Diabetic Ulcers: How to Treat and Prevent a Challenging Complication

By: Diana Barnes-Brown for Diabetes1

For those with diabetes, there are many concerns besides maintaining safe insulin levels. Those with the disease may suffer from a range of complications, as well. These include brittle bones, nerve damage, peripheral vascular or arterial disease (the medical classification for a range of circulatory problems), declining eyesight and ulcerated skin.

Take Action Are you at risk for diabetes? Common symptoms include: Frequent urination Excessive thirst Extreme hunger Unusual weight loss Increased fatigue Irritability Blurry vision To learn more about diabetes its treatment and prevention, visit the American Diabetes Association For more information on diabetic ulcers, click here

In particular, ulcers (slow-healing open wounds) in the feet and legs are common for diabetes patients, because the pain of small cuts or scrapes may not be felt due to nerve damage in the area, and on top of that, poor circulation slows healing time.

Drawbacks of feeling no pain

Though the idea of not being able to feel pain may seem appealing, it is actually a very dangerous problem. Because of the increased risk, even a small blister from ill-fitting shoes or a splinter from a rough floor can be the cause of a serious ulcer down the line.

Without nerves to send important “ouch!” signals to the brain, small injuries in areas with nerve damage have the potential to become inflamed and infected, leading to hard-to-heal ulcers, and in extreme cases, amputated toes, feet and lower legs. In fact, according to the American Academy of Family Physicians, diabetic ulcers are the main cause of nontraumatic (medical rather than accidental) lower extremity amputation in the industrialized world.

Frank Turner M.D., a podiatrist from River Ridge, Louisiana who specializes in treating patients with diabetes, spoke to Wounds1 about the development and treatment of this dangerous complication.

“Diabetic ulcerations are preventable if the diagnosis of possible foot biomechanical problems are picked up early, prior to ulcer development,” he noted.

Seek treatment early

But a common problem is that patients wait until their symptoms have progressed to the ulcer stage, rather than coming in while an ulcer can still be prevented.

“I have been in podiatric practice for 16 years,” said Turner, “and to date I have not had a patient come into the office stating, ‘I think I have the beginning of a foot ulcer.’” Instead, patients have often come to visit with infected ulcers already so severe that the bone is exposed.

“Holistic treatment is fine,” said Turner, “but [patients must] understand that the ulcer will not heal until full off-loading of the foot is initiated and wound care principles implemented.”

Once small injuries have grown into full-blown ulcerations, treatment must be aggressive if patients are to recover and avoid amputations. Keeping weight on an already ulcerated foot or leg reverses the healing process and actually causes the ulcer to enlarge, so a key factor is getting patients off their feet, or using medical devices to keep pressure off the ulcer until healing has occurred.

Medications and treatment aids are out there

There are also specially-designed medications and treatment aids that can be used. These include becaplermin gel, a high-tech compound that contains something called platelet-derived growth factor. Growth factor, a substance already present in the body that speeds healing, may not be present in great enough quantities to aid in the repair of severe wounds. A product known as Appligraf, a “skin substitute” made of living cells and proteins that aid in skin development, is also helpful in treatment of diabetic ulcers.

According to Turner, applying a potent form of these substances, already present in nature, directly to ulcers can give a boost on the road to recovery by “stimulating important cells called fibroblasts, which are needed for would healing.” Antibiotics may be required if infection is present, and it may be necessary to treat bone damage if the ulcer has exposed bone tissue.

Once the ulcer has healed, doctors and patients face another challenge: Keeping ulcers from reopening or returning. This can be done with the aid of specially-designed shoes and other podiatric devices.

Asked what advances in ulcer care he sees on the horizon Turner noted that he hopes to see improved technology surrounding off-loading of the foot, newer graft material, absorbable pins, screws, and plates for bone repair and improved bone stimulators to repair bone loss. In upcoming years, medical scientists may also create a substance that combines growth factor, skin substitutes and antibiotics to increase efficiency of wound treatment.

But, most importantly, Turner argues that there is a need to “reduce the number of lower extremity amputations as a result of physicians taking the short or easy route to resolve a problematic foot ulcer.”

In many cases, he noted, limbs can be preserved. “If you only knew how many limbs I have saved by simply asking the general surgeon to give me a few weeks with the patient to help correct the problem,” said Turner. Even though a few of the cases could not be resolved without some form of amputation, “most healed very well and others had smaller amputation, but they are still able to walk because they still have their foot.”

The importance of doctor-patient communication

A final challenge in diabetes ulcer prevention and treatment is fostering cooperative, communicative relationships between doctors and patients. Doctors must be accessible to their patients, willing discuss all treatment options openly and clearly, and able to think creatively about the same. Patients must be disciplined about following treatment regimens once they have been selected, and seeking help early on if they detect a problem.

If positive treatment relationships such as these can be achieved, however, the outlook is good for patients who suffer from diabetic complications. Looking ahead, Turner and other treatment experts expect that advances in technology and care practices will lead to fewer amputations and healthier patients overall.