Examining The Evidence For Preventing Diabetic Foot Ulcers

Clinical Editor: Lawrence Karlock, DPM

Dr. Habershaw concurs, noting that evidence-based medicine says patients are at risk for ulceration and limb loss if they have clinically diminished protective sensory loss via screening with a Semmes-Weinstein 5.07 filament, 10 years or more of diabetes, poor glycemic control, a history or symptoms of vascular disease, extremity bypass, endovascular surgery or impaired vision. He says other risk factors include: structural abnormalities such as calluses, hammertoes, pes planus/ cavus, or bunions; reduced joint mobility; dry or fissured skin; chronic tinea; or severe onychomycosis.
Greg Mowen, DPM, cites evidence from the Center for Lower Extremity Ambulatory Research (CLEAR), which developed a foot risk classification system and treatment recommendations that rank patients from 0 (no loss of protective sensation) to 3 (prior ulceration or amputation).

Q: What does the evidence show about what works for foot ulcer prevention in patients with diabetes?
A: Home foot temperature monitoring can be effective in preventing ulcers, according to Dr. Bevilacqua. He notes a study by Armstrong, et al., in which the dermal thermometry group underwent monitoring with an infrared thermometer that measured temperatures on the sole of their foot. Temperatures of >4º F were considered to be “at-risk” and Dr. Bevilacqua says researchers found subjects were one-third as likely to ulcerate in the dermal thermometry group in comparison to the standard therapy group.15
Furthermore, Dr. Karlock cites Lavery’s 15-month multicenter study, in which patients had standard footcare, education and footwear were 4.37 times more likely to develop foot ulcers in comparison to those who underwent skin temperature monitoring.16
The panelists also emphasize the importance of a multidisciplinary team approach in preventing ulcers.2 Dr. Habershaw cites the efficacy of routine, regular follow-up visits and care at a “team-oriented” diabetes care center. He says this team would include endocrinology, vascular medicine and surgery, podiatry, nutrition, exercise counseling, eye care and a diabetes teaching nurse. Specifically for podiatry, he notes the importance of routine foot care, monitoring of shoes and orthotics, skin care, and education about foot self-care. Dr. Zgonis says specialist teams can educate patients and family members on properly managing glucose, the importance of foot care and the prompt recognition of sores or pre-ulcerative lesions.
When the skin becomes compromised, he says early, aggressive treatment is essential. Offloading, infection control, vascular workup, metabolic control of glucose, heart, renal and nutrition care are a part of his care regimen. Dr. Habershaw says continued ulcer deterioration warrants early surgical intervention whether it is vascular, reconstructive or both.
Dr. Zgonis cites evidence in the literature showing that preventing diabetic foot ulcers starts with the screening measurements for neuropathy and peripheral vascular disease.17,18 In addition, he notes that researchers have also shown that preventive care increases the survival rate and reduces the rate of ulcerations in patients with diabetes.2,19,20
Dr. Mowen thinks most doctors will do more screening for LOPS and PAD. He says DPMs usually have taught patients to do self-inspection with the use of a mirror and even self sensory evaluation with 5.07 monofilaments. Along these lines, he notes early intervention and offloading of “problem” or “pre-ulcerative” areas have been at least anecdotally beneficial.

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