Diabetic foot ulcer: treatment, warning signs and prevention

The Royal College of Podiatry says that anyone with a diabetes-related foot ulcer needs regular podiatry treatment, and the podiatrist should have experience in diabetes-related foot problems and will draw up a treatment plan. Other specialists may be involved, such as vascular or orthopaedic surgeons, orthotists and infection specialists. NICE says services should include a foot protection service led by a podiatrist with specialist training, and a multidisciplinary foot care service for problems the foot protection service cannot manage.

NICE recommends offering one or more of the following as standard care: offloading, control of foot infection, control of ischaemia, wound debridement and wound dressings. For plantar neuropathic, non-ischaemic, uninfected ulcers of the forefoot and midfoot it advises non-removable casting, with an alternative offloading device until casting is available. The podiatry leaflet explains that ulcers can be hidden beneath hard skin and dead tissue, which the podiatrist must remove, and that this may make the ulcer bleed a little and look larger, which is normal. It says not to try to treat the ulcer yourself.

Antibiotics are given when there are signs of infection, and NICE advises starting them as soon as possible with samples taken first and oral treatment first-line where suitable. Severe infection can need hospital and intravenous antibiotics. The leaflet says an operation to clean the wound may sometimes be needed and, in very severe infection, an amputation may be necessary to save healthy parts of the foot. If circulation is reduced, referral for a procedure to improve blood supply may be offered.

NICE also states that some treatments should not be offered outside clinical trials, including electrical stimulation therapy, platelet-rich plasma gel and hyperbaric oxygen therapy, which is a useful caution about expensive options offered privately.

Diabetes UK lists signs of a foot problem to report to your GP or local foot protection team: tingling or pins and needles, numbness, burning pain, a dull ache, loss of feeling, swollen feet, a lack of sweating, cuts or sores that do not heal, calf cramp when resting or walking, shiny smooth skin and hair loss on the legs and feet.

For someone who already has an ulcer, the Royal College of Podiatry leaflet separates two levels of concern. Contact the foot care team, podiatry department or GP within 24 hours, for pain or throbbing, a foot hotter than usual, new areas of discolouration, inflammation or swelling, any discharge, or a new smell. Go straight to A&E if you have flu-like symptoms, a rash, breathlessness, a body temperature above 38.3C or below 36C, or a heart rate above 90 beats per minute.

• If your usual contacts are not available and the foot is hotter, swollen or painful, or has changed colour, shape or discharge, the leaflet advises ringing NHS 111, who may send you to A&E.

• Cover any new break in the skin or blister with a sterile dressing and do not burst blisters.

• Any delay in getting advice or treatment can lead to serious problems, the leaflet warns.

Diabetes UK explains the chain of events. Over time, raised blood sugar can damage the small blood vessels that supply the nerves in the feet, stopping nutrients reaching them. If the nerves are damaged, a person can lose feeling in the feet, known as peripheral neuropathy, so they may injure their feet without noticing. Damaged blood vessels also reduce the blood supply, so cuts and sores heal poorly, and may cause cramp and pain in the legs or feet.

Diabetes UK also lists related problems: toes bent into a claw shape, hammer toes, corns and bunions, which can result from changed feeling and shape in the foot and create pressure points. Most foot problems, it says, can be prevented by taking care of the feet and having them checked at the annual review.

NICE sets out a risk framework used by NHS teams. Low risk means no risk factors apart from callus alone. Moderate risk means deformity, neuropathy or peripheral arterial disease. High risk includes previous ulceration or amputation, kidney replacement therapy, or neuropathy combined with arterial disease, callus or deformity. An active diabetic foot problem means an ulcer, infection, chronic limb-threatening ischaemia, gangrene, suspected acute Charcot arthropathy, or an unexplained hot, swollen foot with a change in colour.

The Royal College of Podiatry describes a foot ulcer as an area where skin has broken down, or an open sore on the foot with tissue underneath exposed. In some people with diabetes the skin does not heal well and an ulcer or infection can develop after only a minor injury. It stresses that foot ulcers in diabetes are serious, especially if they become infected, because they are linked with a higher risk of heart attacks, strokes, amputation and early death.

An infected ulcer, left untreated, raises the risk of amputation and of sepsis. If circulation to the feet is poor, the leaflet says, these risks increase further. Ulcers can take several weeks or even months to heal and can disrupt life considerably, which is part of why prompt specialist care matters.

The Royal College of Podiatry says ulcers can take several weeks or even months to heal and can significantly disrupt your life. How long yours takes depends on its size and depth, blood supply, whether it is infected and how well pressure is taken off the foot.

Healing depends on following the plan from your foot team: wearing prescribed footwear or a cast whenever you put weight on the foot, keeping dressings dry and in place, attending every appointment, and controlling blood glucose, blood pressure and cholesterol. Stopping smoking also helps, according to the leaflet. If an ulcer is not improving, tell your team, as it may need further assessment for infection or poor circulation.

NICE says that adults with diabetes should have their risk of a foot problem assessed when diabetes is diagnosed, at least annually after that, if any foot problems arise and on any hospital admission. The examination involves taking off shoes, socks and dressings and looking at both feet for neuropathy (using a 10 g monofilament), poor blood supply, ulcers, callus, infection or inflammation, deformity, gangrene and Charcot arthropathy. Diabetes UK says the annual foot check is free on the NHS and may lead to referral to a podiatrist or local foot protection team.

When someone has an ulcer, NICE advises assessing and documenting its size, depth and position and grading severity with a standardised system. For suspected infection, samples from the debrided wound are sent for microbiological testing, an X-ray may be considered, and clinicians are asked to think about bone infection (osteomyelitis) in deep or chronic wounds, with MRI if needed. NICE adds that osteomyelitis may be present despite normal inflammatory markers or X-rays.

The Royal College of Podiatry leaflet advises not interfering with dressings unless you have been shown how, keeping dressings dry (a dressing protector can allow a bath or shower), moisturising the rest of the foot but not broken skin or between the toes, resting the foot and avoiding unnecessary standing or walking, and wearing any prescribed footwear or cast whenever you put weight on the foot. Check both feet every day and wear the correct footwear on the other foot, which is under extra pressure.

It adds that stopping smoking, managing diabetes, cholesterol and blood pressure, being more active and managing weight all help reduce the risk of limb-threatening problems, and that you should ask your diabetes team about exercise that does not put weight on the damaged foot. Living with ulcers can affect quality of life and mental health, and speaking to your podiatrist or practice is encouraged.

NICE sets out that diabetic foot care should be delivered by a foot protection service in the community and a multidisciplinary foot care service for complex problems, with referral within 24 hours for inpatients. Active ulcers are normally managed within these NHS teams because they can draw together podiatry, vascular, infection and orthopaedic skills.

Private podiatrists can provide routine nail and skin care and risk checks, but a person with an active ulcer should make sure the NHS foot team is involved. Ask any private provider whether they have training in diabetic foot disease, and beware of treatments the guidance says should not be used outside trials.