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Indiana Podiatry Group
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Central Indiana Foot Doctors Explain the Dangers of Diabetic Wounds and Ulcers

Diabetic wounds, also known as ulcers, are breaks in the skin where the tissue under the skin surface is exposed to the open air. The skin acts as a protective barrier for the body, to keep microscopic organisms out of the body and cover the vital tissue below, amongst other purposes. When that barrier is broken, organisms such as bacteria can enter the body easily and cause infection. Diabetics not only have a much higher chance of developing a skin wound in their feet, they are also less likely to be able to quickly heal the wound and are much more likely to become infected at the wound.

Diabetes affects many different parts and processes of the body. In particular, diabetes can cause nerve tissue to function poorly, leading to sensation loss. While usually not an outright numbness, diabetic nerve disease (diabetic peripheral neuropathy), can lead to an inability to feel increased pressure on the skin, such as over a callus, a prominent bone, or an area where a shoe rubs on the skin. To others without neuropathy, pressure in these areas may cause discomfort, and therefore one shifts their weight accordingly or replaces a poorly fitting shoe. Since a diabetic with neuropathy can not feel this pressure normally, it continues to be applied to the skin until the skin breaks down from it. The result is cell death of some or all layers of the skin, exposing the fat tissue, tendon, muscle, or even bone below if the wound is deep enough.

Skin wounds are medically classified according to their depth, but in the simplest sense they are separated into either partial thickness wounds, or full thickness wounds. Partial thickness wounds are sores that only go through part of the skin, and typically stop at a firm layer called the basement membrane. Scrapes, burns, and 'road rash' are good examples of what a partial thickness wound can look like. A full thickness wound goes through all the layers of skin, down to at least the fat layer below. These wounds pose a greater danger to a diabetic, as bacteria can travel to deep spaces, including bone if it is exposed, and cause a potential limb threatening infection.

There are other causes of wounds beyond pressure in a diabetic with poor sensation, including traumatic injury, burns, and skin diseases. Poor circulation is another major cause of wounds, and diabetics also have a form of poor circulation that can compromise skin health. On its own, poor circulation (blocked major arteries in the legs, not varicose veins that cause leg swelling) can lead to skin death by reducing the amount of oxygen and nutrients that skin needs to stay healthy and survive. This leads to gangrene and black, hard skin that essentially 'mummifies'. While diabetic circulation problems are not as pronounced, with smaller arteries being affected more than the major leg arteries blocked in traditional poor circulation, they can still hamper the body's ability to heal a wound. Additionally, diabetes is a risk factor for blocked leg arteries, and a diabetic can have both blocked arteries and diabetic circulation disease of the smaller arteries as well.

In rare cases, skin cancer can masquerade as a wound.

Healing diabetic wounds involves controlling pressure, removing bacteria, ensuring the wound surface stays appropriately healthy, and ensuring circulation is adequate. First and foremost, pressure has to be reduced. This can be accomplished by simple measures such wearing deeper or wider shoes, using protective pads, reducing callused skin regularly, or by using specialized shoe inserts. More advanced measures include specialty boots, healing shoes, or braces designed to reduce pressure to the foot to facilitate healing. Finally, surgery may be needed to reduce or correct bone deformity to reduce pressure from below the skin.

Secondly, bacteria has to be controlled. Bacteria does not have to 'infect' a wound to cause problems. Bacteria can simply 'colonize' the wound in small numbers, and produce chemicals that decrease the body's ability to heal a wound. Surface bacteria can be controlled with topical skin agents that have antibacterial properties, and infections can be treated with antibiotic medication. Moderate infections are treated with oral antibiotics, while more serious infections may need to be treated with intravenous antibiotics in a hospital or outpatient clinic setting.

Equally as important as pressure and bacteria control is maintaining a healthy wound surface. This is accomplished through regular removal of unhealthy, nonviable tissue ideally to bleeding by a physician or wound care specialist, as well as the proper selection of dressing material to keep the wound surface moist while removing excessive drainage. Contrary to popular opinion, a wound does not heal well when dry and exposed to open air. Wounds need a moist environment to optimally heal, although too much moisture from drainage can be harmful to the surface. By using dressing materials ideal for one's own particular wound environment, the right balance can be struck. This cycle of tissue removal and regular dressing changes is continued until the wound is healed.

Finally, in order to ensure a wound can heal, the flow of blood going to that wound must be adequate to keep it healthy. If circulation status is in question, testing needs to be performed to determine the nature of the circulation. If it is poor, then a vascular surgeon needs to be consulted to find a way to restore the circulation to an adequate level enough for the wound to heal.