Current Concepts In Diagnosing Chronic Diabetic Foot Ulcerations

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What About Chronic Venous Stasis Ulcerations?

When patients report their history in a particular way, one can suspect chronic venous stasis ulceration. Often, this description will include discomfort that patients report as a deep aching sensation within their legs.

• “I had to stop wearing my compression stockings because they were making my legs swell.”
• “I just began noticing drainage on my stockings.”
• “I noticed water blisters on my legs but did not know what to do about them. Now I have sores on my legs that just will not heal.”

Fluid retention within the legs, ankles or feet is a hallmark of this condition. The pathomechanics for venous ulcer development includes inflammation that stimulates leukocyte activation, endothelial damage, platelet aggregation and intracellular edema. That sounds an awful lot like the mechanism for blood clot formation. Among the risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis and phlebitis.

In this instance, the chronic condition is venous stasis, not necessarily the ulceration. Often occurring on the medial ankle and associated with chronic pain, venous stasis ulcerations require therapy to address the wound as well as mechanisms to address fluid retention in the limb to reverse the process successfully. At times, the medical team employs medications to encourage diuresis when appropriate.

The use of compression hose is the mainstay in long-term management of venous stasis ulcers. Often, these modalities range from 20 mmHg compression to 30 mmHg compression. While elevation, the use of compression hose and local wound care can be effective, the risk and rate of recurrent ulceration is a reality. Researchers have demonstrated that surgical correction of superficial venous reflux reduces 12-month ulcer recurrence.46 In that study, the authors concluded that most patients with chronic venous stasis ulcerations will benefit from simple venous surgery. This conclusion was evident in the fact that 12-month ulcer recurrence rates were significantly reduced in the compression hose and surgery group in comparison to compression therapy alone (12 versus 28 percent).

With this in mind, I cannot overstate the importance of getting a vascular surgery consultation in the case of chronic venous stasis complicated by ulceration. Considering the data that 1 to 2 percent of the population will suffer from chronic venous ulceration, delayed healing times and increased incidence of recurrence are predictable.47,48 Recurrence rates are reportedly as high as 26 to 28 percent and one study reported a 68 percent recurrence rate.46,48-51 As many as 10 percent of the U.S. population may suffer from valvular incompetence in the venous system and 0.2 percent of those patients may develop an ulceration.52 It is understood that recurrent ulceration may occur in as many as 70 percent of those at risk.52

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Molly Judge, DPM, FACFAS

   Diabetic thick skin. When it comes to skin changes that include thickening of the dermis, clinicians can divide this into three main categories: scleroderma-like (commonly in the hand and often accompanied by stiff joints); measurable skin thickness that is clinically insignificant; and scleredema diabeticorum. Thickening of the dorsum of the hands may occur in a third of patients with diabetes.23

   The pathogenesis of diabetic thick skin has not been clearly defined. One theory suggests that polyol accumulation results in the hydration of collagen and subsequently leads to thickened skin.25,33 Another viable theory is that there is a non-enzymatic glycosylation of collagen.27,34 While there are suggested therapies for simple diabetic thick skin, there is no specifically indicated treatment. However, it is intuitive that tight glycemic control could be beneficial and the literature has supported this.35

Pertinent Insights On Neurotrophic Ulcerations

Neurotrophic ulceration. One may suspect diabetic neuropathy when the patient reports the history in a particular way. Consider some of the following examples you may hear from patients.

• “I just began noticing drainage on my socks and had been wondering where it was coming from.”
• “I could tell that my foot was changing shape and it got a lot fatter and more red looking than the other foot.”
• “I have always had this callus but it never hurt. Now it has gotten dark brown and is draining.”
• “It looks like it should hurt but I do not feel it.”
• “My pet began licking my foot and has been doing that more and more often.”

   Often when patients describe purely visual clues in the history of a wound rather than tactile information such as pain, this validates the finding of loss of protective sensation. Regarding neuropathic diabetic foot ulcers, researchers have developed a standard protocol.36 The stepwise approach in this protocol includes a seven-step process beginning with wound measurement; enhanced glycemic control; surgical debridement of necrotic, keratotic and infected tissue; systemic antibiotics when deep infection, drainage or cellulitis are present; offloading of the limb; maintaining a moist wound bed; and treatment with growth factors and cellular therapy if the wound is not healing (not producing a new epithelial layer) after two weeks of care.

   Since as many as 15 percent of diabetic foot ulcers result in amputation of the foot or leg, protocols such as this are beneficial from a practical perspective and aid in the day-to-day management of patients with diabetic foot ulcers including neuropathic ulcers.2,37 At the time that this protocol was published, the prevalence of foot ulcers in the diabetic population was 12 percent and the five-year mortality rate of diabetes-induced limb amputations ranged between 39 and 68 percent.38

   These patients remain at an increased risk for subsequent amputations and when considering the overall cost of care, the statistics published by the National Institutes of Health (NIH) indicate that hospital length of stay is approximately 60 percent longer among patients with diabetic foot ulcers in comparison to those without ulcers.40

   Historically, researchers have devised wound care initiatives with the intent to improve the wound healing rate, reduce the incidence of infection and ultimately reduce the incidence of amputations resulting from ulcerations in the diabetic population specifically.40-44 Critical to the success of any wound care initiative is a decisive program for offloading the limb and detailed patient education that mandates full patient cooperation in the plan.

Addressing Traumatic Ulcerations

Traumatic ulceration. One may suspect a traumatic ulceration when patients report the history in a particular way. Here are just a couple of examples.

• “I hit my shin on the coffee table and the sore just will not get better.”
• “The dog’s chain got wrapped around my leg and as I was trying to get the chain off the dog was trying to run away.”
• “I fell and scraped my ankle on the concrete.”

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