ISSN 2473-4799

DERMATOLOGY
Open Journal PUBLISHERS

Review
Prevention of Diabetic Foot Ulcers at Primary Care Level
Josephine Priyadarshini, RN; Seham Abdi, RN; Azza Metwaly, RN; Badria Al-Lenjawi, MD; Janelle San Jose, RN;
Hashim Mohamed, MD*

Weill Cornell Medicine-Qatar, Doha, Qatar

Corresponding author
*

Hashim Mohamed, MD
Associate Professor, Weill Cornell Medicine-Qatar, Doha, Qatar; E-mail: [email protected]

Article information
Received: January 9th, 2018; Revised: January 30th, 2018; Accepted: February 6th, 2018; Published: February 6th, 2018

Cite this article

Priyadarshini J, Abdi S, Metwaly A, Al-Lenjawi B, Jose JS, Mohamed H. Prevention of diabetic foot ulcers at primary care level. Dermatol Open J. 2018; 3(1): 4-9.
doi: 10.17140/DRMTOJ-3-129

ABSTRACT

Diabetic foot ulcer (DFT) prevention is best achieved at primary care level and should begin with education, appropriate pro-
tective footwear, glycaemic control and regular screening for loss of protective sensation. In the west, specialized diabetic or
podiatry clinics may assess and quantify neuropathy with many tools including monofilaments, biothesiometry, corneal confocal
microscopy and nerve conduction studies. Vascular assessment can be done via measuring ankle-brachial index, duplex ultrasound
studies and toe pressure. Other foot assessment may include measuring plantar foot pressure using computerized dynamic foot
studies (computerized insole sensor system). The ability to stratify patients based on risks is carried out on the basis of a thorough
medical and surgical history in conjunction with these measurements thereby allowing clinicians to determine the type of inter-
vention. Effective strategies for foot ulceration prevention include educating patients, their families, and healthcare workers about
adequate foot care and regular foot examinations along with optimal glycaemic control and smoking cessation. Other effective
clinical interventions may include, foot hygiene, debridement of calluses, management of foot deformities which may at times
require prophylactic foot surgery. Counseling patients regarding daily proper footwear and hygiene should be stressed during each
clinic visit. Educating, screening and managing patients with diabetic foot ulceration and or complications is an essential primary
healthcare strategy to prevent unnecessary morbidity and mortality related to diabetic foot. An integrated (interdisciplinary) ap-
proach including, family physicians with special interest in the diabetic foot, diabetic educators, nurses and family members is a
vital component in this regard.

Keywords
Diabetic foot ulcer (DFU); Neuropathy; Glycaemic control.

INTRODUCTION putation related to diabetes exceeds $350 million annually.4 How-

ever diabetic foot ulcer is preventable by appropriate education,

D iabetic foot ulcer (DFT) is the most common and neglected

complications of diabetes. The risk of death for those with
foot ulcers is 12.1 per 100 person-years of follow-up compared
evidence-based counseling and preventative strategy.

PREVENTION AND TREATMENT OF NEUROPATHY

with 5.1 in those without foot ulcers.1 Similarly, the risk for ampu-
tation in patients with diabetes is 15 times greater than for the non- Neuropathy is the main cause that gives rise to diabetic foot ul-
diabetic population and the majority of amputations are preceded cer especially the insensate foot. Patients might not be aware of it
by DFU.2 It is documented that subjects with foot ulcers have a in the early stages, as they might not feel the pain.5 Furthermore,
poor quality of life and nearly 15% of all diabetics will develop neuropathic wound does not heal fast as it is not protected by pain
foot ulcers. It is also estimated that 15% of all diabetics who get sensation. Optimal glycaemic control can reduce the incidence of
admitted to hospital do so mainly due to foot problems.3 neuropathy and thereby foot ulcer.6 Foot deformities, on the other
hand, can also cause foot ulcers because of the abnormal pressure.7
In the US, direct hospital costs for the treatment of dia-
betic foot infections exceeds $200 million per year and that for am- In diabetes, deformity due to Charcot neuroarthropathy
cc Copyright 2018 by Mohamed H. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which

allows to copy, redistribute, remix, transform, and reproduce in any medium or format, even commercially, provided the original work is properly cited.
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is increasingly recognized.8 It is very important to prevent defor- • Red spots.

mity in diabetic subjects by the use of adequate footwear. Similarly, • Cuts.
acute Charcot neuroarthropathy should be aggressively treated
to maintain the normal architecture of the foot.8 There has been • Blisters.
no controlled trial on surgical correction of deformity in the pre- • Wet or white areas in between the toes.
vention of ulcers but it is worth considering. Recently, surgery to
• Sores.
lengthen the Achilles tendon has been shown to be useful in the
prevention of ulceration of metatarsal heads.9 If there is recur- • Any skin change.
rence of ulceration over a bony prominence or on an abnormal • You should use a mirror to see the bottom of your feet.
weight-bearing part, surgical correction may be indicated.
Figure 1. General Steps to Examine the Diabetic Feet
Key Interventions

• Regular follow-up and surveillance for diabetic retinopathy for

adults with diabetes is required and early laser treatment for
those identified with retinopathy is vital.
• Patients having microalbuminuria should be treated with an-
giotensin converting enzyme (ACE) inhibitors and their rate of 3. If you see thickened skin area (callus) consult your doctor be-
progression to diabetic nephropathy. cause it means the pressure in that area is high; therefore, you
• Strict blood pressure and blood glucose control in people with need a special insert or shoe to relieve the pressure and your
diabetic nephropathy can reduce the rate of deterioration in doctor may want to remove the callus.
their renal function, as well as their risk of cardiovascular dis-
ease. 4. If your feet feel cold don’t use hot water bottle because you
may burn your feet without even feeling it.

Specific Foot Care Advice Given to Patients with High-Risk Feet How Can I Take Care of my Feet?
in Order to Prevent DFU
1. Wash your feet daily using warm water (test it by your elbow),
• Wash your feet daily with mild soaps and keep it moisturized. a mild soap and dry using a towel especially the areas between
• Avoid walking barefoot indoors. your toes.

• Inspect your feet daily. 2. Do not soak your feet because this will dry out the skin and
do not use whirlpool – water if you suffer from cold feet but
• Contact your doctor or podiatrist if there is redness or swelling rather wear socks made of cotton and wool to keep your feet
or a minor cut. warm.
• Wear well-fitting shoes which should offer enough room to
move your toes freely. 3. Use a moisturizer (10% urea cream) because dry skin cracks
and if this happens it can lead to infection and ulcer forma-
• If needed wear special shoes if you have been supplied with tion.
them.
4. Dry up between your toes after washing your feet.
• Never self-treat your own corn or callus. Consult a doctor in-
stead. 5. Cutting your nails regularly once a week is usually enough
• Avoid using a hot water bottle. but if your nails are thick; don’t attempt to cut them because
you may injure yourself. Your doctor can help you by using a
• Wear woolen socks in bed if needed. special scissor. Nails should be cut across and not in a semi-
circular fashion and use a nail clipper instead of scissor & do
General Advice Necessary to Help you Protect your Feet not cut nails too close to the skin.
(Figure 1)
FOOTWEAR CARE
Foot Examination
1. Never walk barefoot even inside the house, socks should be
1. Check your feet daily because some people may not feel injury worn (cotton) all the time to keep skin moist and shoes must
if the nerves in their feet are not working properly. also be worn, to avoid injury to your feet.

2. So, you should look for: 2. Check your shoes before you wear them because you may find
foreign bodies such pieces of stones inside.

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3. Wear socks which are made of cotton or wool.

Figure 3. General Changes Observed in the Skin of Diabetic Foot Patient
4. Shoes should be round in the front, made of leather top or
canvas to let your feet breath. Remember, that you should buy
shoes at the end of the day because feet swell up as the day
goes on. Remember that if shoes are comfortable, when your
feet are swollen at night they will be comfortable all day.

5. Avoid high heels shoes which may put extra pressure on the Things you need to take care of:
bottom of your feet.
1. Keep your blood sugar under control since this will help in
6. If you want to exercise you need to wear soft tennis shoes and preventing complications and speeds up healing. This can be
check your feet before and after exercise. an achieved by eating a healthy and balanced diet, exercise and
proper medical follow-up.
7. Sandals should not be worn nor should you wear nylon socks.
2. Avoid smoking.
Consult your doctor: Consult your doctor before buying a new
pair of shoes and if you do, you need to wear it 1 hour daily initially 3. Have a regular follow-up with your doctor regarding foot care.
until it softens up slowly over several days
4. Report any change in your skin no matter how trivial it may
1. Let your healthcare provider check your feet on a yearly basis look.
at least, but if you are suffering from one of the following you
need to be checked more often: PREVENTION AND TREATMENT OF PERIPHERAL
VASCULAR DISEASE
A. Suffering from numbness or pins and needles in your feet.
The lack of blood supply or ischemia is one of the major reasons
B. Burning sensation in your feet. for diabetic foot ulcers and thereafter amputations. Atherosclerotic
C. Pain in your feet or back of your leg. lesions are more diffuse and distal in diabetics.10 The risk of vascu-
lar diseases in diabetics can be reduced, by lifestyle modifications
D. Cold sensation in your feet.
including daily exercise and avoiding smoking. Many drugs are out
in the market promoted as being useful in the prevention of DFU
2. If you have abnormal looking toes.
and peripheral vascular disease; however, adequate controlled trials
supporting these claims are lacking. Despite this, an argument for
Skin care: To help you have moist skin you need to
the use of aspirin, clopidogrel, statins, fibrates, ACE inhibitors and
folic acid in diabetics can be made in the light of these pieces of
1. Use a moisturizer such as 10% urea cream or Lanolin.
evidence.11-14 On the other hand, agents such as naftidrofuryl and
cilostazol, although helpful in controlling symptoms of intermit-
2. Avoid barrier creams and ointments such as Vaseline because
tent claudication, have not found widespread use in diabetics with
it will not moisturize your feet.
peripheral vascular disease as there is paucity of data on preven-
tion of DFU or amputation.15,16 If a leg is fully ischaemic, vascular
3. Avoid applying a moisturizer in between your toes.
surgery could improve the blood supply.17
4. Avoid Henna because it will dry your skin & cause the skin to
GLYCAEMIC CONTROL
crack.
Normal glucose level is the first line of defense against chronic
If you see any of the following changes in the nail please consult
complications of diabetes. Optimal glycaemic control may prevent
your doctor (Figure 2).
the development of neuropathy. Intensive blood glucose control
reduced the development of neuropathy by 40% in patients with
Figure 2. General Changes Observed in the Nails of Diabetic Foot Patient
type II diabetes18 and by about 60% in patients with type 1 diabe-
tes.19 Raised HbA1c has also been associated with DFU, amputa-
tions and peripheral vascular disease. Therefore, it is very impor-
tant to optimize glycaemic control to prevent DFU in the long run.

REGULAR PODIATRY

Similarly, if you see the following changes in your skin please con-
Podiatry services are essential in the prevention and treatment of
sult your doctor (Figure 3).
DFU.20 Patients should avoid self-treating corns and calluses and

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Dermatol Open J. 2018; 3(1): 4-9. doi: 10.17140/DRMTOJ-3-129

should avoid nail clippings especially if there is retinopathy or the Diet

nails are thick, dystrophic along with the history of the peripheral
vascular disease. If a callus or corn is present it ultimately leads to Maintenance of adequate and balanced diet is the main treatment
unnecessary shear forces and results in high pressure in the foot.21 for diabetes to improve glycaemic control. Obesity should be
At each visit, it’s the clinician utmost responsibility to examine the prevented. These subjects should be actively encouraged to lose
foot and also reinforce foot care education. Prescription footwear weight if they are obese. This will not only improve the diabetes
is of paramount importance, as it prevents pressure sores and ul- control but will also reduce the pressure on the foot. Similarly, a
cers. A shoe that allows free movement of toes is a way of identify- low-fat diet is important to reduce cardiovascular disease.26
ing rightly fitting shoes.
Exercise
Patients with low or medium risk of ulceration should
be advised to buy good quality shoes but those with high risk and Exercise is the cornerstone and prevents peripheral neuropathy.
in subjects who already developed DFU, custom-made prescrip- Exercise or activity is beneficial for people with diabetes. Physio-
tion footwear should be prescribed as these have been shown to therapy can correct the gait abnormality and possibly prevent the
prevent recurrences of DFU.22 Orthotists are of great help in de- development of DFU.27
signing appropriate footwear especially when there is a severe foot
deformity.23 Patients should be advised to ensure that shoes are in a Alcohol
good state of repair and check for any foreign objects before they
are worn. Excessive intake of alcohol has been associated with the devel-
opment of diabetic neuropathy.28 On the other hand, moderate
FOOT CARE EDUCATION consumption has been shown to improve diabetes control and
mortality in general population including diabetic subjects.29 Men
The patient should be taught about foot care. The patient or their should drink no more than 21 units and women no more than 14
care taker should examine the feet at least once a day if needed units each week.
with the help of a mirror to look into the under surface. A proper
foot care education program has been shown to reduce the risk CONCLUSION
of ulceration.24,25 Patients usually become more receptive to medi-
cal advice after first ulceration, so a thorough counseling with the It is essential to screen diabetic patients to identify those at risk for
physician or podiatrist or specialist nurse should be arranged to foot ulceration. Prevention of diabetic foot ulcer is best achieved
discuss foot care. through effective health education30 and evidence-based counsel-
ing to the patient and family, early identification, regular assess-
DETECTION OF HIGH-RISK FEET WITH SCREENING ment and proper foot examination. Specialized clinics such as po-
diatric clinic use advanced foot assessment methods to determine
Screening programs are available in various parts of the world. It’s the type of clinical intervention which proves beneficial for dia-
better to screen patients in 3 months after diagnosing patients with betic patients.
diabetes. All diabetic subjects should be offered a comprehensive
foot-screening program. The patients are classified into high, me- CONFLICTS OF INTEREST
dium and low-risk categories by the screening clinician depending
upon previous foot ulcers, neuropathy, ischemia, deformity, smok- The authors declare that they have no conflicts of interest.
ing habit, and vision. If the patients are high or medium risk, they
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