Managing Diabetic Foot Ulcers

Review Review MANAGING DIABETIC FOOT ULCERS: BEST PRACTICE Despite a wealth of evidence and clinical guidelines, the prevention and management of diabetic foot ulcers remains a challenge. This article aims to defi ne best practice through the exploration of ten key points taken from current evidence and guidelines in an attempt to help non-specialist practitioners to implement best practice when treating patients with diabetes. Caroline McIntosh and Veronica Newton are Senior Lecturers in Podiatry, University of Huddersfi eld The need for standardised care in diabetes has been highlighted by the development of numerous clinical guidelines and best practice statements from key sources such as the National Institute for Health Figure 1. Diabetic foot and Clinical Excellence (NICE, ulcer. 2004); the Department of Health (Dept of Health, 2001); the Scottish Intercollegiate Guidelines Network, (SIGN, 2001), and the Royal College to have an appreciation of the characterised by chronic of General Practitioners underlying disease process. hyperglycaemia. (Hutchinson et al, 2000) (Table 1). New evidence is constantly Diabetes mellitus occurs when There are two main types of emerging within the field there is inadequate uptake of diabetes: type 1 and type of diabetes care, making it glucose by the cells of the body 2. In people with type 1 difficult for the non-specialist resulting in raised blood glucose diabetes, the pancreas does practitioner to remain up-to- levels (Pocock and Richards, not produce enough insulin. date with current best evidence. 2004). This is an autoimmune disease This review aims to identify the whereby the insulin producing basic requirements of diabetic Insulin, a hormone produced β-cells are destroyed by the foot examination and to define in the pancreas, regulates the body’s own immune system. best practice for effective storage and release of energy Without insulin, the storage and management of diabetic from food. Diabetes can occur release of energy from food foot ulceration through the due to failure of the pancreas cannot be regulated and high exploration of 10 key elements. to produce enough insulin or levels of glucose remain in the to the development of insulin bloodstream (hyperglycaemia) Diabetes mellitus resistance, both resulting in (Davey, 2004). Type 1 diabetes To gain an understanding of high blood glucose levels affects approximately 15% of the complexities of diabetic (hyperglycaemia). Diabetes all people living with diabetes in foot ulceration, it is important is a progressive disease England and primarily affects the 122 Wound Essentials • Volume 1 • 2006 122-133DFU.indd 2 8/6/06 8:51:21 am Review Review fundamental to establishing Table 1 ulcer risk and allowing strategies Clinical guidelines and best practice statements to be implemented to prevent ulceration (American Diabetes International Consensus on the Diabetic Foot (International Working Group on the Diabetic Foot, 1999) Association, 2004). If at-risk National Service Framework for Diabetes (Department of Health, 2001) individuals are identified early, Management of Diabetes: A National Clinical Guideline (Scottish Intercollegiate Guidelines Network [SIGN], 2001) diabetes-related foot problems Type 2 Diabetes: Prevention and Management of Foot Problems (National Institute for Health and Clinical Excellence are largely preventable. Table [NICE], 2004) 3 describes risk classifications. A traffic light system has been provided as a visual guide to younger population (<30 years of uncontrolled hyperglycaemia highlight risk status: green age) (Dept of Health, 2001). increases the risk of developing denotes low-risk foot, amber a number of chronic problems denotes at-risk to high-risk foot Type 2 diabetes affects associated with diabetes, and red denotes ulcerated foot. approximately 85% of all people namely vascular and neurological living with diabetes in England (Dept of Health, 2001). Type 2 Diabetes mellitus occurs Table 2 diabetes usually occurs later in when there is inadequate life; it is most common in people uptake of glucose by the Basic foot examination over the age of 40 years. In cells of the body resulting in people with type 2 diabetes, the raised blood glucose levels The examination should include: β-cells are not able to produce (Pocock and Richards, 2004). Use of a 10g monofilament to assess sensory status enough insulin, or there is a Palpation of foot pulses degree of insulin resistance complications. This is primarily Inspection of the feet for deformities where the cells in the body can due to damage of small blood Inspection of footwear for wear and tear and foreign not respond to the insulin that vessels (microvasculature objects that may traumatise the foot is produced by the β-cells. The disease). Initially changes are Source: NICE (2004) storage and release of energy reversible, but with prolonged from food is not regulated and exposure to high glucose levels hyperglycaemia occurs. damage can be irreversible Ten key points in effective and the likelihood of chronic management of diabetic foot Self-monitoring of blood glucose complications increases (Dept of ulceration levels is advocated to people Health, 2001). NICE (2004) guidelines state living with diabetes, with a level of that individuals presenting with 7mmols/l being the optimum. It is Standard diabetic foot ulceration should be referred also possible for trained healthcare examination to the diabetes specialist professionals to measure the All individuals with diabetes multidisciplinary team within 24 percentage concentration of should receive annual hours. The team members must glucose in red blood cells in a test assessment by trained then undertake a comprehensive called HbA1C. practitioners as part of ongoing assessment to establish a diabetes care (NICE, 2004). The management plan tailored to HbA1C is a measure of how minimum requirements of a basic meet the needs of the individual, much glucose is attached to foot examination are detailed in while conforming to best practice the haemoglobin part of the Table 2. in diabetes. Figure 2 shows the red blood cell (glycosylated 10 key elements in effective haemoglobin) and is usually Following a basic foot management of diabetic foot expressed as a percentage. examination, the risk status for ulceration. Levels of 6.5–7.5% are ulceration can be established. optimum figures. Early identification of risk factors Each point will now be explained The effect of prolonged, for diabetic foot ulceration is and then considered in relation Wound Essentials • Volume 1 • 2006 123 122-133DFU.indd 3 8/6/06 8:51:21 am Review Review fat, sugar and salt, high in fruit Table 3 and vegetables and moderate in bread, potatoes, cereals, Classification of risk status pasta and rice. Everyone with diabetes should receive dietary Low-risk No complications: annual review recommended information and support. A state- At-risk foot Neuropathy or absent pulses or bone/joint deformity such as bunion formation or toe deformities: registered dietician can provide 3–6 month review recommended specific dietary advice that takes High-risk foot Neuropathy or absent pulses or bone/joint deformity/previous ulcer: a 1–3 month review with into account lifestyle and cultural an individualised management plan is recommended preferences (Diabetes UK, 2006). Ulcerated foot Urgent treatment From: International Working Group on the Diabetic Foot (1999); NICE (2004) 2. Identify aetiological factors Patient assessment should include evaluation of their to the current evidence base The same studies showed vascular and neurological and clinical guidelines, and that patients with intensive status, skin assessment and recommendations made to blood glucose (i.e. with more a thorough medical and social facilitate the practitioner in frequent glucose monitoring history to establish the cause implementing best practice. points throughout the day), of the wound. The International who controlled their diabetes Working Group on the Diabetic 1. Advocate tight glycaemic with either sulphonylureas or Foot (IWGDF, 1999) suggests control insulin, had fewer microvascular most ulcers on the diabetic foot NICE guidelines (2002) for complications. The UK can be classified as neuropathic, patients with type 2 diabetes Prospective Diabetes Study ischaemic or neuroischaemic. recommend self-monitoring and (UKPDS) Group (1998) also management of blood glucose demonstrated an increased risk The IWGDF (1999) and NICE with HbA1C measurements by of cardiovascular events such as (2004) suggest that the most a healthcare professional at myocardial infarction and strokes frequent cause of diabetic foot 2–6 monthly intervals. A level of when HbA1C concentrations rise ulceration is ill-fitting shoes, 6.5–7.5% is a measure of good above the normal range. which may be too small, too big glycaemic control (McIntosh or excessively worn and advise et al, 2001). High glycaemic Use of combination therapy meticulous routine examination levels can detrimentally affect (treatment with more than one of footwear in all patients. the tissue electrolyte balance type of oral hypoglycaemic) Practitioners should examine and white blood cell activity for management of type 2 them for wear and tear and and hence prolong infection diabetes can optimise glycaemic foreign objects such as small and delay healing, which is control further by increasing stones, glass fragments, drawing why controlling blood sugar in sites of action of drug therapy, pins, pet hairs, etc that may the absence of other disease leading

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