Diabetes mellitus (DM) is a public health problem, according to the International Diabetes Federation for the year 2017 worldwide 425 million cases were registered, by 2021 nearly 500 million people have the disease. In Colombia, it is estimated that 8% of the population has DM, that is to say nearly 2.5 million people.
Poor control of this disease leads to multiple complications, both microvascular (nephropathy and neuropathy) and macrovascular (coronary, cerebrovascular, lower limb or carotid artery disease).
It is currently estimated to enter
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What is diabetic foot syndrome?
It is a serious complication of poorly controlled diabetes, which damages the nerves of sensitivity and the arteries that oxygenate the foot, forming ulcers that are easily infected, do not heal, deepen, the tissues become necrotic, that is to say die, and end in amputation.
Going a little deeper, international scientific societies and national guidelines consider that the diabetic foot should be considered a clinical syndrome (that is, a set of events), hence the name diabetic foot syndrome, because the its origin is multifactorial:
Peripheral neuropathy: continued damage to peripheral nerves due to poor glycemic control, with damage to sensitivity that generates alteration in support with repetitive damage not perceived by the person, and alterations in gait that generates trauma due to poor plantar support.
Peripheral arterial disease: damage to arterial vessels related to inadequate control of cardiovascular risk factors such as hypertension or dyslipidemia (elevated cholesterol, mainly LDL), smoking (smoking), physical inactivity and poor glucose control.
Mechanical alterations to the gait and plantar support secondary to the first 2 mentioned.
Triggering and/or aggravating factors of diabetic foot that can be modified through prevention strategies:
- The time of diabetes: the more years of diabetes, the greater the risk
- Metabolic control: the higher the HBa1c value, the greater the risk
- The presence of diabetic neuropathy (loss of sensitivity or numbness of the extremities)
- The presence of peripheral arterial disease (occluded arterial vessels)
- The presence of deformities or alterations in the biomechanics of the foot (alterations in the shape or functionality of the foot)
- The presence of aggregated infections
- Ulcers and previous amputations
- Inadequate lifestyle (sedentary, cigarette, alcohol, abandonment of treatments, uncontrolled comorbidities, nutritional factors or malnutrition)
5 daily activities recommended for people with diabetes listed in treatment guidelines:
1. The direct observation of the foot daily in the search for injuries or evidence of future injuries in a timely and early manner
2. Keep the skin clean, fresh and moisturized by using alcohol-free creams, since the dryness of the skin of the foot is the access route of multiple injuries. This dryness can be a consequence of the simple misuse of caustic substances such as talc, to sympathetic dysautonomia (loss of sweating or abnormal sweating due to damage to the peripheral nerves generated by poorly controlled diabetes).
3. Daily change of stockings or after each activity that involves foot sweating. There are special stockings that are padded and technically made for the prevention of foot injuries and with anti-sweat and anti-fungal mechanisms. In general, it is recommended that they be white or light in color to easily highlight secretions or bleeding.
4. The footwear, which must be adapted to the type of foot you have with characteristics that protect against injuries and prevent deformities. There are basically 3 types of footwear that can be used in the treatment of the diabetic foot: preventive, therapeutic and rehabilitation footwear. The doctors who are experts in these decisions are orthopedic specialists.
5. The direct, immediate and trusting communication between the patient and the family or the close group when a foot ulcer appears, which should motivate an early but scheduled consultation at their health service.
How is diabetic foot syndrome classified?
According to the literature that is reviewed there are more than 24 classifications for diabetic foot, depending on the place where it is reviewed, it is necessary to explain that this classification must be in charge of the health personnel and it is mentioned in this document here thinking about it someone looking for some additional information.
- In primary care the classification to be used in that of the University of Texas.
- At higher levels of care it is recommended to use classifications that include individual characteristics of ulcer severity such as the Saint Elian classification (system) as the first choice or the WIFI classification.
- In none of the international guides or the national guide is it recommended to evaluate using Wagner’s classification.
- To determine the severity of the infection (ulcer with signs of infection or purulent discharge) the IDSA-IWGDF scale is recommended. However, the selection of the antibiotic has individualized characteristics expressed in the guide.
What is the treatment?
Interventions to improve glucose control, HBA1c, avoid hypoglycemia, and reduce glycemic variability are really useful interventions in the treatment of diabetic foot.
The multidisciplinary assessment requires the very important participation of nutrition, psychology, social work and nursing groups, from patient education in healthy lifestyles, education in medication administration, such as insulin administration or non-injectable drugs insulins, identification of patients at risk of complications such as diabetic foot, early identification of ulcers and, together with the wound clinic groups, start their early management.
Wound clinic groups are very important in the management of complications related to diabetic foot in all phases, the goals of these therapies are collagen lysis (cleaning the edges of the wound), neovascularization, synthesis of collagen and re-epithelialization (all these to generate new healthy tissue on the ulcer). The Shaio Clinic has a group of nurses with great experience in wound clinic management with very good results.
One of the most recommended tools for treatment groups and even for families and patients are risk scales for diabetic foot.
The scales most used to identify people at risk of developing complications related to the diabetic foot are the PIE-RISK for nurses and the PIE-RISK for patients, which must be completed by the patient and by the group that accompanies him in the treatment at least once a year, even more frequently according to the risk profile considered by the attending physician.
Vitamin B12 or folic acid supplements have not been proven to be of any use in this condition, unless people have a proven deficiency in one of these micronutrients.
The painful sensory neuropathy (pins and needles, burning or burning in the feet) that often accompanies the diabetic foot syndrome, is treated with neuromodulators or specific antioxidants, because conventional analgesics such as NSAIDs alone are not useful in this medical condition.
Peripheral arterial disease (clogged arterial vessels or no circulation), are initially diagnosed through the physical examination with the measurement of the arterial pulses, if these are abnormal continue with an image study, only if confirmation or intervention is required through invasive procedures or even surgery, however, these are not recommended for all people and must be performed specifically for each patient according to the individualized condition. In some cases only drug treatment is necessary, this decision can only be made by the doctor.
Not all patients need antibiotic treatment for the management of diabetic foot and equally not all need to be hospitalized, there are several scales that are used to determine the best course of action regarding treatment. The 2019 national guidelines recommend using IDSA-IWGDF as previously mentioned, with respect to the severity of the infection and the most appropriate treatment for it.
The surgical procedures used may include tissue debridements (removing diseased tissues), drainage of abscesses, joint remodeling, amputations of phalanges or major segments of the limbs depending on the level of disease involvement, both in extent and depth of the fabrics Surgery may also be required with the intent to rehabilitate or correct secondary bony deformities, or to manage peripheral nerve compression syndromes.
1. Colombian guidelines for the prevention, diagnosis and treatment of the diabetic foot A comprehensive management. 2019. Colombian Diabetes Association, endorsed by multiple scientific societies.
2. Clinical practice guide for the diagnosis and treatment of patients with complicated diabetic foot. 2019. Colombian Diabetes Association, endorsed by multiple scientific societies
3. Management recommendations for diabetic foot patients. Instructional course. Triana-Ricci R. Colombian Journal of Orthopedics and Traumatology 35 (2022) 330—357
4. Retinopathy, Neuropathy, and Foot Care: Standards of Medical Care in Diabetes-2022. Diabetes Care Volume 45, Supplement 1, January 2022
5. Practical Guidelines on prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev 2020;36(S1):e3266.
6. Guidelines on diagnosis and treatment of infection of notes in people with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020;36(S1):e3280.
This article was written by Dr. Oscar Leonardo Medina Espitia, an endocrinologist at the Shaio Clinic.