Stages of having diabetic feet

Diabetes mellitus is a metabolic endocrine disorder caused by either a generalized deficiency of insulin (Type 1) or impaired insulin function (Type 2), which results in hyperglycemia.

• In 5% to 10% of cases globally, type 1 diabetes, typically found in younger patients, is caused by the body's immune system attacking the pancreatic B-islet cells that produce insulin, leaving the patient insulin deficient.

• 90% to 95% of instances of diabetes are type 2, caused by hereditary and environmental causes. As a result, insulin resistance and pancreatic beta-cell malfunction lead to relative insulin insufficiency. For many years, this kind of diabetes has been clinically undetectable.

Both can result in diabetic foot ulcers, a disabling complication that raises patients' overall morbidity.

What is a diabetic foot?

Diabetes can result in inadequate blood flow, nerve damage, and severe foot issues. The term "diabetic foot" describes a range of pathological diseases that can impact a patient's feet when they have diabetes. In addition, long-term high blood sugar levels can harm nerves and blood vessels.

Poor blood flow and foot sensation loss can result from blood vessel and nerve damage. Due to nerve loss, a person may not recognize foot injuries and neglect to seek medical attention. In addition, their body cannot recover from diseases because of insufficient blood flow. Ulcers may result from this and the wound's ability to heal.

What is a diabetic foot ulcer?

Diabetic foot ulcers (DFUs) are complications of diabetes. Foot ulcers refer to lesions that involve a skin break and epithelium loss. They can spread into the dermis and deeper layers, occasionally impacting bone and muscle. They develop in the foot's weight-bearing regions, including the heel, toe tips, and ball of the foot.

Diabetes-related foot ulcers (DFU) are a significant drain on healthcare resources and are linked to severe life impairment, increased morbidity, and mortality. Although readily avoidable, diabetic foot issues are among the most frequent reasons for hospital inpatient admission in Western nations. The cost of DFUs and the anguish experienced by those impacted are staggering.

Why does this happen?

The two most significant contributing factors to foot ulceration are peripheral vascular disease (PVD) and diabetic neuropathy.

• Diabetic Neuropathy

The nerves in the legs and feet are most often damaged by diabetic neuropathy. The most prevalent type of diabetic neuropathy is peripheral neuropathy. Usually, your hands and arms come afterward, then your feet and legs. Diabetic neuropathy symptoms can range from severe stabbing pain to diminished pain perception in the legs, feet, and hands, depending on the affected nerves.

As a result of the loss of protective sensation, pressure points on the leg are subjected to repeated stress and injuries that go unnoticed, leading to the development of painless ulcers. Ingrown toenails, calluses, blisters, scrapes, burns, and other wounds can all cause diabetic foot ulcers.

A 2020 study found that people with moderate to severe sensory loss have a seven-fold higher risk of getting their first foot ulcer than those without neuropathy.

One of the following colors could be a neurotrophic ulcer:

• Pink.
• Red.
• Brown.
• Black.
• Any combination of those colors.

Peripheral Arterial Disease (PAD)

The narrowing or obstruction of the blood arteries that convey blood from the heart to the legs is referred to as peripheral arterial disease (PAD) in the legs or lower extremities. The main signs of PAD include aches, pains, weariness, burning, or discomfort in the thighs, calves, or feet muscles.

These obstructions may hamper circulation. As a result, your vital organs, arms, legs, and feet can hurt without blood flow. One of the most severe symptoms of advanced peripheral artery disease is foot ulcers, wounds, or open sores that do not heal.

Distal arterial disease is more common in diabetes patients and is known to be associated with a worse prognosis.

In contrast to neurotrophic ulcers, arterial ulcers can develop in a variety of body areas, such as:

• On your heels.
• On the tips of your toes.
• In-between the toes (where your toes rub together).
• Your feet's bony areas rub against your bedding, stockings, or shoes.
• Nail beds (if your toenail cuts into your skin, if your toenail was trimmed aggressively, or if you had an ingrown toenail removed).

Arterial ulcers are:

• Yellow.
• Brown.
• Grey.
• Black.

How are diabetic foot ulcers graded or staged?

The general characteristics of these wounds are categorized using a variety of techniques. Additionally, the ulcer's depth can vary. There are numerous classification schemes for determining an ulcer's depth. Using a scale from 0 to 5, doctors that employ the Wagner Diabetic Foot Ulcer Classification System classify DFUs according to their severity.

Grade 0: Your skin is intact (undamaged). 

This is a regular foot and free of risk factors.

Grade 1: The ulcer is "superficial," which refers to damaged skin and a shallow lesion (in the upper layers of the skin).

Wounds that only reach the epidermis or the epidermis and dermis, but not the tendon, capsule, or bone. However, this is already considered high-risk because the damaged skin is exposed to environmental risk factors that could worsen the wound.

Grade 2: The wound is "deep" due to the ulcer. 

The bone and joints are unaffected. However, this wound penetrates the tendon or capsule. A tiny crater is created as the sore deteriorates and penetrates the tissue beneath the skin. Fat may also show in the sore. 

Grade 3: A portion of your foot's bone is visible.

In this instance, wounds reach the bone or a joint. The harm from this deep puncture, which penetrates bone and muscle, is causing extensive damage.

Grade 4: There is gangrene on the front of your foot, which is the area closest to your toes (necrosis).

Necrosis is the term used to describe the death of some body tissue or an organ. For example, this indicates that the front of the foot has gangrene or dead tissue.

Grade 5: The foot is entirely gangrenous.

Due to this wound, the entire foot has been affected by gangrene. Additionally, it denotes a foot that cannot be saved. While wet gangrene can still be treated with antibiotics and oxygen therapy, most severe diabetic foot infections require some surgical intervention, ranging from modest (debridement) to major interventions, including amputation. Amputation means the removal of a terminal, non-viable portion of the limb.

How can I determine if I'm developing a foot or toe ulcer?

You might notice skin changes like these when an ulcer on your foot or toe is beginning to form:

• Dry skin.
• Skin flaking.
• Scaly skin.
• Redness.
• Rashes.

As the ulcer worsens, it can get more comprehensive and longer and more profound — even reach the bone. In later phases, you might notice:

• A callus.
• A halo (ring) around the wound's center that is harder to the touch than the skin around it.
• Drainage or pus, a symptom that you might have an infection (you might notice this when you take off your socks.
• A brownish discoloration.
• A bad odor.

How are ulcers in the feet and toes diagnosed?

Your primary care physician can identify an ulcer, but they could refer you to a specialist for care. A physical examination and medical history will be performed.

Your doctor will inquire whether you have a foot ulcer about when you first noticed it. They also want to know if you have other illnesses that could raise your chance of developing foot ulcers, such as peripheral neuropathy or lower extremity arterial disease.

Your doctor examines the foot, toes, and toenails to look for any blisters, wounds, scratches, or ingrown toenails that could cause more ulcers. By sensing the pulse, they also gauge the blood flow rate in the foot.

The doctor may ask you to stand and walk so they may examine how your body's weight is distributed across your bones and joints in your feet. A limp could signify structural damage, and an unsteady gait could lead to blister formation. Additionally, the foot's shape is assessed because an irregular alignment may raise the incidence of ulcers.

Four observations can be used to determine the type of ulcer:

• The appearance of the ulcer.
• Location of the ulcer.
• The way the borders look.
• The way the skin around it seems.

What examinations determine if I have a foot or toe ulcer?

To determine the extent of the ulcer and evaluate whether it infected an adjacent bone, they may request a:

MRI 

A magnetic field and radio waves are used in MRI scans to provide digital, three-dimensional images of the soft tissues inside the body. If your doctor wants further information about the degree of ulcer damage, they can suggest this test. Inflammation can indicate an infection and can also be seen on MRI images.

CT scan

For individuals with diabetic foot ulcers, a CT scan is a sensitive method for identifying aberrant bone appearance. On a CT scan, abnormalities in the bone's appearance, such as bone erosions, Charcot joints, reduced joint space, osteopenia, and osteophyte production, can be seen.

X-ray

Your doctor may advise X-ray imaging to check changes in the alignment of the bones in the foot, which might contribute to an ulcer. X-rays can also show a reduction in bone mass, which may be brought on by hormonal disturbances brought on by diabetes.

Low bone mass weakens bones and can cause Charcot foot, a disorder that causes recurrent minor fractures and other foot problems. Early diagnosis of this condition will help you avoid the foot bones becoming permanently out of alignment, which can stop new ulcers from developing.

Blood Test

Your doctor can advise a blood test to screen for infection if the affected foot exhibits symptoms like redness, swelling, and warmth. The procedure is done at a doctor's office, and the results are often ready in a week.

How should I take care of my foot and toe ulcers?

Your doctor might provide you with instructions on how to treat your ulcers at home. Possible instructions include:

• Gently wash the area with soap and water.
• Keep the wound clean and dry.
• Change the bandages as necessary.
• Take prescribed drugs as indicated.
• Be sure to get enough fluids. How much water you should consume each day should be discussed with your doctor.
• Adhere to your doctor's advice regarding a healthy diet.
• Regular exercise, as directed by your healthcare physician.
• Put on appropriate footwear.
• Wear compression wraps as directed.

How can I lower my chance of getting foot and toe ulcers?

You can take several steps to help lower your chance of developing foot and toe ulcers. Occasionally, forming these behaviors can even prevent them from resurfacing. Try to:

• Controlling your diabetes. You can keep your blood sugar levels within the desired range by monitoring your food intake. Monitor your blood sugar levels, and take prescribed medications. Never walk barefoot if you have diabetes, and always wear suitable footwear.

• Every day, check your legs, feet tops and bottoms, and the spaces between your toes. Check for sores, wounds, cracks, blisters, or other injuries. Ingrown toenails, corns, calluses, increased temperature, and redness should also be examined. If required, use a mirror to see your foot or leg. Ask a family member to look at the area for you if it's tough to see. Consult a doctor right away if you experience any issues.

• Quit smoking. Smoking has an impact on blood flow and can exacerbate foot issues. Consult your doctor about medications and stop-smoking programs if you need assistance quitting. These may improve your chances of successfully quitting.

• Keep your blood pressure in check. Change your diet to control your triglyceride and cholesterol levels. Reduce your intake of salt.

• Regularly take care of your toenails. When your toenails are soft after a bath, trim them. Trim toenails straight across, then file them smoothly. Deal with ingrown toenails.

• Engage in some exercise. Spend at least 30 minutes each day working out. Keep a healthy weight.

• Ask your doctor to examine your feet each time you see them. Visit your podiatrist if you are experiencing foot issues. Avoid attempting to address your foot issue by yourself. Over-the-counter medications (such as corn removers) or home remedies may be dangerous.

In order to treat mechanical, wound, microbiological, vascular, metabolic, and educational elements of diabetic foot care, multidisciplinary management is required at all stages. Each stage requires strong metabolic regulation of blood sugar, lipids, and blood pressure and education to teach each stage-appropriate foot care.