Proactive Measures To Prevent Diabetic Complications
Focal Pressure Keratosis: A Common Precursor To Ulceration
In a position statement on diabetic foot care, the American Diabetes Association (ADA) has identified four conditions that are associated with an increased risk of amputation.4 These conditions include: • Peripheral neuropathy • Altered biomechanics (i.e., pressure callus, limited joint mobility, bony deformity or severe nail pathology) • Peripheral vascular disease • History of ulcer or amputation Patients exhibiting any of these conditions have an abnormality that requires regular podiatric evaluation and management. In particular, a pressure callus or focal pressure keratosis frequently can lead to ulcerations that fail to heal in the neuropathic patient. These patients can have even more problems healing if they have PAD as well. In 2001, our group at Loyola University Chicago and Hines VA Hospital published a study in the Journal of the American Podiatric Medical Association (JAPMA) in which we reviewed 233 cases of diabetic foot ulceration admitted to our hospitals over a seven-year period.5 We found that 82 percent of these ulcers were preceded by a focal pressure keratosis. Those patients who had frequent outpatient podiatric care had significantly lower grade ulcerations and were significantly less likely to require any form of surgical intervention. Conversely, the worst ulcerations were those without documentation of any prior podiatric care. The frequency of podiatric visits depends on the severity of the abnormality and the degree of intervention necessary to control the ulcer risk. Some patients with severe hemorrhagic keratosis under an isolated metatarsal head may require monthly debridement of the keratosis or perhaps biweekly debridement in order to prevent ulceration. In my experience, debridement is extremely effective in preventing ulceration, infection, hospitalization and amputation. Managing a focal pressure keratosis is critical. Debridement of chronic pressure keratosis at appropriate intervals can prevent ulceration and decrease hospitalizations and amputations. The natural history of untreated pressure callus in a diabetic neuropathic patient is ulceration, infection and amputation. The minor trauma associated with focal pressure callus leading to ulceration, faulty healing, infection and amputation is a classic example of Pecoraro’s triad, which he suggested is responsible for 80 percent of all diabetes-related amputations.4
Emphasizing Appropriate Shoegear And Patient Education
In addition to debridement of the keratosis or ulcer, we found in the aforementioned JAPMA review that the prescription of protective shoes and patient education were effective in decreasing ulcer grade.5 One should provide each of these elements of care during the podiatric evaluation and management visit. Pressure relieving shoes and orthotics help lower the risk of ulceration. Clinicians should also make a point of educating the patient at every visit. Explain the potential impact of neuropathy. Emphasize the importance of visual foot exams at home. Review good skin care and hygiene principles. Encourage compliance with diabetes control and cardiovascular risk reduction measures. Explain the indications for professional treatment. Recommend appropriate intervals for office visits.