Current Concepts In Diagnosing Chronic Diabetic Foot Ulcerations

Molly Judge, DPM, FACFAS

Offering pearls from the literature as well as her clinical experience, this author discusses the impact of infection, reviews common diabetic dermatopathology and notes other pertinent diagnostic keys.

Beginning with the initial patient presentation, there are a number of keys to manage chronic diabetic foot ulcerations. The first of these is the ability to make a definitive diagnosis.

   When a patient reports to the office with a concern about pre-ulcerative or ulcerative conditions, it is critical to determine the etiology of the condition and make an accurate diagnosis. To some, this may sound overly basic but it is not uncommon for a patient to report being treated for a prolonged period of time and never getting any better.

   Often when patients are asked if they received a diagnosis, they say the doctor told them they had an ulcer and that was the extent of the diagnosis. When asked about the plan for home care, patients often say they only got instructions to put antibiotic ointment and a bandage over the ulcer. Other patients will ask rhetorically, “What home care?”

   About 2.5 percent of patients with diabetes develop foot ulcers each year and foot ulcers are the most common cause of hospitalization for the patient with diabetes.1 Furthermore, 15 percent of diabetic foot ulcers result in amputation of the foot or leg.2

   Given these statistics, clinicians need to strive for an accurate, timely diagnosis, determining specific wound measurements and quickly beginning an aggressive wound management program. This typically includes the benefit of baseline radiographs and ancillary imaging when indicated. At the beginning of wound care planning, one should consider offloading the limb, systemic conditions such as enhanced glycemic control, dietary adjustments and neurovascular testing among other factors.

   When there is no suspicion of infection, the need for blood work becomes debatable. Baseline serologic testing may include complete blood cell count (CBC), C-reactive protein (CRP) and a complete metabolic profile as these patients often do not present regularly (if ever) for care by an internist. When treating a wound over time, there may come a point where the wound progress stalls or one suspects infection. At this point, it may be regrettable that one did not perform baseline serologic screening as neutropenia and hematologic imbalances can influence a patient’s ability to mount a sufficient immune response to infection. This is particularly true in the patient with diabetes.

Recognizing Acute, Chronic And Mechanical Wounds

The history of the condition will often shed light on the etiology. For instance, certain chief complaints often correlate with the etiology of the ulcerative condition.

   One must differentiate acute wounds from chronic wounds as they have a different prognostic potential. An acute wound caused by trauma breaks down intact skin. These wounds should have a predictable timetable to healing that correlates with the nature and extent of the injury. Acute injuries as a result of surgery, trivial trauma (abrasions, contusions) or otherwise (gunshot wounds or burns) often have a clinical course in healing that is predictable once the wound has become fully apparent.

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