Diabetic Ulcer


Article Author:
Corrine Packer


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Biagio Manna


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Venkat Minnaganti
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Phillip Hynes
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Sandeep Sekhon


Updated:
3/24/2019 11:09:49 PM

Introduction

Diabetes mellitus is a metabolic endocrine disorder due to an overall deficiency of insulin (Type 1) or defective insulin function (Type 2) which causes hyperglycemia. Type 1 diabetes which is usually seen in younger patients accounts for 5% to 10% of cases worldwide and is secondary to autoimmune destruction of B-islet cells of the pancreas.  Type 2 diabetes accounts for 90% to 95% of cases worldwide and is due to genetic and environmental factors with resultant insulin resistance and pancreatic beta-cell dysfunction. Complications arising from hyperglycemia can either be macrovascular or microvascular. The macrovascular disease affects mainly the cardiovascular and cerebrovascular systems, and the microvascular disease includes nephropathy, retinopathy, and neuropathies.

A debilitating complication of diabetes mellitus is diabetic ulcers, which leads to increased overall morbidity in patients. This complication may be prevented, as the inciting factor is most often minor trauma. Early identification of these cutaneous injuries also can lead to improved outcomes while decreasing the risk of progression. Diabetic patients (type 1 or 2) have a total lifetime risk of a diabetic foot ulcer complication as high as 25%.  [1]

Etiology

The Six Stages of a Diabetic Foot as described by the 7th Practical Diabetes International Foot Conference 

  • Stage 1 - Normal foot with no risk factors;
  • Stage 2 - High-risk foot
  • Stage 3 - Ulcerated foot
  • Stage 4 - Cellulitic foot
  • Stage 5 - Necrotic foot
  • Stage 6 - Foot that cannot be rescued

There are three types of diabetic foot ulcer described namely neuropathic, neuroischaemic, and ischaemic.[2] [3]  Sensory neuropathy leads to the majority of ulcers as a result of minor trauma which is not perceived by the patient and further goes untreated as there are no associated pain symptoms unless there is a routine evaluation to assist in identification. [4] Myocardial infarction is one of the most significant events related to peripheral arterial disease increased risk of ischemia. However, ischemia leading to diabetic ulcers adds severe morbidity and health care cost as it can be a chronic complication which is difficult to treat as there is insufficient blood supply.

Major Risk Factors [5]

  • Peripheral motor neuropathy: Abnormal foot anatomy and biomechanics, with clawing of toes, high arch, and subluxed metatarsophalangeal joints, leading to excess pressure, callus formation, and ulcers
  • Peripheral sensory neuropathy: Lack of protective sensation, leading to unattended minor injuries caused by excess pressure or mechanical or thermal injury
  • Peripheral autonomic neuropathy: Deficient sweating leading to dry, cracking skin
  • Neuro-osteoarthropathy deformities (i.e., Charcot disease) or limited joint mobility
  • Abnormal anatomy and biomechanics, leading to excess pressure, especially in the midplantar area
  • Vascular (arterial) insufficiency: Impaired tissue viability, wound healing, and delivery of neutrophils
  • Hyperglycemia and other metabolic derangements: Impaired immunological (especially neutrophil) function and wound healing and excess collagen cross-linking 

Epidemiology

 The pooled worldwide prevalence of diabetic foot ulceration was 6.3%. North America had the highest prevalence of 13%; Oceania had the lowest prevalence of 3%. The prevalence in Africa was 7.2% which was higher than Asia 5.5%. Diabetic foot ulceration was more prevalent in male diabetic patients, 4.5%, than female patients, 3.5%. Patients with type 2 diabetes mellitus (T2DM) had a higher prevalence of ulceration at 6.4% compared to patients with type 1 diabetes mellitus (T1DM), 5.5%. [6][7]

In a systematic review and meta-analysis by Zhang et al. published in 2016, patients with diabetic foot ulceration had the following characteristics: older age (61.7 plus or minus 3.7 versus 56.1 plus or minus 3.9), longer diabetic duration (11.3 plus or minus 2.5 versus 7.4 plus or minus 2.2), lower body mass Index (BMI, 23.8 ± 1.7 versus 24.4 plus or minus 1.7), higher percentage of smokers (29.1%, 95%CI: 18.3% to 39.8% versus 17.4%, 95% CI: 12.4% to 22.4%), hypertension (63.4%, 95%CI: 49.4% to 88.3% versus 53.1%, 95%CI: 33.8% to 72.5%), and diabetic retinopathy (63.6%, 95%CI: 38.8% to 88.3%% versus 33.3%, 95%CI: 13.8% to 52.7%) than patients that did not develop diabetic foot ulceration. 

Pathophysiology

Atherosclerosis and diabetic peripheral neuropathy are the two main causes leading to a complication of diabetes such as ulcers. Atherosclerosis leads to decreased blood flow in large and medium-sized vessels secondary to thickening of capillary basement membrane, loss of elasticity, and deposition of lipids within the walls. Further arteriosclerosis leads to small vessel ischemia. Peripheral neuropathy affects the sensory, motor, and autonomic nervous system. There are multifactorial causes such as vascular disease occluding the vasa nervorum, endothelial dysfunction, chronic hyperosmolarity, and effects of increased sorbitol and fructose. 

History and Physical

The evaluation of patients presenting with diabetic ulcers can be divided into a clinical and radiologic assessment.

A clinically pertinent history of the type of diabetes, medication history, comorbidities, symptoms of peripheral neuropathy, and vascular insufficiency should be elucidated. Symptoms of neuropathy include hypoesthesia, hyperesthesia, paresthesia, dysesthesia, and radicular pain. Vascular insufficiency has varying presentations and most patients are asymptomatic. However, they can present with intermittent claudication, rest pain, and healing or non-healing ulcers.

In the examination of the legs and foot, an inspection should be performed in a well-lit room with appropriate exposure. Proper documentation using descriptions of ulcer characteristics with size, depth, appearance, and location performed. Presence of discoloration, necrosis, or areas of drainage are signs of infection, and further care is required. Other abnormalities such as nail discoloration, callus formation, and deformities should be noted. Imbalance in the innervations of the foot muscles from neuropathic damage can lead to the development of common deformities seen in affected patients. Hyperextension of the metatarsal-phalangeal joint with interphalangeal or distal phalangeal joint flexion leads to hammer toe and claw toe deformities, respectively. Charcot arthropathy is a commonly seen deformity. Assessment of footwear is important as it can be a contributing factor to the development of foot ulceration. The presence of callus or nail abnormalities should be noted. 

Examine the cardiovascular system, checking popliteal, posterior tibial, and dorsalis pedis pulse. Claudication, loss of hair, and the presence of pale, thin, shiny, or cool skin are physical findings suggestive of potential ischemia. If a vascular disease is a concern, the evaluator should measure the ankle-brachial index (ABI). ABIs can, however, be falsely elevated in diabetic patients due to calcification of vessels. More reliable methods of assessing the potential for healing foot ulcers in diabetic patients suspected of having peripheral ischemia involve systolic toe pressure measurements by photoplethysmography or measurement of distal transcutaneous oxygen tension. 

Evaluation

Based on wound depth and necrotic tissue, diabetic ulcers can be classified by the Wagner ulcer classification system. [8][9][10]

Wagner-Meggitt Classification of Diabetic Foot 

  • Grade 0 - Foot symptoms like pain, only
  • Grade 1 - Superficial ulcers
  • Grade 2 - Deep ulcers
  • Grade 3 - Ulcer with bone involvement
  • Grade 4 - Forefoot gangrene
  • Grade 5 - Full foot gangrene

Radiologic evaluation involves plain radiographs in two-thirds of the views assessing for deformity. If there is suspicion of osteomyelitis, MRI imaging should be performed.

Treatment / Management

Multimodal Diabetic Ulcer Management[11][12]

  • Patient Education: Education on foot care, as well as control of blood sugar levels, should be performed early. This can also be done with the aid of diabetic educators and social workers. 
  • Blood-Sugar Control: This is managed using a team approach of primary care physician, podiatry, and vascular specialist and based on the severity of the disease and the patient’s attitude toward medication, especially insulin. 
  • Decreasing Pressure, preventing further or new trauma: Offloading pressure to the area can be done with crutches, wheelchairs, and casting. Ulcer healing is improved with total contact casting, irremovable cast walkers compared to removable cast walkers. [13]
  • Improve Peripheral Vascular Circulation: Antiplatelet agents are the initial drug therapy; however, insufficiency requires surgical bypass. 
  • Prevent or Control Infection: Systemic and source control is achieved using antibiotics and surgical debridement.  
  • Topical Ulcer Care:  Principles of wound care include the use of topical agents with dressing and debridement. 

Differential Diagnosis

  • Venous Ulcers
  • Diabetic Dermatopathy

Enhancing Healthcare Team Outcomes

The management of a diabetic ulcer is very difficult and is best done with a team that includes an endocrinologist, surgeon, wound care nurse, internist, physical therapist, vascular surgeon, an infectious disease expert, and dietitian. Besides ensuring that glucose levels are controlled, one has to ensure that the tissue has an adequate blood supply. All diabetics should be urged to stop smoking and resume an exercise program. Close follow up is required by a multidisciplinary team as these ulcers can rapidly lead to necrosis and loss of a digit or a limb.[14]


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Diabetic Ulcer - Questions

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A 23-year-old female with diabetes mellitus presents with ulcer to the base of the first metatarsal. Examination reveals an ulcer with bone involvement. What is the severity grade based on Wagner-Meggitt classification?



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Which of the following is not a major risk factor for diabetic ulcers?



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Which geographical area has the highest prevalence of diabetic ulceration?



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A 65-year-old female who is obese presents with an ulcer on her forefoot. She reports that she noticed a small sore to the area a few weeks ago but does not recall stepping on anything or injuring her foot. Despite using an antibiotic cream daily, it has worsened. On examination, she is ill appearing and there is a 3 x 4 cm ulceration with slough at the base. Her blood pressure is 100/58 mmHg, heart rate 102 beats/min, temperature 101.4 F, and respiratory rate 12. Her random blood glucose is 340 mg/dL. What is the most likely diagnosis?



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A 45-year-old male presents to his primary care provider (PCP) with a history of a diabetic ulcer. Thus far, treatment of his ulcer has been unsuccessful. His PCP recommends a multimodal approach to improve the chances of healing. Which of the following is not part of a multimodal approach for the management of diabetic ulcers?



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Diabetic Ulcer - References

References

Comprehensive foot examination and risk assessment. A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists., Boulton AJ,Armstrong DG,Albert SF,Frykberg RG,Hellman R,Kirkman MS,Lavery LA,LeMaster JW,Mills JL Sr,Mueller MJ,Sheehan P,Wukich DK,, Physical therapy, 2008 Nov     [PubMed]
New treatments in ulcer healing and wound infection., Edmonds M,Bates M,Doxford M,Gough A,Foster A,, Diabetes/metabolism research and reviews, 2000 Sep-Oct     [PubMed]
The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks?, McNeely MJ,Boyko EJ,Ahroni JH,Stensel VL,Reiber GE,Smith DG,Pecoraro RF,, Diabetes care, 1995 Feb     [PubMed]
Diabetic foot infections: what have we learned in the last 30 years?, Uçkay I,Aragón-Sánchez J,Lew D,Lipsky BA,, International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases, 2015 Nov     [PubMed]
Managing diabetic foot infections: a review of the new guidelines., Gariani K,Uçkay I,Lipsky BA,, Acta chirurgica Belgica, 2014 Jan-Feb     [PubMed]
2. Classification and Diagnosis of Diabetes: {i}Standards of Medical Care in Diabetes-2018{/i}. Diabetes care. 2018 Jan;     [PubMed]
Geraghty T,LaPorta G, Current health and economic burden of chronic diabetic osteomyelitis. Expert review of pharmacoeconomics     [PubMed]
Zhang X,Sun D,Jiang GC, Comparative efficacy of nine different dressings in healing diabetic foot ulcer: A Bayesian network analysis. Journal of diabetes. 2018 Oct 15;     [PubMed]
Levy N,Gillibrand W, Management of diabetic foot ulcers in the community: an update. British journal of community nursing. 2019 Mar 1;     [PubMed]
Bolton L, Managing Patients With Diabetic Foot Ulcers. Wounds : a compendium of clinical research and practice. 2018 Dec;     [PubMed]
Parker CN,Shuter P,Maresco-Pennisi D,Sargent J,Collins L,Edwards HE,Finlayson KJ, Implementation of the Champions for Skin Integrity Model to improve leg and foot ulcer care in the primary health care setting. Journal of clinical nursing. 2019 Feb 21;     [PubMed]
Borys S,Hohendorff J,Frankfurter C,Kiec-Wilk B,Malecki MT, Negative pressure wound therapy use in diabetic foot syndrome-from mechanisms of action to clinical practice. European journal of clinical investigation. 2019 Jan 1;     [PubMed]
Giacomozzi C,Sartor CD,Telles R,Uccioli L,Sacco ICN, Ulcer-risk classification and plantar pressure distribution in patients with diabetic polyneuropathy: exploring the factors that can lead to foot ulceration. Annali dell'Istituto superiore di sanita. 2018 Oct-Dec;     [PubMed]
Xiang J,Wang S,He Y,Xu L,Zhang S,Tang Z, Reasonable Glycemic Control Would Help Wound Healing During the Treatment of Diabetic Foot Ulcers. Diabetes therapy : research, treatment and education of diabetes and related disorders. 2019 Feb;     [PubMed]

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