Diabetic Foot Disease

Introduction

Diabetic foot disease is any problem that occurs on the feet of people with diabetes. The most common problem with diabetic feet is foot ulcers caused by loosening of the skin or mucous membranes of the feet. Neuropathy or peripheral vascular disease caused by diabetes is an important cause of or worsening foot ulcers caused by diabetes.

About 15% of people with diabetes have foot ulcers more than once in their lifetime, and about 1 to 3% of them undergo surgery to cut a part of their legs.

Foot ulcers from diabetes are often recurrent. About 30% of patients experience relapse within a year, and more than half of those who have had surgery due to diabetic foot disease will have surgery on the other side within 4 years of surgery. In particular, about 40% of diabetic patients are hospitalized because of diabetic foot disease.

It is also known that more than half of the causes of amputation of the legs, except for trauma, are diabetic foot disease. Diabetic foot disease is a very important cause of deteriorating quality of life for diabetics.

However, most diabetic foot disease starts with very small problems, so if properly managed early, serious conditions can be prevented. Therefore, diabetic patients are advised to check if the risk of developing diabetic foot disease is high and prevent it and treat it early. If you understand and master how to care for your own feet, you can significantly reduce the problems that can result from diabetic foot disease.

Symptoms

1. Diabetic Neuropathy

Diabetic neuropathy is an autonomic condition that regulates the secretion of sweat or the contraction and expansion of blood vessels when there is an abnormality in the sensory nerve that feels pain or a cold, hot sensation. It can be divided into cases of abnormalities in nerves.

1) Sensory nerve damage

If you have a sensory nerve abnormality, not only do you have an abnormal sensation, but you may not feel pain and a cold, hot sensation. When the sensation is deteriorated, it is difficult to feel the pressure caused by a foreign body wound or a tight-fitting shoe that does not fit the foot, so it is easy to injure the foot and delay the detection of the wound.

2) Motor nerve damage

If the patient’s motor nerves become abnormal, the action of the small muscles of the foot causes problems and the shape of the foot changes. When the shape of the foot changes, pressure is constantly applied to the back or tip of the toe and the metatarsal head. Continued pressure on the same area causes calluses, bleeding beneath it, and skin tissue is destroyed, resulting in ulcers. If you have calluses on the soles of your feet, you are 11 times more likely to develop foot ulcers than those without.

3) Autonomic nerve damage

Diabetic neuropathy can also cause abnormalities in the autonomic nervous system. The autonomic nervous system is responsible for regulating various physical activities that occur without our awareness, such as sweat secretion, heart rate or blood pressure, and contraction or expansion of blood vessels.

If the autonomic nerve is damaged, the sweat does not sweat well on the feet, causing the skin to dry out and crack, which can cause bacteria to penetrate between the cracked skin. In some cases, a bacterial infection can only cause inflammation of the skin, but it can also penetrate into deeper areas such as subcutaneous tissue, muscles, and bones, causing serious infections.

In addition, if the autonomic nerve is damaged, an abnormality may occur in the skin vascular reaction due to temperature change, and due to the expansion of the veins of the foot and the impaired blood circulation, oxygen and nutrients to the wound are problematic, so wound healing may be delayed.

2. Peripheral Vascular Disease

Peripheral vascular disease can also cause foot ulcers. About one-third of diabetics with foot ulcers have peripheral vascular disease. Peripheral vascular disease accompanying diabetics usually occurs in thin arteries below the knee arteries, and is far more severe and wider than those in people without diabetes.

If you have a blood circulation disorder, the skin of your feet and legs is pale and cool, and your muscles are atrophied, leading to thin legs and hair loss. In severe cases, the color of the tip of the toe may turn black. If there is peripheral vascular disease, the blood supply to the wound site decreases, reducing the supply of nutrients or oxygen, so foot ulcers or infections are not as well.

Diagnoses

It is important to check if there are any risk factors for diabetic foot disease, and in the hospital, you can test blood vessels and nerves as well as the condition of the feet.

Diabetics should check their feet for signs of corn, calluses, and foot deformities, as well as skin cracks, redness or heat, athlete’s foot, and toenail deformities. If you have foot ulcers, both neuropathy and peripheral vascular disease can be the cause. If neuropathy is the main cause, it tends to occur in areas of high pressure, such as the heel or the back of the bone, and if peripheral vascular disease is the main cause, it occurs in the edge of the foot. Of course, in these cases, it is important to identify the cause in the hospital.

1. Examination for Neuropathy

Several tools can be used to screen for diabetic neuropathy. There are vibration sensory tests using a sound fork, pain sensory tests using a pin, protection sense (pressure sensing) of a foot using a mechanism called nylon monofilament, and deep gun reflex testing using a reflex hammer. In particular, the nylon monofilament (Semmes-Weinstein monofilament) test is a quick and simple test method that evaluates whether the pressure sensation is normal with a thin nylon thread applied to a specific location on the soles and feet. If there are many areas where the sensation cannot be felt, it can be said that the pressure sensation has decreased, which means that there is a high risk of foot ulcers.

In addition, a neuroconductive rate test can be performed more accurately to determine whether neuropathy is present by using electrophysiological test methods, but in most cases, the presence or absence of neuropathy can be confirmed by using clinical symptoms and examination findings and simple tests described above.

2. Examination for Peripheral Vascular Disease

1) Palpation of foot pulse

The simplest way to check if there is a problem with your feet’s blood circulation is to touch the instep and pulse of the peach bone. It is the simplest way to check for the presence or absence of peripheral vascular disease, but it is recommended to consult with your doctor as it may be promoted even with peripheral vascular disease.

2) Doppler ultrasound

Doppler ultrasound is a device that can check blood flow and is one of the methods to check for the presence or absence of peripheral vascular disease. Using Doppler ultrasound, blood flow can be checked by sound or waveform, and the narrowed area and degree of blood vessels can be checked.

3) Ankle-arm pressure index

In normal people, systolic blood pressure in the leg is higher than systolic blood pressure in the arm. This can be used to estimate the presence of peripheral vascular disease by comparing systolic blood pressure measured at the ankle and upper arm. The ankle-brachial pressure index is a simple and meaningful way to diagnose peripheral vascular disease.

4) Lower extremity angiography

Lower extremity artery angiography is a method for visually checking that blood vessels are narrowed or blocked. After inserting a thin tube into the artery to be examined, a contrast agent is injected to check the shape of the blood vessel.

This method provides the most accurate view of the shape of the blood vessels, but may have side effects such as the need to put a tube through the artery and irritability or worsening kidney function due to the use of contrast agents.

5) Computed tomography angiography or magnetic resonance angiography

There is a method to check the shape of blood vessels by using CT or MRI without directly inserting the tube into the artery.

In the past, it was a problem because the resolution was not good, but in recent years, the resolution has improved a lot, and unless it is a special case, it is common to identify an vascular condition by performing angiography using CT or MRI rather than angiography.

3. Examination for Infectious Diseases

Bacterial culture tests should be done if the patient’s foot is suspected of having an infectious disease, or if effusion (pus) comes from the foot ulcer. It is important to know the causative agent of the infection through the culture test and to determine the susceptibility to antibiotics.

If the patient has symptoms such as high fever or chills, and systemic infection is suspected, a blood culture test is also performed.

Additional tests include simple x-rays of the affected area, bone scans, and MRI scans. These tests can be used to determine the presence or absence of foreign objects, and to what extent the infectious disease has spread (whether the muscles, joints, bones are inflamed, etc.) and how wide it is.

Depending on the test results, the appropriate antibiotic and treatment period can be determined and whether surgery is necessary.

Treatments

1. Treatment of Diabetic Neuropathy

Diabetic neuropathy is the most important risk factor for diabetic foot disease, so it is important to accurately diagnose and treat it early. If symptoms are present, treatment should be taken to relieve symptoms, and if neuropathy is involved, treatment should be performed to prevent progression. Even if you haven’t been ill, you should be well aware of how to prevent it.

Since the development of diabetic neuropathy is closely related to the degree and duration of hyperglycemia, it is most important to strictly control blood sugar. It is also important to maintain stable blood sugar so that it doesn’t change badly as it moves back and forth between high and low blood sugar.

Anti-depressants or anticonvulsants are the most commonly used drugs to relieve symptoms such as pain, numbness and burning. Drugs to stop the progression of neuropathy include alpha lipoic acid and gamma linoleic acid.

2. Treatment of Diabetic Foot Ulcer

If you have a problem with the feet of a diabetic patient, you must seek medical attention. In some patients, blisters on the feet may be touched with undisinfected tweezers, knives, or toothpicks, or to remove calluses or corns with a knife or chemicals, which is very dangerous. If done wrong, it can exacerbate the wound and lead to a secondary infection, which can result in a large wound.

If you have an ulcer on your feet, the most important treatment is to remove dead tissue, reduce the pressure on the ulcer area, and cleanly disinfect the wound. It is essential to remove dead tissue by professional medical staff, because removing the dead tissue can help to create new flesh.

In addition, avoiding pressure on the ulcer area can promote wound healing. To do this, you can use gypsum bandages, customized shoes, and insoles according to the shape of your feet. In addition to the above methods, it is important to disinfect the wound, and recently, drugs that promote the formation of new flesh are also used.

3. Treatment of Peripheral Vascular Disease

To prevent the development of peripheral vascular disease in diabetics, blood sugar, blood pressure, and cholesterol must be controlled, smoking cessation, and the presence or absence of peripheral vascular disease should be checked regularly.

If there is peripheral vascular disease, there is a problem in blood supply, and nutrients and oxygen are not delivered properly, so the wound does not heal well and is easy to recur.

When it is confirmed that there is peripheral vascular disease, drugs such as vasodilators, anti-platelets, and blood-improving agents help improve blood flow. In some cases, radiation-mediated balloon dilatation or surgical methods are used. If the thick blood vessel is narrow, but the length is short, you can use a balloon to widen the narrowed area or to put a stent in the narrowed area.

However, peripheral vascular disease accompanying diabetics is more likely to occur in thin blood vessels in the area below the knee, and the blood vessels are often narrowed rather than locally, so it is important to select a person who can help with this procedure. To do.

Arterial bypass may help if the narrowed blood vessels are thin blood vessels that cannot be ballooned, or if the blood vessels are narrowed overall. Arterial bypass is a surgical method that creates a new blood flow by connecting new blood vessels (the patient’s own blood vessels or artificial blood vessels) between the upper and lower blood vessels around the blocked blood vessel area.

If the peripheral blood circulation disorder is severe and the blood flow disorder cannot be improved or necrosis continues, surgery may be required to cut a part of the lower extremity.

If you have peripheral vascular disease, your cardiovascular or cerebral vessels may also have problems. More than 50% of people who have undergone extensive amputation surgery are known to die within a year, most of whom die from heart disease (angina, myocardial infarction) or cerebrovascular disease (brain hemorrhage, cerebral infarction). Therefore, a person with peripheral vascular disease should undergo examination and management for coronary artery disease or cerebrovascular disease, and receive appropriate treatment if necessary.

4. Treatment of Infectious Diseases

If you suspect that a foot ulcer is accompanied by an infection, antibiotic treatment is required. Depending on the severity of the infection, you may be able to treat antibiotics that you eat, but in severe cases you will be hospitalized for intravenous antibiotic treatment. Surgical treatment should be considered in situations where these treatments do not respond or are life-threatening.

In this case, if there is a blood circulation disorder, it may be difficult to heal wounds after surgery. When a part of the leg is amputated, the amputation site is determined to minimize dysfunction after surgery, and a special type of brace is required for walking after surgery.