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SPECIAL REPORT

Preventing Diabetic Foot Ulceration in Primary Care Preventing Diabetic Foot Ulceration in Primary Care A Potentially Existential Threat Obscured Symptoms, Risk Factors and Poor Outcomes Looking at the Big Picture Care for the Feet

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PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

SPECIAL REPORT

Preventing Diabetic Foot Ulceration in Primary Care Preventing Diabetic Foot Ulceration in Primary Care

Contents

A Potentially Existential Threat Obscured Symptoms, Risk Factors and Poor Outcomes Looking at the Big Picture Care for the Feet

Foreword

2

John Hancock, Editor

Preventing Diabetic Foot Ulceration in Primary Care 3 Dermatonics Ltd

Background NICE Guideline NG19

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Published by Global Business Media

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Managing the Risk of Developing a Diabetic Foot Problem What Has Changed Since NG19 Replaced CG010? Step by Step Guide to an Effective Diabetic Foot Assessment in Your Surgery

A Potentially Existential Threat

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John Hancock, Editor

A Growing Healthcare Challenge

Publisher Kevin Bell

An Existential Threat for People with Diabetes

Business Development Director Marie-Anne Brooks

Prevalence and Consequences of Diabetic Foot Ulcers

Editor John Hancock

Obscured Symptoms, Risk Factors 10 and Poor Outcomes

Senior Project Manager Steve Banks

What is a Diabetic Foot Ulcer?

Camilla Slade, Staff Writer

Advertising Executives Michael McCarthy Abigail Coombes

Symptoms and Signs that an Ulcer Might be Developing

Production Manager Paul Davies

Outcomes can be Poor

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Looking at the Big Picture

Possible Causes of and Risks Leading to Diabetic Foot Ulcers

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Peter Dunwell, Medical Correspondent

Related Conditions and Co-Morbidities The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. Š 2015. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Diagnosis of Diabetic Foot Ulceration Assessment and Treatment

Care for the Feet

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John Hancock, Editor

Wound Management for Foot Ulcers Wound Treatment Regimens for Foot Ulcers Cared For Feet Will be Healthier Feet

References 16


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Foreword P

EOPLE WITH diabetes are all too aware that

The article goes on to examine the salient points

they have to monitor and take particular

around prevention as published in the NICE Guideline

care of their health. Even from first diagnosis

NG19 and sets out a step by step guide to effective

and certainly as the condition progresses,

diabetic foot assessment in surgeries.

diabetes is increasingly likely to be accompanied

In the second article, we consider DFUs, what they

by co-morbidities and related conditions. As

are, why they are difficult to manage, how they can

these develop, so they can give rise to further

impact on life, their prevalence and the consequences

complications and, while it might not yet be

to which they can give rise, including the risk of

possible to prevent all of those complications,

fatality. Then, Camilla Slade takes a closer look at

good general healthcare with a focus on known

the symptoms that could indicate that a foot ulcer

vulnerabilities will help. With diabetic foot ulcers

is developing as well as some of the known causes

(DFUs), there is a lot that patients and clinicians

and risks that might make a person with diabetes

can do to reduce the chances of the condition

prone to a DFU. Stepping back a little, Peter Dunwell

developing in the first place or, in the event that it

next considers DFUs in the overall health landscape

does develop anyway, to manage and treat it. And

focusing also on diagnosis and emphasising the

that’s important because DFUs have the potential

need for rapid response when a DFU is suspected

not only to degrade quality of life but to threaten

or diagnosed. But, in diabetic foot ulcers as in

amputation or death.

any condition, the first line of defence should be

The opening article in this Special Report looks at

prevention and, where that fails, a managed treatment

the incidence of Patient Diabetic Foot events treated

programme. So our final article looks at a number of

by the NHS and various strategies for the prevention

options and methods for foot care to prevent and to

of Diabetic Foot ulceration, where mortality rates post

help to heal diabetic foot ulcers.

amputations are as high as 50% after 2 years and 70% after 5 years, which is similar to bowel cancer and higher than both lung and pancreatic cancer.

John Hancock Editor

John Hancock has edited Primary Care Reports since launch. A journalist for 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms.

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PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Preventing Diabetic Foot Ulceration in Primary Care Dermatonics Ltd

Background In the UK over the last 3 years there were 143,503 In-Patient Diabetic Foot events taking over 1.3m bed nights at NHS hospitals . The incidence of these events by Trust/CCG represented up to 34.4 events per 1000 Diabetic patients and was on average 19.2 events per 1000 patients with Diabetes. The cost of these events equates to around £650m annually, and is growing, when QALY costs are added the total costs are believed to be £1bn. Virtually every GP Surgery will have experienced an ulceration or an amputation and will understand the costs and time associated with these. The average CCG/Trust will spend £3m on treating such events but a very small amount on effective prevention strategies Mortality rates post amputations are as high as 50% after 2 years and 70% after 5 years which is similar to bowel cancer and higher than both lung and pancreatic cancer. One in 10 ulcerations lead to an amputation. Yet the lowest rate of Foot care events in a Trust/ CCG in the UK was 7.7 per 1000 compared to the average of 19.2- reducing the overall rate to 7.7 would save many lives and substantial sums annually. While demographics can explain some of the difference between rates in various Trusts protocols and prevention strategies can make significant improvements. The Incidence rates for your Trust can be found at http://www.yhpho.org. uk/diabetesprofilesfoot/default.aspx The Chief Executive of the NHS has called for the NHS to “get serious about prevention” and NHS England has launched Commissioning For Prevention. At the same time, the National Diabetes Audit suggests “effective risk management is dependent on people with Diabetes understanding what their risk factors are and what they can do to minimise those risks”. The simplest of these prevention strategies is to ensure patients with dry skin apply cream to their feet daily. The Young Townson FootSkin Hydration Scale for Diabetic Neuropathy, recently published in the Diabetic Foot Journal, was

written with improved prevention in mind, and also communicates risk factors to practitioners and patients. If it seems fanciful that just by applying an emollient to the feet we can reduce ulceration rates by 13% and save the NHS £15 for every additional £1 spent on Dermatonics, as suggested in a report written by Oxford University Statistics Department, then there is a clear and much better known parallel – we all know that we must avoid becoming obese to greatly reduce the risk of Type 2 Diabetes.

NICE Guideline NG19 This Guideline was published on 26 August 2015 and contains a number of changes from the previous Guidelines CG010 and CG119. Practitioners, NHS Trusts, and the Society of Podiatrists are busy interpreting the new Guidelines. However the salient points around prevention, and the role of GP surgeries are set out below. Before we look at these, a recent Legal case has made NICE Guidelines binding unless CCGs have a better evidence base than NICE when making their decisions l  Sir Andrew Dillon, Chief Executive of NICE, said: “This court ruling highlights that CCGs cannot simply ignore NICE guidelines without having a clear clinical case for doing so. NICE guidelines are based on the best available evidence. l http://tiny.cc/wdra7x l  CCG’s ignoring this case and NG19 would seem to do so at their peril with potential legal claims for ulcerations which may have been avoided with appropriate prescribing 1.3.4 Assessing the risk of developing a diabetic foot problem For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times: When diabetes is diagnosed, and at least annually thereafter (see recommendation 1.3.11). WWW.PRIMARYCAREREPORTS.CO.UK | 3


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Mortality rates post amputations are as high as 50% after 2 years and 70% after 5 years which is similar to bowel cancer and higher than both lung and pancreatic cancer

If any foot problems arise. On any admission to hospital, and if there is any change in their status while they are in hospital. When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors: Neuropathy (use a 10 g monofilament as part of a foot sensory examination).

1.3.9 The foot protection service should assess newly referred people as follows: Within 2–4 weeks for people who are at high risk of developing a diabetic foot problem. Within 6–8 weeks for people who are at moderate risk of developing a diabetic foot problem. 1.3.10 For people at moderate or high risk of developing a diabetic foot problem, the foot protection service should: Assess the feet.

Limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease).

Give advice about, and provide, skin and nail care of the feet.

Ulceration. Callus.

Assess the biomechanical status of the feet, including the need to provide specialist footwear and orthoses.

Infection and/or inflammation. Assess the vascular status of the lower limbs. Deformity. (Usually defined as not being able to fit into normal high street shoes). Gangrene. Charcot arthropathy. 1.3.5 Use ankle brachial pressure index in line with the NICE guideline on lower limb peripheral arterial disease. Interpret results carefully in people with diabetes because calcified arteries may falsely elevate results. 1.3.6 Assess the person’s current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification: Low risk: no risk factors present. Moderate risk: 1 risk factor present. High risk: previous ulceration or amputation, on renal replacement therapy, or more than 1 risk factor present.

Managing the Risk of Developing a Diabetic Foot Problem 1.3.7 For people who are at low risk of developing a diabetic foot problem, continue to carry out annual foot assessments, emphasise the importance of foot care, and advise them that they could progress to moderate or high risk. 1.3.8 Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service. 4 | WWW.PRIMARYCAREREPORTS.CO.UK

Liaise with other healthcare professionals, for example, the person’s GP, about the person’s diabetes management and risk of cardiovascular disease.

What Has Changed Since NG19 Replaced CG010? Firstly there appears to be no mention of the need to have trained staff carrying out the annual foot checks. However we would expect that the potential savings from better prevention would be sufficient to encourage CCGs and GPs to give annual training to those involved in Diabetic Foot assessments. The requirement to refer to the Foot protection service has increased in many instances, with a single risk factor being sufficient to require a referral. If followed to the letter, this might swamp the services The status of the Foot Protection Service has been upgraded The Multidisciplinary Foot service, which manages complex cases and hospitalisations, will be lead by a Senior named individual It identifies callus as a specific risk factor It requires the provision of skin and nail care for patients with just a single risk factor


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Step by Step Guide to an Effective Diabetic Foot Assessment in Your Surgery NG19 requires each GP surgery to carry out annual foot checks on all Diabetes patients It tells the Practitioner what to do, but is silent about how to carry out the assessment. In order to complete this section we have discussed with leading practitioners what they believe represents Best Practice in carrying out a Diabetic Foot assessment stage by stage. The first key step is to ensure that, before starting a Diabetic foot assessment, the practitioners who carry out the assessments are fully trained. When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings so you can see the entire foot – examine the entire foot.

If a patient presents with an ulceration in your practice, refer to the local pathway to the acute multidisciplinary foot team, vascular service or community Foot Protection Service immediately. The degree of ulceration can be identified using either the SINBAD or TEXAS wound care scales If the patient has a previous ulceration it is likely they will be under the care of the foot protection service. If not, they will be at high risk and may even be under MDfT in some areas. Callus The identification of callus may sound simple but there are grey areas and, given its importance as a risk factor, it is vital to ensure it is correctly identified. Use a validated photographic scale to ensure consistency between practitioners. The peer reviewed Young Townson Footskin Scale published in The Diabetic Foot Journal is available on line at: www.dermatonics.co.uk/footskinscale

The following paper is of interest in this context: http://tiny.cc/ipra7x On p309, Neil Baker and Colin Kenny list actions to be undertaken. Additional information can be found in the Diabetes UK patient leaflet: http://tiny.cc/tsra7x Neuropathy (use a 10 g monofilament as part of a foot sensory examination). Ensure the monofilament used has an evidence base and is validated. Ensure the practitioner is trained in its use. Ensure the monofilament is replaced after every 10,000 uses equal to 500 patient assessments – References: Booth, J. Young M (2000) Differences in the performance of commercially Available 10-g Monofilaments, Diabetes Care 23(7):984-988 Limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease). Ulceration

This scale is recommended by the Society of Podiatrists and included in their Diabetes training module and was written by two leading practitioners with a view to improving and standardising emollient practice to reduce ulcerations, save lives and reduce costs to the NHS. Whist NG19 suggests a referral to the Foot protection team once callus is identified, this may take 2 to 4 weeks and therefore we suggest Dermatonics Once Heel balm be prescribed which, in 95% of cases, will remove the callus within 7 days and in 99% will remove all callus within 14 days. This will quickly reduce the risk of ulceration by removing the callus and, where successful in doing so, will save the patient the need to travel to see the Foot health Service and save the Surgery the referral fee. Normal practice would be to prescribe Dermatonics Once Heel Balm on an ongoing basis as neuropathic Diabetics suffer from impaired sweat glands hence the need to supply moisture from an external source. WWW.PRIMARYCAREREPORTS.CO.UK | 5


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Early diagnosis and appropriate management is critical to outcome and prevention of limb loss and premature death

Infection Compromise of the blood supply from microvascular disease, often in association with lack of sensation because of neuropathy, predisposes people with diabetes to foot infections. These infections span the spectrum from simple, superficial cellulitis to chronic osteomyelitis. Early diagnosis and appropriate management is critical to outcome and prevention of limb loss and premature death. Signs and symptoms associated with a foot infection in someone with diabetes may be suppressed due to an immuno-compromised response to inflammation. To ensure the right diagnosis is made, it is essential that the examination includes important questions on history and current general well being. It is likely that a person with a foot infection is systemically unwell also. Reference must be made to the local foot infection protocol formulary, which may include guidance such as broad spectrum antibiotic for minimum of two weeks, referral for cultures if infection is present, referral to vascular services in presence of peripheral arterial disease or spreading infection or to the acute foot MDT, particularly if wound is associated with neuropathy. Time is critical and decisive action required to ensure the best outcome for the patient. Ensure local pathways and contact details for the infected diabetic foot pathway is close to hand and available to all within the practice.

Deformity (usually defined as not being able to fit into normal high street shoes). Trauma is the most common causal factor for wound development in people with diabetes. An acute event, such as standing on a nail is not an unfamiliar presentation. However, the majority

of foot wounds are associated with an existing foot deformity. The most common of these appear in the forefoot and may be associated with or exacerbated by ill fitting footwear. Such deformity is more likely to be associated with callus, which is a risk factor in its own right. The presence of sudden onset deformity, particularly in the mid foot is particularly indicative of Charcot Arthropathy and urgent referral to the acute foot team is required as these patients are at high risk of ulceration. Gangrene

The presence of devitalised tissue in the form of gangrene is the most visual indication of significant occlusion and clinical risk. NG19 is quite clear about gangrene as a high risk factor requiring immediate referral to the acute foot team or vascular service depending on the local pathway. Gangrene is one example why a good foot inspection is so essential as it is possible for a patient not to be aware of this level of damage. Charcot Arthropathy NG 19 makes the following recommendations regarding Charcot Arthropathy, which is a major and disabling complication associated with diabetic foot disease. Treatment and long term management is complex and the condition is always at high risk of ulceration and infection. 1. Be aware that if a person with diabetes fractures their foot or ankle, it may progress to Charcot Arthropathy. 2. Suspect acute Charcot Arthropathy if there is redness, warmth, swelling or deformity (in particular, when the skin is intact), especially in

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PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

the presence of peripheral neuropathy or renal failure. Think about acute Charcot Arthropathy even when deformity is not present or pain is not reported. 3. To confirm the diagnosis of acute Charcot Arthropathy, refer the person within 1 working day to the multidisciplinary foot care service for triage within 1 further working day. Offer non-weightbearing treatment until definitive treatment can be started by the multidisciplinary foot care service. 4. If acute Charcot Arthropathy is suspected, arrange a weight-bearing X-ray of the affected foot and ankle. Consider an MRI if the X-ray is normal but Charcot Arthropathy is still suspected.

Whist NG19 suggests a referral to the Foot protection team once callus is identified, this may take 2 to 4 weeks and therefore we suggest Dermatonics Once Heel balm be prescribed which, in 95% of cases, will remove the callus within 7 days and in 99% will remove all callus within 14 days

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PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

A Potentially Existential Threat John Hancock, Editor

Diabetic foot ulcers are relatively easy to start, relatively difficult to manage or eliminate and dangerous to leave untended

Mortality rates make sobering reading for anybody involved with the care of people with diabetes, starting with the need for those patients to be able to articulate any changes in their condition that might presage a foot ulcer and for GPs or diabetic nurses to be able to diagnose the onset of an ulcer before it becomes too established

A Growing Healthcare Challenge Diabetes, especially Type 2 Diabetes, is a growing challenge for global healthcare bodies and in the UK alone, there are currently 3.2 million people with diabetes (two and a half times the levels of the mid-1990s). This figure is expected to grow again to some 5 million by 2025. Growth in Type 2 Diabetes has largely followed the growing obesity ‘epidemic’ but, whatever the reasons for it, with growth in the prevalence of diabetes there is also growth in the co-morbidities and conditions that accompany diabetes. Many of these conditions are sufficiently debilitating as to be life changing or likely to reduce the quality of life and that is particularly true for diabetic foot ulcers. As Wounds International explains in the paper ‘Best practice Guidelines: wound management in diabetic foot ulcers’1 “In England, foot complications account for 20% of the total National Health Service spend on diabetes care, which equates to around £650 million per year (or £1 in every £150 [of total spend]). Of course, these figures do not take account of the indirect costs to patients, such as the effect on physical, psychological and social wellbeing and the fact that many patients are unable to work long term as a result of their wounds.”

An Existential Threat for People with Diabetes It would be difficult to overestimate the serious nature of diabetic foot ulceration which can often lead to lower limb amputation and to premature death for patients whose condition is not fully managed or properly treated. As it is, the UK National Institute for Health and Care Excellence (NICE) 2 tells us that, “The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macrovascular complications.” Without wishing to ‘pile it on’, the NICE Guidance adds, “Foot complications are common in people with diabetes. It is estimated 8 | WWW.PRIMARYCAREREPORTS.CO.UK

that 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives... Diabetes is the most common cause of non traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes. After a first amputation, people with diabetes are twice as likely to have a subsequent amputation as people without diabetes. Mortality rates after diabetic foot ulceration and amputation are high, with up to 70% of people dying within five years of having an amputation and around 50% dying within five years of developing a diabetic foot ulcer. This high mortality rate… emphasises the importance of good diabetic and cardiovascular risk management.” That emphasis on good management is very important because people who have diabetes can find that their elevated blood sugar levels will contribute to a gradual loss of sensation and circulation at the extremities, such as the feet, so that the normal warning signals of pain or soreness might not be felt to alert the patient that a traumatic injury or abrasion has caused damage to their foot. Only proper risk management and foot care can avoid the problem.

What is a Diabetic Foot Ulcer? Ulcers are wounds that neither close easily nor heal in a reasonable time and therefore, can become a source of further infection. People with both type 1 and type 2 diabetes are prone to ulcers on their feet which, for a number of reasons (see above), their bodies are less able to detect in good time or naturally heal. Put simply, a diabetic foot ulcer (DFU) is a chronic wound which can easily become a non-healing wound and which, from its exposure to the outside or from the health risks associated with its underlying causes can become infected. Whatever the infection, it will be serious but if the wound becomes gangrenous, that will, at the least threaten amputation or,


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

at worst, death. DFUs are graded according to diameter, depth, condition (degree of infection) and where they are in order to create a basis on which a treatment programme can be settled.

Prevalence and Consequences of Diabetic Foot Ulcers Looking back to the Wounds International paper (above), we learn that, “DFUs are relatively common – in the UK, 5-7% of people with diabetes currently have or have had a DFU. Furthermore, around 25% of people with diabetes will develop a DFU during their lifetime.” Looked at another way, the highest proportion (47%) of patients admitted to hospital for diabetes related treatments, are admitted with foot problems (Journal of Foot and Ankle Research3) According to The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)4, DFU rates are increasing with the highest rates occurring in the 45 to 64 years age group and with a consistently higher rate in males than in females. But it isn’t only the prevalence of diabetic foot ulcers or the high incidence of the condition in the population with diabetes that is of concern; it is the devastating consequences that make proper foot management so important for people with diabetes, and diagnosis, treatment and management of foot ulcers so critical when they do occur. As cited above, mortality rates make sobering reading for anybody involved with the care of people with diabetes, starting with the need for those patients to be able to articulate any changes in their condition that might presage a foot ulcer and for GPs or diabetic nurses to be able to diagnose the onset of an ulcer before it becomes too established. There is an obvious physical devastation as a result of an amputation, which might, at least, be mitigated with a prosthetic limb. But, beyond that, there are limitations that could follow, such as a need to change or cease work or sports

activities and the consequent psychological impact which can lead to quite severe depression. That can have implications for patient care or at least for a patient’s motivation to adhere to a care regime. For these reasons among others, clinicians will want to consider carefully before discussing amputation. The Wounds International paper sets out some simple circumstances in which amputation might be indicated as the best treatment… • Ischaemic rest pain that cannot be managed by analgesia or revascularisation; • A life-threatening foot infection that cannot be managed by other measures; • A non-healing ulcer that is accompanied by a higher burden of disease than would result from amputation. In some cases, for example, complications in a diabetic foot render it functionally useless and a well performed amputation is a better alternative for the patient.

It is also the case that an infection in any part of the body can become a threat to the whole body; particularly true for long-term open and slow healing wounds such as ulcers. For the same reasons, the best thing when a foot ulcer is first detected is to put in place a sound regime of wound care and management. As in any health issue, prevention of diabetic foot ulcers is better than having to cure them. WWW.PRIMARYCAREREPORTS.CO.UK | 9


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Obscured Symptoms, Risk Factors and Poor Outcomes Camilla Slade, Staff Writer

Although more prone to foot ulcers, people with diabetes may not recognise the symptoms or feel the warning signs

Knowing why people with diabetes can be prone to foot ulcers is important in any programme to prevent their occurrence in a patient

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Symptoms and Signs that an Ulcer Might be Developing Most health conditions will be preceded by some physical or behavioural changes, the body’s reaction to which will offer symptoms from which a clinician will be able to deduce what is happening. Unfortunately, for people with diabetes, the sensory warning signals that can be read as symptoms of a pending foot ulcer might not always be there. There is no doubt that if a patient with diabetes presents with any of…5 •S  ores, ulcers, or blisters on the foot or lower leg; • Pain; • Difficulty walking; • Discoloration in feet: black, blue, or red; •F  ever, skin redness, swelling, or other signs of infection. … it will be likely that they have or are developing a diabetic foot ulcer. But because people with diabetes are not always so sensitive to pain and soreness, some of these symptom might be missed by a patient. Diabetes UK6 suggests that people with diabetes ask themselves some simple questions to identify danger signs that they might be at risk of a ‘foot attack’. The questions are:• Is your foot red, warm or swollen? • Is there a break in the skin or any discharge (or oozing) onto your socks or stockings? • Do you feel unwell? It also advises, “Remember you may not experience pain even with a visible wound. If your sight is not good make sure someone else looks at your feet every day.” Diabetes UK advice does emphasise the serious nature of any symptoms or danger signs; explaining that, “It is a medical emergency that needs attention.” Also, putting a colder light on it, as well as being a medical emergency for the patient, a diabetic foot ulcer will be a financially expensive event for the healthcare system. As the UK’s

National Institute for Health and Clinical Excellence (NICE) explains7 “Foot problems in people with diabetes have a significant financial impact on the NHS [UK National Health Service] through primary care, community care, outpatient costs, increased bed occupancy and prolonged stays in hospital. A report published in 2012 by NHS Diabetes estimated that around £650 million (or £1 in every £150 the NHS spends) is spent on foot ulcers or amputations each year.” In light of that, the more we know about the condition, the better for patients and for the financial viability of the healthcare system.

Possible Causes of and Risks Leading to Diabetic Foot Ulcers Perhaps we would be better asking ‘why are people with diabetes more prone to foot ulcers?’ This has already been alluded to above but it will be useful to see the full reasons as set out by Wounds International8. “Peripheral neuropathy may predispose the foot to ulceration through its effects on the sensory, motor and autonomic nerves: • The loss of protective sensation experienced by patients with sensory neuropathy renders them vulnerable to physical, chemical and thermal trauma; • Motor neuropathy can cause foot deformities (such as hammer toes and claw foot), which may result in abnormal pressures over bony prominences; • Autonomic neuropathy is typically associated with dry skin, which can result in fissures, cracking and callus. Another feature is bounding pulses, which is often misinterpreted as indicating a good circulation.” It is that loss of protective sensation that reduces a patient’s awareness of changes which contributes to their susceptibility. Oxford Journals’ ‘The treatment of diabetic foot infections’9 spells out the type of problem that might arise;


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

“As a result of damage to sensory nerves, minor trauma (from something as seemingly trivial as an ill-fitting pair of shoes or walking barefoot on unfamiliar terrain) can go unnoticed. Neuropathy can also deform the architecture of the foot to such a degree that joints and digits are placed in mechanically unfavourable positions, making them highly vulnerable to injury… Each pathological driver – inappropriate weight-bearing due to neuropathy, ischaemia and infection – needs tackling for resolution of the ulcer”

There are some obvious risks that can be avoided including the wearing of ill-fitting shoes and walking barefoot. Diabetes.co.uk10 is blunt in its summation of the risks, adding to the above, “People who have diabetes for a longer period or manage their diabetes less effectively are more likely to develop foot ulcers. Smoking, not taking exercise, being overweight, having high cholesterol or blood pressure can all increase diabetes foot ulcer risk.”

Outcomes can be Poor Knowing why people with diabetes can be prone to foot ulcers is important in any programme to prevent their occurrence in a patient. Diabetic foot ulcers are often slow to heal or do not heal at all which can contribute to, at the least, a poor quality of life for patients and amputation of the foot or lower leg or, at worst, can be fatal. This is confirmed in a November 2005 article in the Lancet, ‘Treatment for diabetic foot ulcers‘11 which says; “When infection complicates a foot ulcer, the combination can be limb or life-threatening.” It isn’t just the foot ulcer that can cause such disastrous outcomes. Often the original ulcer, if left untreated or uncared for, can be accompanied by Charcot arthropathy (where bones and joints fracture and dislocate with little or no trauma) or Gangrene (where the death of body tissue can threaten viability of the whole body). And beyond those, where the problem is peripheral arterial disease (poor blood supply) further complications can include increased risk of heart attack or stroke. The American Diabetes Association12 has also found evidence that “one-third of people presenting with their first diabetic foot ulcer had clinically significant depression (combining minor and major depressive disorders), and this was associated with an approximately threefold increased risk of death 18 months later.” Any treatment that can help the prevention of diabetic foot ulceration will make a very positive contribution to this condition and its poor outcomes.

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PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Looking at the Big Picture Peter Dunwell, Medical Correspondent

Diagnosis and treatment should include not only the diabetic foot ulcer but all of its contributory and consequent factors

Some of the effects of diabetes will reduce a patient’s sensitivity to pain and soreness so that what they might report as a minor pain could actually emanate from a serious condition, including the development of a foot ulcer

W

HILE NO-ONE should minimise the serious nature and potential for poor outcome inherent in a diabetic foot ulcer (DFU) itself, it is also the case, as with many conditions, that co-morbidities and related conditions can be as threatening as the ulcer. It would be difficult to overstate the potential risks for patients with a DFU but the difference from other life threatening conditions is that a poor outcome is not always inevitable; indeed the development of a foot ulcer need not be an inevitable consequence of diabetes. While management for a resolution let alone prevention of the problem is not easy, it is possible and will be assisted by understanding how DFUs come about (see previous article) what are the co-morbidities and related conditions and who is prone to having a DFU.

Related Conditions and Co-Morbidities For all the reasons already specified, foot complications are often an accompaniment to diabetes and people with diabetes need to be meticulous in their foot care regime. Foot care extends to more than simply keeping feet clean and toenails neatly clipped, although thorough washing and maintaining clean nails is important. Diabetes.co.uk13 offers a nine-point illustrated foot care programme which includes a lot of common sense but, assembled in this way, becomes a useful guide to help avoid problems before they start. As well as the ulcer itself, people with diabetes often also suffer what is known as a Charcot arthropathy or Charcot joint which, as Wounds International14 explains, is, “a form of neuroarthropathy that occurs most often in the foot and in people with diabetes. Nerve damage from diabetes causes decreased sensation, muscle atrophy and subsequent joint instability, which is made worse by walking on an insensitive joint. In the acute stage there is inflammation and bone reabsorption, which weakens the bone. In later stages, the arch falls and the foot may

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develop a ‘rocker bottom’ appearance. Early treatment, particularly offloading pressure, can help stop bone destruction and promote healing.”

The seriousness with which Charcot joint is treated may be gauged from the UK National Institute for Health and Care Excellence (NICE) guideline15 ‘Diabetic foot problems: prevention and management’ which emphasises the need for speed; “To confirm the diagnosis of acute Charcot arthropathy, refer the person within 1 working day to the multidisciplinary foot care service for triage within 1 further working day. Offer non weight bearing treatment until definitive treatment can be started by the multidisciplinary foot care service.” The reason for the urgency is that a Charcot foot (often swollen and warm to the touch) is at very high risk of ulceration and infection and, as with any medical condition, prevention of an ulcer is better than a cure. People who are prone to DFUs are those with diabetes who smoke and who do not wear properly fitted footwear. Although there might be racial predispositions to having diabetes, there is no noticeable racial difference in DFU incidence.

Diagnosis of Diabetic Foot Ulceration Whenever a patient with diabetes presents with any other concerns, no matter how vaguely expressed, clinicians need to instigate a thorough examination process, if only to eliminate diabetes


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

related conditions which, if left untreated, could develop into high cost (in human and financial terms) and potentially life threatening conditions (see earlier articles). This will, of course, include the usual diagnostic steps of interview, medical history and general physical examination. The problem is that, as we have already seen, some of the effects of diabetes will reduce a patient’s sensitivity to pain and soreness so that what they might report as a minor pain could actually emanate from a serious condition, including the development of a foot ulcer. For these reasons, NICE guidelines (see above) are very specific in what should be the process to diagnose and refer any foot problem in a person with diabetes. The guidelines specify the examinations and tests that should be carried out (too lengthy to reproduce here) and include notes with which to, “Assess the person’s current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification: • Low risk: no risk factors present. • Moderate risk: 1 risk factor present. • High risk: previous ulceration or amputation, on renal replacement therapy, or more than 1 risk factor present. • Active diabetic foot problem: ulceration, spreading infection, critical ischaemia, gangrene, suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain. The guidance also sets out examples of the most frequent limb threatening or life threatening problems.

Assessment and Treatment Once ulceration has been diagnosed, the clinician will need to measure and record the size, depth and position plus rate its severity. This is usually accomplished using the University of Texas classification system, SINBAD (Site, Ischaemia, Neuropathy, Bacterial infection, Area and Depth).

Using this information and with the severity of the condition established, a treatment plan will need to be devised and agreed with the patient, and then implemented. The prognosis for people with diabetes who have foot ulcerations will not be good and can be catastrophic if proper treatment and care is not instigated at the first opportunity. The best treatment for DFUs, according to Wounds International (see references above) “involves a holistic approach that includes: • Optimal diabetes control; • Effective local wound care; • Infection control; • Pressure relieving strategies; • Restoring pulsatile blood flow.” NICE suggests that diabetic foot ulcers are treated with… offloading of pressure (usually using a cast), control of foot infection, control of ischaemia, wound debridement and wound dressing. If the ulceration does not improve, then further measures might be necessary and these are included in the next article. Whatever the treatment programme, urgency should be the key word to minimise the risk of a limb threatening or life threatening outcome.

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PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

Care for the Feet John Hancock, Editor

Prevention of diabetic foot ulcers is best but even if they do develop, foot care is the front-line process for treatment

Wound management includes a number of steps with the purpose of improving the wound condition, halting the spread of infection, treating the infection and healing the wound

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I

F, DESPITE everybody’s best efforts, a diabetes patient develops a foot ulcer, a several treatments are possible. While the first step will often be wound cleaning and debridement, the most important thing is to treat what has caused the ulcer which might mean tackling the poor blood supply to the affected area and administering antibiotics as well as medication to place over the ulcer. It is important to stop any further progress in the infection process. The care with which chronic wounds are managed can mean the difference between a tolerable if unwelcome condition with long-term improvement or uncomfortable to painful soreness with chronic infection.

Looking specifically at diabetic foot ulcers and following the November 2014 ‘Foot in Diabetes UK’ conference, Mölnlycke Health Care 16 highlighted the role of exudate in wound healing and, “the problems that can arise as a result of a wound overproducing exudate. Exudate amount and composition depends on wound aetiology, wound healing stage, underlying pathology and wound environment. Healing is largely determined by a balance of these factors, and chronic wounds often produce higher levels of exudate because the inflammatory phase of healing is prolonged. In these cases, exudatelevel management is key to preventing skin damage or wound enlargement.”

Wound Management for Foot Ulcers

Wound Treatment Regimens for Foot Ulcers

Wound management includes a number of steps with the purpose of improving the wound condition, halting the spread of infection, treating the infection and healing the wound. Debridement is an important step to remove dead or infected tissue; any infection needs to be controlled and addressed plus, as importantly for comfort, any swelling needs to be dealt with. Wound moisture levels are important and dressings should be capable of managing wound exudate (i.e. prevent leakage) while not adding unnecessary moisture to the wound environment. Dressings need to be comfortable and may well, in the case of a foot ulcer, have to incorporate a degree of pressure offloading.

While, ultimately, some form of dressing will usually be applied, before that stage there needs to be a thorough assessment of the wound and a plan for appropriate wound management. The ulcer and its site need to be prepared to maximise healing and minimise the possibility of further infection and that will include debridement, i.e. removal of dead and non-viable tissue to present a clean wound bed for treatment. Because the wound can often be very sensitive and painful if any pressure or abrasion occur, the dressing technique will often include pressure offloading – structuring the dressing in such a way that pressure is transferred no uninfected tissue and nothing puts direct pressure or abrasion on the wound. The skill of how to place a dressing for a patient with a chronic wound is less often discussed but is nonetheless as important as any of the clinical skills required in treatment. “Wounds in some areas of the body are particularly difficult to dress, despite the wide range of dressing products available.” So says World Wide Wounds in its ‘Dressings: cutting and application guide’17. There are several problems that can arise with ill-fitting or poorly placed dressings. If there is leakage or detectable unpleasant odour from the wound, the patient may become embarrassed and


PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

withdraw from normal life. Similarly, if the poor placement causes pain (a real possibility with a foot ulcer), the patient may delay a redressing appointment until it cannot be avoided. Both cases will diminish a patient’s quality of life but also, if the result is a reduced frequency of treatment, they will degrade their health, extend healing time and increase the cost of treatment. Dressings need to be changed regularly to support comfort, minimise infection by disposing of infected material and bring the patient before the clinician so that any other changes can be noted and addressed. Where debridement has been performed, dressings might also need to be supported with a skin graft to help close the wound and promote healing. Especially pertinent for people with diabetes, CVS Pharmacy18 explains, “Infected ulcers can raise high blood sugar levels. High blood sugar levels can then lower the body’s ability to fight infections. The high level also keeps the wound from healing. Improved blood sugar control will help… fight any infections and heal… wounds. This control is often done with adjustments in… diet or medications. Sometimes insulin shots are needed in the short-term until [the patient is] healthy again.” There are also ways to speed

healing such as hyperbaric oxygen therapy where the patient is placed in a chamber into which pure Oxygen is pumped to improve healing. However, not all healthcare facilities will have access to a hyperbaric chamber. And finally in the matter of wound management, not all patients will always comply with whatever regime has been agreed and that can not only degrade the quality of outcomes but also add to the cost. For instance, 3M Health Care Academy 19 suggests, when using pressure offloading that; “Non removable total contact casting is widely recognised as best practice for off-loading the diabetic foot. As the cast cannot be removed, the risks of the patient not complying with pressure relief are significantly reduced.”

Cared For Feet Will be Healthier Feet So, the first step that any person with diabetes needs to take in respect to foot ulcers is to prevent them and that requires good foot care. CVS Pharmacy again, see reference above, sets out a useful list of tips for diabetes foot care which includes no tight garters or stockings around the legs (they will make poor circulation worse) and to buy properly fitted shoes. Also, WebMD20 recommends; “Keep your feet from drying and cracking with regular applications of foot cream.” There are a number of foot creams available but it should be borne in mind that patients need to be able to live with the treatment in respect of which the smell, texture and absorption of a cream or balm is very important. As with many conditions related to diabetes, taking care of oneself is the best first step towards avoiding and managing foot ulcers.

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PREVENTING DIABETIC FOOT ULCERATION IN PRIMARY CARE

References: 1

Wounds International, ‘Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers’

http://www.woundsinternational.com/media/issues/673/files/content_10803.pdf 2

NICE https://www.nice.org.uk/guidance/ng19/chapter/introduction

3

Journal of Foot and Ankle Research http://www.jfootankleres.com/content/5/1/26

4

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

http://www.niddk.nih.gov/about-niddk/strategic-plans-reports/Documents/Diabetes%20in%20America%202nd%20Edition/chapter18.pdf 5

CVS.com http://health.cvs.com/GetContent.aspx?token=f75979d3-9c7c-4b16-af56-3e122a3f19e3&chunkiid=102704

6

Diabetes UK https://www.diabetes.org.uk/Guide-to-diabetes/Complications/Feet/

7

NICE https://www.nice.org.uk/guidance/ng19/chapter/introduction

8

Wounds International, ‘Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers’

http://www.woundsinternational.com/media/issues/673/files/content_10803.pdf 9

Oxford Journals http://jac.oxfordjournals.org/content/65/suppl_3/iii3.long

10

Diabetes UK http://www.diabetes.co.uk/diabetes-complications/diabetic-foot-ulcers.html

11

‘Treatment for diabetic foot ulcers’ The Lancet http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2805%2967699-4/abstract

12

Diabetes Care http://care.diabetesjournals.org/content/30/6/1473.full

13

Diabetes.co.uk http://www.diabetes.co.uk/diabetes-footcare.html

14

Wounds International, ‘Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers’

http://www.woundsinternational.com/media/issues/673/files/content_10803.pdf 15

NICE, ‘Diabetic foot problems: prevention and management’ https://www.nice.org.uk/guidance/ng19#

16

Mölnlycke Health Care http://www.molnlycke.co.uk/education/diabetic-foot-ulcer/exudate-managment-using-exufiber-gelling-fibre-dressing/?gclid=CK-H_6imwMkCFasEwwodQxYLaQ

17

World Wide Wounds, ‘Dressings: cutting and application guide’

http://www.worldwidewounds.com/2007/may/Fletcher/Fletcher-Dressings-Cutting-Guide.html 18

CVS.com http://health.cvs.com/GetContent.aspx?token=f75979d3-9c7c-4b16-af56-3e122a3f19e3&chunkiid=102704

19

3M Health Care academy http://www.3mlearning.co.uk/news/treating-diabetic-foot-ulcers.aspx

20

Web MD http://www.webmd.com/diabetes/features/diabetes-wounds-caring-sores?page=2

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Primary Care Reports – Preventing Diabetic Foot Ulceration in Primary Care – Dermatonics  

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Primary Care Reports – Preventing Diabetic Foot Ulceration in Primary Care – Dermatonics  

Primary Care – Preventing Diabetic Foot Ulceration in Primary Care – Dermatonics