deep and can allow entry of infection-causing bacteria. Most wounds heal on their own if properly cared for. An ulcer may not heal, however, if there is recurring injury, infection, dead tissue, or poor blood flow to the affected area. Dead tissue must be trimmed away and any infection should be treated with appropriate antibiotics. Ulcers need to be protected from pressure. Continued walking on an ulcer can enlarge it and lead to a more serious infection. In some cases, a special cast may be applied to protect the foot.

Circulation problems from PAD reduce the ability of the skin to resist injury, fight infection, and to heal. In some cases, however, circulation problems may not be recognized until an ulcer forms. Because diabetes may cause arteries to harden from calcium in the artery wall, some tests for PAD may yield unreliable results. Special tests in a vascular laboratory, however, can provide information about the presence and severity of a circulation problem in someone with diabetes.

Brenda's tests showed that she had mild PAD, but her circulation was probably adequate for healing. Had she been found to have more severe circulatory problems further evaluation, and possibly surgery or angioplasty, would have been necessary to improve blood flow. With good care, Brenda's foot ulcer healed within two weeks, but she remains aware that her feet need special care. Scar tissue under the healed wound may break down easily. She now has special shoes that protect the area of the healed ulcer, preventing the ulcer from coming back.

Brenda's outcome was good, but many people with diabetes-related foot problems may not be so fortunate. A minor problem like Brenda's can lead to serious infection, gangrene, and may ultimately lead to the need for an amputation.

Foot problems related to diabetes can be prevented and managed. The keys are proper foot care, attention to proper diabetes management and establishing a good relationship with a knowledgeable health care provider.

About the author: Dr. David L. Dawson is a vascular surgeon with special interest in the medical, surgical, and endovascular treatment of peripheral arterial disease. He is Associate Professor at the University of California, Davis.