Diabetic Foot Ulcers
Diabetic foot ulcers (DFU's) are highly prevalent and the primary source of hospitalizations and amputations in persons with diabetes. In the US alone, 82,000 amputations are performed each year on persons with diabetes, roughly half of whom are 65 or older. Diabetic foot ulcers (DFU's) occur in approximately 15% of patients with diabetes, and of these, up 24 % of ulcers will end in amputation. Amputations in patients with diabetes are associated with a high morbidity and a 5-year survival rate of 31%.
If you believe you have a diabetic foot ulcer, you can receive a professional consultation with a wound specialist by calling (212) 263-7187.
Click on the links below to learn more about diabetic foot ulcers:
What is a diabetic foot ulcer?
What causes diabetic foot ulcers?
Can I expect my diabetic foot ulcer to heal?
What if I am above the age of 65, can I expect my wound to heal?
Why do many DFU's have a diminished ability to heal?
If I am living with diabetes, will I develop a foot ulcer?
How can avoid developing a diabetic foot ulcer?
Am I at risk for amputation due to a diabetic foot ulcer?
What risks are associated with DFU's?
If I have diabetes and foot ulcer, when should I seek medical care?
What is the treatment course for diabetic foot ulcers?
What will be done to address my pain?
Why is my wound photographed during clinical visits?
What is debridement and how will it help my wound?
How does the surgeon determine what is good tissue vs. non-healing tissue?
What is Apligraf and how will it help me heal?
What is osteomyelitis and, if I have it, how will it affect my wound?
What is callus, and when would the doctor remove callus from my foot?
When would a doctor remove a fungal nail?
What are my risks of infection, and how is this addressed?
How important is it that I stay off my foot?
Q. What is a diabetic foot ulcer?
A. Diabetic foot ulcers (DFU) are defined as "any breakdown in the skin on the foot of a diabetic person." This includes even minor redness, callus, blisters or sores. If you believe you have a diabetic foot ulcer, contact your doctor immediately. Early identification of a diabetic foot ulcer will improve your chances of healing.
Q. What causes diabetic foot ulcers?
A. Neuropathy (loss of sensation) and/or ischemia (inadequate blood flow) are the major causes of diabetic foot ulcers. Both are common complications associated with diabetes. Persons living with diabetes also have a diminished ability to fight infection, which can delay the healing process once an ulcer is formed, so it is important to consult a doctor if you have any loss of sensation in your feet.
Q. If I am living with diabetes, will I develop a foot ulcer?
A. Anyone living with diabetes is at risk of developing a diabetic foot ulcer. Of the more than 20 million people in the US with diabetes, as many as 25% will develop a foot ulcer in their lifetime. At particularly high risk, are those with either loss of sensation in their feet (neuropathy) or inadequate blood flow (ischemia). If you experience either of these symptoms, consult a doctor immediately.
Q. Why do many DFU's have a diminished ability to heal?
A. Several impairments associated with diabetes, such as a weakened immune system, nerve damage and poor circulation, can diminish the body's ability to fight infection. In the presence of infection, a wound is unable to progress through the natural stages of healing, and becomes locked in a perpetual inflammatory state. Such chronic wounds require professional intervention to heal.
Q. Can I expect my diabetic foot ulcer to heal?
A. It is our philosophy that if treated early and comprehensively, every diabetic foot ulcer should heal.
Q. What if I am above the age of 65, can I expect my wound to heal?
A. On average, elderly persons (ages 65+) with diabetes have more physiological impairments to healing. However, evidence shows that they should expect the same frequency of healing as younger populations, albeit at a slower rate. Thus, it is our philosophy that if treated early and comprehensively, every wound should have a chance to heal, regardless of the patient's age.
Q. How can avoid developing a diabetic foot ulcer?
A. If you are a person living with diabetes, there are several preventative measures you can take to avoid developing a diabetic foot ulcer.
- Most importantly, take time to empower yourself through education. Use the resources on this site or that you may receive from your physician.
- Involve your physician. Receive a foot examination at least once a year to assess parameters like foot deformity, ulceration of the skin, callus formation, fungal infection of the toenails, possible loss of sensation in the foot, adequate blood flow, and proper footwear.
- It is important that you perform daily foot examinations and alert your physician if you experience any of the following:
• Ulceration (cut or blister)
• Callus formation
• Long, infected toe nails
• Loss of sensation
• Foot deformity - Maintain good foot care, by:
• Wearing comfortable or protective shoes.
• Washing your feet daily
• Keeping toe nails clean and trim.
Q. If I have a diabetic foot ulcer, what is the risk of amputation?
A. The moment a person with diabetes suffers a break in the skin of the foot, they are at serious risk of amputation due to their bodies weakened ability to fight infection. Of the more than 20 million people in the US with diabetes, as many as 25% will develop a foot ulcer in their lifetime. Of these, 14-24% will end in amputation.
There are many factors that can compound this risk, which are listed below. If any one of these applies to you, consult your doctor.
- Loss of sensation in the feet.
- Inadequate blood flow.
- Deformity in the feet.
- Callus formation resulting in focal areas of high pressure.
- Dry, fissured skin of feet.
- Limited joint mobility.
- Obesity.
- Impaired vision.
- Poor glucose control leading to impaired wound healing.
- Poor footwear that causes skin breakdown or inadequately protects the skin from high pressure and shear forces.
- Prior foot ulcers and/or lower extremity amputations
Q. What risks are associated with DFUs?
A. Eminently treatable wounds in the non-diabetic patients often become chronic, non-healing wounds in patients with diabetes, posing serious risk for infection, sepsis, and amputation.
Q. If I have diabetes and foot ulcer, when should I seek medical care?
A. Immediately. Even if there are no signs of infection, simply having diabetes makes any wound on the foot a serious risk for infection and amputation. The earlier you find professional treatment for your diabetic foot ulcer, the more likely you are to heal your wound and return to your normal life.
Q. What is the treatment course for diabetic foot ulcers?
A. The following is an established protocol developed for patients with diabetic foot ulcers:
- Measurement of the wound by photography
- Optimal glucose control
- Surgical debridement of all hyperkeratotic, infected, and nonviable tissue
- Systemic antibiotics for deep infection, drainage, and cellulitis
- Offloading
- Moist-wound environment
- Treatment with growth factors and/or cellular therapy if the wound is not healing after 2 weeks with this protocol and a new skin is not forming.
Q. What will be done to address my pain?
A. We treat your pain by addressing the underlying problem. This requires an understanding of the mechanisms of pain and an understanding of all the different options available to correct it. At the NYU Wound Healing and Regenerative Medicine Division, your wound care specialist remains in constant communication with a pain management expert to decide on the best strategy for minimizing your discomfort. If any therapy is not working, you can expect our team to promptly address the issue and make the necessary changes to your pain management plan. Patients and families must be aware that any pain in or surrounding even a small foot ulcer must be brought to the attention of the physician.
Q. Why is my wound photographed during clinical visits?
Our clinical team has designed a Wound Electronic Medical Record (WEMR) to acquire and display the requisite data and provide the decision support necessary to improve the care of patients with chronic wounds. As part of this medical record, photographs are of the wounds are taken upon each clinical visit to record the progress of healing. Using these photographs and a computer program, our team calculates wound area as a method of tracking the healing rate. As part of each visit, you can view these photographs and a graph of your wound area to see improvement over time.
Q. What is debridement and how will it help my wound?
A. Debridement is widely accepted as the most definitive treatment for the diabetic foot ulcer. Sharp debridement of the diabetic foot ulcer stimulates the edge of the wound, , releases growth factors and reduces the local inflammatory and proteolytic environment. Moreover, by removing dead, diseased or infected tissue from the wound bed, debridement improves the potential for healthy tissue to heal. Dead, diseased, and infected tissue is a source of bacterial overgrowth, which can lead to pain, sepsis, and eventually, amputation. Thus, it must be removed to create the most ideal healing environment. Debridement is a widely employed method.
Q. How does the surgeon determine what is good tissue vs. non-healing tissue?
A. To verify that we have sufficiently removed all of the dead, diseased, and infected tissue, we analyze the tissue that is removed as well as the tissue that is left behind. These specimens are analyzed under a microscope for cellular abnormalities. As well, we utilize genetics studies to research non-healing genes.
Q. What is Apligraf and how will it help my diabetic foot ulcer heal?
A. Apligraf is a human living cellular therapy that has been shown to accelerate healing of chronic wounds. Derived from fetal foreskin, Apligraf stimulates healing of the wound by initiating the release of a multitude of growth factors into the wound, stimulating the natural healing process.
Q. What is osteomyelitis and, if I have it, how will it affect my wound?
A. Osteomyelitis refers to an infection of the bone, typically caused by bacteria. Osteomyelitis is present in many diabetic foot ulcers and is treated most effectively by surgical removal of the infected bone. After the infected bone is removed, the patient requires only antibiotics for control of bacteria in the surrounding soft tissue.
Q. What is callus, and when would the doctor remove callus from my foot?
A. Callus refers to nonviable, hyperkeratotic tissue, and is common to diabetic foot ulcers. The presence of callus can prevent healing and can also create increased pressure from footwear or improper gait in the neuropathic diabetic foot, ultimately leading to further ulceration. When necessary, the entire callus is removed with a sharp scalpel. There is little to no pain associated with this procedure.
Q. What are my risks of infection, and how is this addressed?
Diabetic foot ulcers act as portals of entry for systemic infection (from cellulitis, infected foot ulcers, and osteomyelitis), which can have particularly deleterious effects on patients with diabetes, whose impaired immunity increases their risk for local and systemic infection. Local bacterial contamination is always present in a nondebrided wound, and because of diabetic immune system impairments, sepsis is possible. Debridement and antibiotic therapy must be initiated as early as possible. Hyperglycemia also should be monitored closely and controlled, because it may increase the virulence of microorganisms.
Q. When would a doctor remove a fungal nail?
A. Fungal toenails constitute a danger in the diabetic foot, as they can lead to eventual ulceration. The foot wounds of patients with fungal nails are three times more likely to become gangrenous when compared to patients without fungal nails. Treatment can take the form of partial or complete removal of the infected nail, or the application of topical antifungal medication. Nail debridement or excision has been shown to be safe and effective.
Q. How important is it that I stay off my foot?
A. The goal of offloading is to create an environment that enhances soft-tissue viability and promotes wound healing. Reducing pressure applied to the wound, especially in the forefoot, is essential for optimal treatment. Even light pressure applied to a healing wound can be detrimental to healing. Unrelieved pressure impairs healing and increases the risk of complications.
