Dry skin, interdigital fissuring and forefoot plantar hyperkeratosis are all signs and symptoms that may predispose patients to forefoot ulcerations. A diabetic lower extremity examination may seem routine but documenting and addressing these seemingly small changes may deter the devastating effects of peripheral neuropathy. Moisture balance therapy, accommodative shoe gear and routine diabetic foot care remain important factors in the preventative care of the diabetic population.
Essential Principles In Treating Diabetic Forefoot Ulcers
Emphasizing The Importance Of Optimizing Glycemic Control And Vascular Supply
Optimizing glycemic control is often a difficult task in patients with diabetes. Hyperglycemia leads to microvascular complications, retinopathy, renal disease and poor wound healing.29 Tight control of glucose levels is necessary to prevent diabetic complications that predispose the patient to neuropathy, ischemia and infection. Multiple authors have demonstrated that tight glycemic control decreases complications, lowers the HbA1c and decreases wound healing time.29,30 This in turn will decrease the portal of entry time for infection and increase a patient’s quality of life. Game and colleagues noted that “A patient with glycosylated hemoglobin of >8% and an average daily glucose of >250 mg/dL will experience prolonged wound healing.”31
In your clinical assessment, it is imperative to conduct a thorough vascular evaluation with palpation of all lower extremity pulses.32 One can also confirm these pulses with the use of a Doppler waveform. If there is suspicion of vascular insufficiency, a reproducible and quantitative vascular assessment would be appropriate by evaluating a patient’s ankle brachial index (ABI) as well as his or her toe brachial index (TBI).28 Clinicians should perform transcutaneous partial pressure of oxygen testing (TcPO2) if the patient has a chronic wound with palpable pedal pulses and no macrovascular disease. This microvascular analysis will help assess whether hyperbaric oxygen therapy (HBOT) will be beneficial.31
If you consider the patient to be at risk of significant vascular disease, consider a referral for therapeutic revascularization as vascular supply is essential to wound healing.28
Performing Debridement And Addressing Potential Infection
Debridement is the first step in wound bed preparation and activating the healing process. Aggressive surgical debridement enables one to transform a chronic wound into an acute wound by removing all necrotic dysfunctional tissue, restoring normal moisture balances, controlling bacterial loads and resetting the healing cascade at the wound border to a surface that is primed for subsequent healing.33 Aggressive surgical debridement in acute wounds is equally important to remove necrotic damaged tissues as well as any foreign materials.
Many diabetic wounds are stuck in a chronic inflammatory state. The presence of infection in either the soft tissue or bone prolongs the inflammatory phase of wound healing. Steed noted that “Increased levels of bacterial proteases break down endogenous growth factors and membrane receptor sites on the surface of cells involved in the healing process.”34 Taking a simple culture or tissue specimen can determine the organism(s) responsible for infection. Once you have identified the organism, you can select the appropriate antibiotic coverage and secondary wound healing can proceed.35