Type 1 Diabetic Foot Complications

The Journal of Diabetic Foot Complications Open access publishing Type 1 diabetic foot complications

Authors: Amit Kumar C. Jain, MBBS, D.DIAB, F.DIAB, DNB, FPS*

Abstract: Diabetic foot problems are an unfortunate complication of diabetes, and their incidence is increasing worldwide. Diabetic foot ulcers (DFU) affect 15% of patients with diabetes during their lifetime. For years DFUs have been commonly categorized through the Wagner classification. Recently, a new diabetic foot classification was proposed that evaluates the diabetic foot beyond ulceration. This classification includes all the common diabetic foot complications seen in day-to-day practices. Just the way diabetes mellitus is classified intoType 1 diabetes mellitus, Type 2 diabetes mellitus, and others, this new diabetic foot classification categorizes diabetic foot complications into three simple types.This study highlights various Type 1 diabetic foot complications seen in our practice, and represents the first time this type of study is presented in the literature.

Key words: Abscesses, Diabetic Foot, Necrotizing Fasciitis, Wet Gangrene

Corresponding author

* Amit Kumar C. Jain, MBBS, D.DIAB, F.DIAB, DNB (General Surgery), FPS (Podiatric Surgery) Consultant General Surgeon, Diabetic Lower Limb and Podiatric Surgeon Assistant Professor Department of Surgery St John’s Medical College Bangalore, India 560034 Email: [email protected]

INTRODUCTION Diabetes is one of the major non- This author’s classification for diabetic foot communicable diseases affecting people complications, Table 1, is a new and simpler worldwide, and it is one of the most challenging classification, is easy to understand, and includes health problems in the 21st century.1 The number all the common diabetic foot complications.6,7,9,10 of people with diabetes worldwide was estimated Table 1. Author’s new classification of diabetic foot at 131 million in 2000; it is projected to increase problems. Type of to 366 million by 2030.2 Lesions Complications Approximately 3.1 million people in England Type 1 Diabetic Cellulitis, Wet Gangrene, have diabetes.1 Diabetes is a very common 1 foot complications Abscess, Necrotizing Fasciitis, [Infective] Osteomyelitis, etc. disease in India, with a prevalence of 12%-17% in Non-healing Ulcers, Peripheral the Indian urban population and a prevalence of Type 2 Diabetic Arterial Disease, Hammer Toes, 2.5% in the rural population.3 2 foot Complications Entrapment Neuropathies, [Non-Infective] Diabetic Neuro-Osteoarthropathy, Diabetes related foot disease remains one etc. of the most frequent causes of diabetes specific Type 3 Diabetic Example -Charcot Foot with hospital admissions.4 Every year 5% of diabetic 3 foot complications Infected Ulcer, Non-healing Ulcer patients will develop a foot ulcer.5 Approximately [Mixed] with Osteomyelitis, etc. 15% of all diabetics will develop some foot problem during the course of their illness.5 For According to this new classification, Type 1 many years, Wagner’s classification has been a diabetic foot complications are the most common popular classification through which DFUs were complication seen in hospitalized patients in 7,11 being studied.6,7,8 India. Type 1 diabetic foot complications 17 The Journal of Diabetic Foot Complications, 2016; Volume 8, Issue 1, No. 3, Pages 17-22 Open access publishing

account for 86.6% to 91.06% of patients with Clinically, there is no clear line of diabetic foot problems admitted to the hospital.7,11 demarcation in wet gangrene (Figure 1). Complications include, for example, wet Histologically, there is liquefaction necrosis of gangrene, cellulitis, abscess, and necrotizing tissue.14 fasciitis. Type 1 diabetic foot complications can occur either in isolation or in combination. Various studies have shown that Type 1 diabetic foot complications are the most common cause for major amputations.7,11 In the Jain et al. series7, all major amputations done had Type 1 diabetic foot complications. In the Kalaivani series,11 75% of the major amputations done in the diabetic foot had Type 1 diabetic foot complications. The major amputation rate in Type 1 diabetic foot complications ranges from 8.89% to 13.39%.7,11 This article briefly reviews the common Type I diabetic foot complications seen in busy diabetic foot centers. Figure 1. Wet Gangrene of 2nd toe of the right foot (note that there is no line of demarcation). WET GANGRENE Wet gangrene is one of the common causes Gangrene is a form of tissue necrosis with of amputation in the diabetic foot. The incidence added putrefaction.12 There are three main types of wet gangrene in recent studies shows a range 7,11 11 of gangrene that affect the extremity. They are from 31.3% to 35.7%. In one study it is the dry gangrene (ie, with or without secondary most common Type 1 diabetic foot complication infection), gas gangrene, and wet gangrene.12 seen in hospitalized patients for diabetic foot problems. Wet gangrene of the foot is one of the characteristic lesions seen in diabetes and is ABSCESSES sometimes called “Diabetic gangrene”.13 Wet gangrene is often seen in a well vascularized Abscess in the diabetic foot can occur foot13 and is easily distinguishable from dry either in the dorsum (Figure 2) or on the plantar gangrene seen in arteriosclerosis of the large aspect of the foot. Abscesses can also develop vessel.14 at the nail fold area (ie, paronychia) and web spaces.15 The entry of infection, especially on The moist appearance of the affected the plantar aspect, is usually from a trauma like part, along with gross swelling and blistering, a nail puncture or foreign body injury that occur characterizes the wet gangrene. This type of gangrene develops rapidly and is almost painless because of the associated neuropathy.13 Wet gangrene is believed to develop from thrombosis of the small vessels due to infection.13 The affected part is soft, swollen, putrid, necrotic, and darkened to black color. The affected part (ie, digit or toe) is engorged with blood which favors the rapid growth of putrefactive bacteria.12 There is often a foul smell, and the toxins produced from the bacteria can get absorbed, producing the systemic manifestation of 12 septicemia. Figure 2. Abscess over the dorsum of the left foot. 18 The Journal of Diabetic Foot Complications, 2016; Volume 8, Issue 1, No. 3, Pages 17-22 Open access publishing in neuropathic feet. The insensitivity allows such injury to go unrecognized. Infections in the web spaces are insidious due to poor foot hygiene with accumulation of moist detritus or fungal infection in the interdigital web spaces. Web space abscesses are dangerous because of the proximity to the digital vessels.15 On the plantar aspect of the foot, the central space is most commonly involved as compared to medial or lateral space abscesses. Many times the web spaces, or the central space Figure 3. Tinea Pedis (inter-digital type) involving 4th web infection, can cause thrombosis of the vessels space of the right foot. 15 leading to digital gangrene. resulting in a secondary infection. Tinea pedis In the Jain et al. series7 foot abscesses can create inflammation and fissuring that leads were the most common Type 1 diabetic foot to breaches in the epidermis. This can produce complication seen in hospitalized patients and a portal of entry for a bacterial infection leading accounted for 42.2% of the cases. In another to abscess, cellulitis, and gangrene of the digits. study by Jaykar et al.3 the most common mode Therefore, one should not underestimate these of presentation of diabetic foot complication was conditions. Most often these two conditions are again abscesses.3 often ignored by the treating doctors. Even in the two studies done on this new classification,7,11 TINEA PEDIS there was no mentioning of tinea pedis in the Two common fungal infections affecting the cases, and it is obvious that they were probably diabetic foot are tinea pedis (ie, athletes foot) not recorded in the case sheets. and onychomycosis (ie, fungal nail infection).16 Approximately 15% of the population has a OSTEOMYELITIS podiatric fungal infection at any given time, and This complication is a bit less common over 70% of individuals will experience foot- than the Type 1 diabetic foot complication and based fungal infection over their lifetime.17 The is more frequently seen in Type 3 diabetic foot prevalence of diabetes among the patients with complications where it can occur from a non- tinea pedis is around 24.8%.18 In fact, people with healing ulcer. The osteomyelitis in the Type diabetes will get tinea pedis and onychomycosis 1 diabetic foot is frequently a sequelae of an 2.5-2.8 times more frequently than non- underlying abscess (Figures 4 and 5) and very diabetics.19 rarely is from a haematogenous route. The Tinea pedis is most commonly caused by incidence of osteomyelitis in the Type 1 diabetic trichophyton rubrum (80%) and trichophyton interdigitale (15%) and less likely due to epidermophyton floccosum and microsporum.16 The three variants of tinea pedis are interdigital type, moccasin type, and vesiculobullous type.18 Interdigital tinea pedis is the most common form and often manifests in the fourth web space (Figure 3) and may spread to the undersurface of the toes.18 Tinea pedis and onychomycosis can lead to serious complications. In onychomycosis, Figure 4. Sausage shaped great toe of the left foot (patient had underlying abscess and was on oral antibiotics, pre- the thick, sharp, brittle nail can pierce the skin scribed by the physician, for the prior three weeks). 19 The Journal of Diabetic Foot Complications, 2016; Volume 8, Issue 1, No. 3, Pages 17-22 Open access publishing

foot complications is around 2.68%.11 In another redness of the skin.24 Local examinations reveal series of Jain et al.,20 9.52% of patients with tenderness, pitting oedema, and a local elevation osteomyelitis occur secondary to an abscess, in in temperature.21,24 Systemic manifestations comparison to 90.48% that develop in an ulcer. such as fever, tachycardia, and hypotension are present in up to 40% of the cases.25 Cellulitis is often treated conservatively with antibiotics until local or systemic complications occur. Cases that do not respond to antibiotics, or that are more severe, may progress to necrotizing fasciitis.21

NECROTIZING FASCIITIS Necrotizing fasciitis (Figure 7) is a severe form of a soft tissue infection involving superficial and deep fascia.26,27 This disease spreads rapidly and can involve the whole limb within hours.28 Necrotizing fasciitis can be classified into two types.26 Type 1 necrotizing fasciitis is a Figure 5. The x-ray of the left foot of the above patient in polymicrobial infection, and Type 2 necrotizing Figure 4. (note the extensive osteomyelitis [Amit Jain’s Type 1C diabetic foot osteomyelitis]). fasciitis is a monomicrobial infection caused by a streptococcus bacteria.27 CELLULITIS Lower limb cellulitis is a common reason for medical admission and causes significant long term morbidity.21 Venous eczema and tinea pedis are recognised risk factors for developing lower limb cellulitis.22 Cellulitis is common among patients with diabetes.23 The relative frequency of foot cellulitis is more than nine times greater in diabetics than in non-diabetics.15 Most often, this superficial soft tissue infection is caused by Figure 7. Necrotizing Fasciitis affecting the entire left lower gram positive organisms like streptococcus and limb (note the necrosis over the leg and thigh on the medial staphylococcus.23 aspect; patient also had necrosis over posterior and lateral parts of the leg and thigh; cellulitic changes over the entire The common symptoms of cellulitis (Figure limb and blisters over leg can be well appreciated in the 6) are swelling of the lower limb, pain, and Figure).

Several predisposing factors, such as diabetes mellitus, alcohol, and chronic liver disease contribute to necrotizing fasciitis.26,29 Diabetes was present in up to 64% of patients affected with necrotizing fasciitis.26 The overall incidence of necrotizing fasciitis in diabetic foot complications in developing countries like India varies from 8.89% to 27.67%.7,11 In the early clinical course of the disease, the presentation is similar to the pattern found in cellulitis, and sometimes there is paucity of 30,31 Figure 6. Cellulitis affecting the right foot and leg. cutaneous findings. A high index of suspicion 20 The Journal of Diabetic Foot Complications, 2016; Volume 8, Issue 1, No. 3, Pages 17-22 Open access publishing is therefore required.31 In cellulitis, the infection expert diabetic limb salvage center,27 necrotizing involves the dermis and subcutaneous tissue, fasciitis resulted in a 26.4% incidence of major whereas in necrotizing fasciitis, it starts at the amputation with mortality of 6.8%.27 Aggressive level of the subcutaneous fat and deep fascia.29 debridement is the key to a successful 27,30 Rapidly spreading erythema, oedema, outcome along with prompt detection. and severe pain that is out of proportion to the nature of the lesion, are characteristics of CONCLUSION necrotizing fasciitis.31 Extensive skin and fascial Diabetic foot problems are one of the most necrosis, and grey malodourous fluid referred feared complications from diabetes. Type 1 to as “dishwater pus”, characterize necrotizing diabetic foot complication is the most common fasciitis.29,30,31 type of complication seen in hospitalized patients, Necrotizing fasciitis is associated with a ranging from 86.6% to 91.06% occurrence. higher amputation rate and mortality. Mortality Unfortunately, major amputations often become in various studies has ranged from 25% to 60% necessary in Type 1 diabetic foot complications, with limb amputation as high as 39%.26 In one of ranging from 8.89% to 13.39% of cases. the largest series on necrotizing fasciitis from an References 1. Mc Innes AD. Diabetic foot disease in the United Kingdom: about time to put feet first.J Foot Ankel Res. 2012;5:26. 2. Clayton W, Elasy TA. A review of the pathophysiology, classification and treatment of foot ulcers in diabetic patients. Clinical Diabetes. 2009;27(2):52-58. 3. Jaykar RD, Kasube PS, Kakani NV. Prospective study of infections of foot in diabetic patients. Int J Recent Trends sci Tech. 2014;10(2):389-395. 4. Gooday C, Murchison R, Dhateriya K. An Analysis of clinical activity, admission rates, length of hospital stay and economic impact after a temporary loss of 50% of the non-operative podiatrists from a tertiary specialist foot clinic in the United Kingdom. Diabetic Foot and Ankle. 2013;4:21757. 5. Shah SF, Hameed S, Khawaja Z, Abdullah T, Waqar SH, Zahid MA. Evaluation and management of diabetic foot: A multicentre study conducted at Rawalpindi, Islamabad. Ann Pak inst Med Sci. 2011;7(4):233-237. 6. Jain AKC. A new classification of diabetic foot complications: a simple and effective teaching tool. J Diab Foot Comp. 2012;4(1):1-5. 7. Jain AKC, Viswanath S. Distribution and analysis of diabetic foot. OA Case Reports. 2013;2(21):117. 8. Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJM. A comparison of two diabetic foot ulcer classification systems.Diabetes Care. 2001;24(1):84-88. 9. Jain AKC, Joshi S. Diabetic foot classifications: review of literature.Medicine science. 2013;2(3):715-721. 10. Kalaivani V, Vijayakumar HM. Diabetic foot in India- Reviewing the epidemiology and the Amit Jain’s classifications.Sch Acad J Biosci. 2013;1(6):305-308. 11. Kalaivani V. Evaluation of diabetic foot complication according to Amit Jain’s classification.JCDR . 2014;8(12):7-9. 12. Mohan H. Textbook of pathology. 3rd ed. Jaypee Brothers, India, 1998. 13. Faris I. The management of the diabetic foot. Churchill Livingstone, 2nd edition, UK, 1991. 14. Kozak GP, Campbell DR, Frykberg RG, Habershaw GM. Management of diabetic foot problems. 2nd ed. WB Saunders, Philadelphia, 1995. 15. Bowker JH, Pfeifer MA. In: Levin and O’Neal’s the diabetic foot. 7th ed. Mosby, Philadelphia, 2008 16. Chadwick P. Fungal infection of the diabetic foot: the often ignored complication. Diabetic Foot Canada. 2013;1(2):20 -24. 17. Kumar V, Tilak R, Prakash P, Nigam C, Gupta R. Tinea Pedis- an update. AJMS. 2011;2:134-138. 18. Mansoor AA, Hamdi KI. Tinea pedis among diabetics in Basrah: prevalence and predictos. J Chinese Clin Med. 2007;2(9):488-492. 21 The Journal of Diabetic Foot Complications, 2016; Volume 8, Issue 1, No. 3, Pages 17-22 Open access publishing

References (cont.) 19. Matricciani L, Talbot K, Jones S. Safety and efficacy of tinea pedis and onychomycosis treatment in people with diabetes: a systematic review. J Foot Ankle Resear. 2011;4:26. 20. Jain AKC, Viswanath S. An analysis of osteomyelitis in diabetic foot using Amit Jain’s Classification of diabetic foot osteomyelitis. SEAJCRR. 2014;3(4):794-801. 21. Cox NH. Management of lower leg cellulitis. Clin Med JRCPL. 2002;2:23-27. 22. Wingfield C. Lower limb cellulitis: a dermatological perspective.Wound. 2009;5(2):26-36. 23. Abbas ZG, Lutale JK, Archibald LK. Risk factors associated with lower limb cellulitis in diabetic patients, Dar es Salaam, Tanzania. J Med Res Sci. 2011;2(1):192-197. 24. Eagle M. Understanding cellulitis of the lower limb. Wound Essentials. 2007;2:34-44. 25. Lasschuit DA, Kuzmich D, Caplan GA. Treatment of cellulitis in hospital in the home: a systematic review. OA Dermatology. 2014:2(1):2. 26. Suykerbuyk C, Frykberg R. Necrotizing fasciitis: A case report. J Diab Foot Comp. 2010;2(1):1-5. 27. Jain AKC, Varma AK, Mangalanandan, Kumar H, Bal a. Surgical outcome of necrotizing fasciitis in diabetic lower limbs. J Diab Foot Comp. 2009;1(4):80-84. 28. Tang WM, Ho PL, Fung KK, Yuen KY, Leong JCY. Necrotising fasciitis of a limb. J Bone Joint Surg. 2001;83:709-714. 29. Cheung JPY, Fung B, Tang WM, Ip WY. A review of necrotising fasciitis in the extremities. Hong Kong Med J. 2009;15:44-52. 30. Smeets L. Nous A, Heyman’s O. Necrotizing fasciitis. Case report and review of literature. Acta Chir Belg. 2007;107:29-36. 31. Wilkes A. A case report on necrotising fasciitis. Primary Intention. 2005;13(2):83-88.