My first podiatric mentor, Leonard Levy, DPM, challenged me to always practice to the furthest extent of my license. From day one of my education, Dr. Levy advised: Do the right thing for your patient first and, if necessary, ask for forgiveness later.
I should probably mention now that my first mentor, Dr. Levy, is currently serving a Fulbright Fellowship, the first ever by a podiatrist. Dr Levy is now in his seventies. Remarkable, isn’t it?
Along those lines, I would like to share the following article with my fellow podiatrists. Reporting on three cases, Kalinchenko and colleagues discuss the use of testosterone in treating patients with diabetic foot ulcers (DFUs) and peripheral arterial disease (PAD).1 Some will say that this course of treatment is far beyond our scope of practice. Others will be challenged by it and embrace the possibilities. I throw it out there as a possible answer to the wounds that challenge us, those wounds that confound us on a daily basis.
These Russian authors discovered a unique, previously undiscovered mechanism of action, namely “ … an inverse relation between plasma testosterone and insulin sensitivity, type 2 diabetes mellitus and HbA1c concentrations.”
These authors found in meta-analyses that diabetic men have lower serum testosterone concentrations than men without diabetes. Up to one-half of all men who experience type 2 diabetes mellitus are now recognized as being testosterone deficient.
These authors found that testosterone treatments reverse some particular key aspects of metabolic syndrome. Low plasma testosterone level appeared to be associated with endothelial dysfunction in men.
This is one association that we, as podiatrists, have not investigated in detail. However, with this hint of a possible relationship, I imagine that in no time there will be multiple studies in the future between testosterone levels and recalcitrant diabetic foot wounds.
As a diabetic foot researcher, it is exciting to me that there is another pathway for investigation that has been opened up for us. Now is there is a DPM researcher who is brave enough to walk through this door to investigate this new pathway?
Apparently, it comes down to the normalization of serum testosterone levels, an improvement of hyperglycemia, the corresponding decrease of leukocytes and fibrinogen increase of antithrombin III activity, and eventual tissue oxygen pressure. Eventually, these changes help create a granulation bed in the diabetic wound as all effects of the treatment with testosterone reportedly improve vascularization and create anti-inflammatory effects.
Perhaps there is an entirely new spectrum of treatment that podiatry has not yet considered for patients with DFUs and PAD. I would venture to say that there are those of us out there in podiatry who are open to these non-traditional approaches to wound care. The Reyzelmans, Armstrongs, Laverys, Harklesses, Drivers, Wus and others along those lines have been trained to buck tradition and look for answers where others have not looked before. If an injection of testosterone may help to heal a diabetic foot wound, I know that the aforementioned researchers would be more than willing to give it a try.
I invite their comments and those of others to see if they think this is a pathway worth pursuing.
1. Kalinchenko S, Zemlyanoy A, Gooren LJ. Improvement of the diabetic foot upon testosterone administration to hypogonadal men with peripheral arterial disease. Report of three cases. Cardiovasc Diabetol 8:19, 2009.