Diabetic Foot Ulcers
Diabetic Foot Ulcers (DFU)
- Approximately 19-34% of U.S. adults with diabetes develop DFUs in their lifetime
- Approximately 15% of people with diabetes will develop a foot ulcer and it is estimated that more than half of these will experience a second ulcer
- Up to 70% of all non-traumatic, major lower limb amputations are performed on diabetic patients
- The 5-year mortality after amputation in diabetes patients ranges from 39%-68%
Diabetic Foot Ulcers Becoming Chronic
Diabetic foot ulcers, like other types of wounds, become chronic when they fail to progress through a normal, orderly, and timely sequence of repair, leading to stalled or delayed healing for weeks, months, and even years, and by a resistance to treatment with conventional dressings and therapies.
This persistence is often exacerbated in diabetic patients due to underlying factors specific to the disease, such as neuropathy (nerve damage) which can mask pain and delay detection, and peripheral artery disease (PAD) which impairs blood flow to the feet.
Furthermore, chronic diabetic foot ulcers are also subject to the same general characteristics of chronic wounds, including increased levels of proteases (MMP-2 and MMP-9) that degrade the extracellular matrix and inactivate growth factors, and persistent overproduction of reactive oxygen species (ROS), all of which actively hinder the healing process. Therefore, when these ulcers fail to heal despite standard care and exhibit the biochemical hallmarks of chronicity, they are considered chronic wounds.
Background
Diabetic foot ulcers (DFUs) are open sores that develop on the feet of individuals with diabetes. They are a significant health burden, leading to substantial costs and a reduction in the quality of life for affected patients.
Diabetic foot ulcers are a significant problem on a global basis. Approximately 15% of people with diabetes will develop a foot ulcer and it is estimated that more than half of these will experience a second ulcer. Diabetic foot ulcers occur most commonly due to neuropathy (loss of sensation in the lower extremity) and peripheral vascular disease. Neuropathy can occur partially as a complication of prolonged glucose elevation (Steed 2007) Failure of diabetic foot ulcers to heal may result in amputation.
The main reasons for diabetic foot ulcers failing to heal are two-fold. One primary cause is that the person with the foot ulcer continues to walk on the ulcer causing irritation and skin breakdown. They may also have some type of foreign body enter the skin and be unaware of this happening. For the healing process to take place, these wounds usually have weight redistributed away from the wound in what is known as offloading. Specialty shoes and devices are available to assist with this process.
The second main reason that these ulcers fail to heal is related to proper diabetes control. Uncontrolled blood sugar can prevent the body from healing itself by preventing certain healing process from occurring. Management includes prevention of weight bearing (off loading) , debridement of devitalized tissue, prevention of infection and local wound management.
DFUs are the most common cause for hospitalization of patients with diabetes. Approximately 19-34% of U.S. adults with diabetes develop DFUs in their lifetime. Up to 70% of all non-traumatic, major lower limb amputations are performed on diabetic patients, amounting to about 82,000 limb amputations each year. The 5-year mortality after amputation in diabetes patients ranges from 39%-68%.
Diabetic Foot Ulcer Causes and Risk Factors
These ulcers occur due to a combination of factors common in diabetes, including:
- Neuropathy (nerve damage): High blood sugar levels can damage nerves, particularly in the feet, leading to a loss of sensation. This means patients may not feel pain from minor injuries, cuts, or blisters, allowing them to worsen without detection.
- Peripheral Artery Disease (PAD): Diabetes can cause atherosclerosis, narrowing or blocking arteries and reducing blood flow to the feet. This impaired circulation deprives tissues of oxygen and nutrients, hindering healing and increasing the risk of tissue death and ulcer formation.
- Impaired immune function: Diabetes can weaken the immune system, making individuals more susceptible to infections in wounds.
- Structural foot deformities: Long-term diabetes can lead to changes in foot shape, creating pressure points that are prone to breakdown.
Characteristics of Diabetic Foot Ulcers
- Location: Often found on the bottom of the foot, especially under pressure points like the big toe, ball of the foot, or heel.
- Appearance: Can vary, but may have a “punched-out” appearance. The surrounding skin may be calloused due to repetitive trauma.
- Pain: Often painless due to neuropathy, which can delay diagnosis and treatment.
- Infection: Highly susceptible to infection, which can spread rapidly and lead to major tissue destruction and amputation.
Successful treatment of diabetic ulcers is challenging because they are difficult to heal and closure is often unstable. Treatment typically involves surgical debridement, adequate off-loading (reducing pressure on the ulcer), and moist wound healing.
Chronic diabetic foot ulcers are characterized by stalled or delayed healing, resistance to conventional therapies, increased levels of proteases (like MMP-2 and MMP-9), and persistent overproduction of reactive oxygen species (ROS), all of which impede the healing process.
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