Foot problems are among the most feared complications of uncontrolled diabetes, and for good reason. More than 60 percent of lower-limb amputations that aren’t a result of trauma occur in people with diabetes. But even if you already have complications of diabetes, amputation is by no means a given—or likely. Your best defenses: good glucose control and knowledge about foot problems, including how to prevent or treat them.
Call ’em sores or wounds—they’re broken skin, and that can let in harmful bacteria or fungus. Minor cuts and scrapes aren’t usually a big deal, except where diabetes is concerned. When a break in the skin doesn’t heal or heals poorly, it can become a chronic wound known as an ulcer. According to Lee Rogers, DPM, codirector of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles, a quarter of all people with diabetes will develop a foot ulcer in their lifetime, half of those will have infected ulcers, and, of those, 1 in 6 will require amputation. That’s why you’ll hear podiatrists stress proper foot care: Early treatment is crucial.
|Signs of Foot Problems|
|Cracked, peeling, and flaking skin and blisters that ooze or crust. Ask your doctor about: Athlete’s foot|
|A break in the skin, redness, or swelling. Ask your doctor about: Ulcer|
|A swollen, red foot that’s warm to the touch. Ask your doctor about: Charcot foot|
|Thick, cracked, crumbling, broken or jagged, and darkened (brown or yellow) nails. Ask your doctor about: Toenail fungus|
There are a number of reasons people with diabetes are more likely to have hard-to-treat ulcers. For one, neuropathy and the loss of sensation that may follow make it difficult for people to notice wounds. If they don’t check regularly, a minor cut could become infected. Foot deformities, previous ulcers, obesity, poor circulation, and uncontrolled glucose are additional risk factors.
People with uncontrolled type 1 or 2 diabetes are more susceptible to infections in the first place because of poor immune function. Combine that with poor circulation—namely, impaired blood flow to the feet, which slows healing—and you have the potential for longer-lasting infections. There are various factors related to the lessened blood flow, but the four biggies are older age, smoking, high LDL (“bad”) cholesterol, and peripheral arterial disease.
Even the smallest wound can get out of control quickly. “You may have a subtle injury, even a blister,” says Robert Frykberg, DPM, MPH, chief of podiatry in the Department of Surgery at the Carl T. Hayden Veterans Affairs Medical Center. “But if you continue to walk, that creates further trauma. The injury just compounds itself.”
Avoid: If you have neuropathy, it’s important to check your feet daily (including if you take pain meds) to prevent wounds that could later cause major problems. If you can’t easily reach and see the bottom of your feet, use a long-handled mirror. Proper shoe fit and orthotics can help prevent ulcers and other foot problems.
Treat: Early on, infected wounds can be treated successfully with antibiotics. But if you wait too long, tissue damage may occur, gangrene may set in, or the infection may spread to the bone. A bone infection, known as osteomyelitis, requires surgery and is difficult to treat.
Just as you might cut your foot without noticing, you may otherwise injure your feet and not feel pain. That puts you at risk for a serious, though not common, condition known as Charcot foot, which is characterized by redness, swelling, and warmth to the touch. When people who don’t have a loss of sensation twist, sprain, or fracture their feet, overwhelming pain prevents them from going about business as usual. If it doesn’t feel injured, however, you can’t get help and won’t stop walking on it, Rogers says: “You’ll continue to injure it.”
|Neuropathy may cause the skin to stop sweating, resulting in dry, cracked skin. That leaves room for infection, so it’s important to keep your feet well moisturized at all times. Slather on a rich moisturizer daily, avoiding between the toes where bacteria and fungus thrive on moisture. Another tip: Coat feet in a thick moisturizer—creams tend to be thicker than lotions, though they may leave your feet greasier, too, so use caution if you plan to walk around afterward—slip on warm socks, and head to bed. In the morning your feet will feel softer.|
Though Frykberg says some people are genetically susceptible to developing Charcot foot, neuropathy is the primary culprit, and not just because it causes a loss of sensation. Damaged nerves can lessen the blood flow to the feet, causing bone softening. With added trauma each time the injured foot is used, the arch may collapse, bones can disintegrate, ulcers may form and get infected, and foot and ankle deformities take shape.
Avoid: There may not be an outward sign, such as bleeding and broken skin, that you’ve injured your foot, but you can still catch an injury before too much damage is done. About half of all people with Charcot foot remember tripping or slipping before developing the condition. “The goal is to get people at the earliest injury so they can get off their feet and prevent further damage,” Frykberg says.
Treat: The best things you can do if you notice symptoms are get off your foot and see a doctor. Early treatment includes casting, which might last more than five months. Protective shoes are sometimes recommended. Severe cases (meaning those not caught soon enough) may require immobilization, surgery, and sometimes amputation.
Because of a weakened immune system, people with uncontrolled diabetes are more likely to get and hold on to fungal infections, such as athlete’s foot, which begins as cracked, peeling, or flaking skin, especially between the toes, and can progress to oozing or crusted blisters. It’s important to treat early so the infection doesn’t cause breaks in the skin, allowing bacteria to enter, or move to the nails.
Avoid: Athlete’s foot loves moist environments. Keeping foot skin dry (especially between the toes), letting your shoes air out, wearing socks that wick away moisture, and avoiding going barefoot can help prevent infection in the first place.
Treat: The first line of defense is an over-the-counter antifungal medication. Thoroughly washing your feet (and drying between the toes) can also help control the infection. If the athlete’s foot doesn’t clear up after a couple of weeks, talk to your doctor.
|Foot Checks Without Neuropathy?|
|If you don’t have neuropathy, your chances of developing serious foot conditions are slimmer. You’ll be able to feel any cuts, bumps, bruises, or other pain to your foot, which means you’ll get help before it gets out of hand. But that’s no reason to forgo foot checks, says Robert Frykberg, DPM, MPH. “It’s a good habit to get into,” he says. Even if you don’t commit to daily checks, try to inspect your feet regularly, and have your doctor do so at each office visit.|
The same fungus that causes athlete’s foot is behind toenail infections, too. But nail fungus isn’t easy to get rid of. At the first sign of infection—nails may appear darkened (brown or yellow), thick, cracked, crumbling, or jagged—see a doctor.
Toenail fungus can make clipping thickened nails difficult and sometimes requires a doctor’s help. Cutting the nail incorrectly could lead to jagged edges that might slash skin and lead to infection. Fungus can lead to infection in another way, too: Pressure from shoes on top of a thickened nail may cause ulcers beneath the toenail, which are hard to spot and treat, leading to infection.
Avoid: Prevent infection before it starts by keeping your feet clean and toenails short and clipped straight across. Moisture ups your chances of a fungal infection, so thoroughly dry your feet after showering, wear moisture-wicking socks, and air out your shoes if they’re extra sweaty. Above all, don’t go barefoot—shoes can protect you from infections, yes, but also from any sharp objects that might cut your feet.
Treat: When you’re diagnosed with toenail fungus, your doctor may recommend a topical antifungal, an oral medication, or laser therapy. In the past, health care providers worried about the safety of the oral meds (older versions often caused liver damage), but the newer drugs are safer. Still, use them with caution if you have kidney disease. Though oral medications are the most effective treatment, it may take six months or longer on the medication for you to notice a difference. Even then, the fungal infection may come back.