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Diabetic Foot Wounds: Myths, Care & Healing
Dr. Wienke discusses common wound care myths, how to properly care for a wound and when should you seek a professional to examine it.
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Learn more about Jeffrey Wienke, Jr. DPM, CWSP
Jeffrey Wienke, Jr. DPM, CWSP
Dr. Wienke, originally from the Twin Cities in Minnesota, received his Bachelor of Science degree from Minnesota State University, Mankato in Exercise Science while also earning a Minor in Chemistry. From there, Dr. Wienke attended Des Moines University College of Podiatric Medicine and Surgery and earned his Doctor of Podiatric Medicine degree. He then completed a 3 year podiatric medicine and surgery residency with a reconstructive rearfoot and ankle certification at Trinity Regional Medical Center in Ft. Dodge, Iowa.Learn more about Jeffrey Wienke, Jr. DPM, CWSP
Transcription:
Diabetic Foot Wounds: Myths, Care & Healing
Melanie Cole, MS (Host): Welcome to Bryan Health podcast. I'm Melanie Cole and today we’re discussing foot care and wound care. Joining me is Dr. Jeffrey Wienke. He’s a podiatrist at Capital Foot and Ankle. Dr. Wienke, it’s a pleasure to have you join us today. So tell us what type of wounds you see in the wound clinic.
Jeffrey Wienke, Jr. DPM, CWSP (Guest): We really see a wide range of wounds there. Being a podiatrist, primarily the wound that we see most common is the diabetic foot ulcer. We also see wounds related to chronic venous insufficiency or swelling, surgical wound dehiscence, and even traumatic wounds.
Host: Why are diabetics at particularly higher risk of foot wounds and foot wounds that don’t heal?
Dr. Wienke: Well, that’s a great question. So most of the patients that we see that have foot wounds or foot ulcers at are at increased risk because they have what’s called diabetic peripheral neuropathy. So extended periods of elevated blood sugars will cause patients with diabetes to lose sensation in their feet. When that happens, if they were to step on an insulin needle or something sharp, stand on a hot piece of concrete, have a rock in their shoe, something like that they aren’t able to sense that and continue to walk or continue to stand there. Eventually the skin will break down. This can happen even from high pressure points in shoes. If a patient with diabetes has a pressure point underneath a spot in their foot and they can't feel that, they’ll continue to walk until the area becomes calloused or blistered and eventually breaks down and becomes an open ulcer. As far as the healing goes, elevated blood sugars also impede healing by a number of ways. Most commonly we see it with issues with the circulation.
Host: Well thank you for that answer. So let’s talk about some of the other wounds and some myths surrounding them when people see these wounds. I also would like you to tell us how often you want people to check their feet for these kinds of wounds, and what that means when you say check their feet. Speak about whether we’re soaking them or if alcohol disinfects them or if small wounds don’t always require treatment. Give us some of those myths and tell us how to properly check our feet.
Dr. Wienke: Well, excellent. This is one of the things I'm most passionate about and one of the things I get to lecture on most often are common myths and misconceptions involving wound healing. So you’ve hit on a couple of them. First involving alcohol or hydrogen peroxide. Those are both excellent first aid tools, but they really don’t have any place as far as wound care or wound healing goes. If you were to get a road rash, alcohol or hydrogen peroxide will disinfect the skin. Prolonged use of either of those is actually cytotoxic. So it kills both unhealthy cells and healthy cells and will slow would healing. So if you get a wound, especially a traumatic wound, it’s okay to rinse it off with hydrogen peroxide or alcohol, but then that should get put back in the cupboard. One of the other big ones you touched on is soaking. Soaking an open wound does a couple of things. Number one, it predisposes it to bacteria. Even if you put Epsom salts or something in your soak solution, you're still increasing your risk of infection.
The other issue actually goes to one of the third big wound myths we see in patients often believe that wounds need air to heal. I think we’ve been told that from our grandparents for generations and generations. What studies actually show is that a moist wound will heal up to five times faster than a dry wound. So soaking your foot or soaking a wound will dry it out, just like if you're washing dishes and you get those dishpan hands. It will suck the moisture out of the wound. So showering is great for wounds. It will rinse bacteria off and make it tough for bacteria to stick to the wound bed, but we don’t want to soak. Then as far as wound cares go, it’s important to talk to your doctor specifically about what they recommend. In general for a diabetic foot wound, we would want to donate moisture by applying some sort of topical medication. Then keeping that dressing on and covered 24 hours a day unless you're bathing or changing because, again, we want to keep that wound bed moist.
One of the other kind of last real big wound care myths is that diabetic foot wounds or open wounds need an antibiotic. The Infectious Disease Society of America came out with a position statement back in 2010. If there's no infection, we don’t want to take a culture of the wound. We don’t want to treat that with antibiotics. Patients with diabetes are already at increased risk of developing resistance with antibiotic. So we want to save those antibiotics only if and when the ulceration becomes infected.
Host: Very comprehensive approach and answer, Dr. Wienke. Does a scab mean the wound is healing?
Dr. Wienke: So a scab should be formed or is useful to form when we have what we call kind of a partial thickness wound. So, again, if you get a scrape, if you get road rash, if you get a wound that causes some bleeding but doesn’t break all the layers of the skin then a scab is great. It will protect the tissue underneath there and you want to leave that in place. The wounds that we’re talking about here are more chronic in nature. They're much, much deeper. If we allow a scab to form, the scab is going to contribute to drying of the wound bed. Again, that’s been shown to slow down wound healing. So part of what happens during a checkup with a wound expert is that the wound will likely be debrided. So we’ll use a scalpel or a tissue nipper or a curette and we will debride or remove and eschar or scab material, even callous material, from the top of the wound in order to allow the medication to penetrate and to keep that wound bed moist.
Host: Earlier you mentioned shoes and the pressure that they can put on. Tell us about shoes and socks and how they can contribute or help if somebody has a non-healing foot wound.
Dr. Wienke: So in general, if a patient does have a wound on their foot we actually more often than not would like them not to be wearing shoes at all. That may involve crutches or a wheelchair. It may involve a special walking boot. It may involve a cast, but in general in order to get a foot wound to heal we have to remove the pressure that caused the wound in the first place. Diabetic shoes are fantastic, but shoes—even custom inserts and custom diabetic shoes—have been shown not to be real effective at getting wounds to heal. Now, once we have healed a wound successfully then shoes are extraordinarily important. We want a very custom well-balanced insert to offload the high pressure areas of the foot. We want to pair that with a shoe that controls motion and is appropriate fitting in length, width and depth. So for most of my patients, once we’ve got a diabetic foot ulcer that was successfully healed we will transition a patient to custom inserts and custom offloading diabetic footwear in order to keep the wound healed. Again, patients with diabetes who have some neuropathy or decreased feeling can't sense if there's areas of pressure. They will likely re-ulcerate. In fact, 81% of the time they’ll break back open in the first two years. It’s imperative that we are very careful with the shoes and inserts that we wear in order to remove areas that are high in pressure, so the ulcer doesn’t come back. As far as socks go, patients with diabetes do need to be careful with their socks also. We want to try to avoid socks that have seams, again, that could rub on their feet or toes when they aren’t able to feel that. We want to be careful that we’re using a sock that’s going to help with removing any moisture from excessive sweating.
Host: Dr. Wienke, before we wrap up, when we’re thinking about what we want to keep on hand, do you prefer gauze or Band-Aids? Do you like Bacitracin or Neosporin? Do any of these kinds of things really matter in the big picture of taking care of our foot wounds so that they don’t become something that can really get dastardly?
Dr. Wienke: Yeah, absolutely. Until you see your doctor, if you have an open wound Bacitracin, Neosporin, a triple antibiotic ointment, all of those are going to be equally effective at donating moisture to the wound which is our goal. So any of those are fine. In the long term setting, I actually prefer a hydrogel which is just a normal saline like you get in an IV in a gel form. That way there’s nothing to react to, nothing to become allergic to, and nothing to become resistant to. As far as your question of having gauze or Band-Aids on hand, gauze is now a little bit outdated. We found that gauze will stick to the wound and will promote an inflammatory reaction which slows wound healing. So for most of my patients, I actually recommend an antibiotic ointment or a wound gel with a non-stick dressing like a Band-Aid. Any of those options are great until you get in to see your doctor and give the doctor a chance to evaluate the wound. Then maybe tailor the wound care depending on the ulcer. As far as having on hand, antibiotic ointment and a Band-Aid is a great first line treatment.
Host: So now summarize it for us with your best advice about foot wounds, checking out feet, the importance of checking our feet, and blood sugar levels even, and how we know when it’s time to see a professional to check that foot wound.
Dr. Wienke: So as far as the American Diabetic Association goes, they recommend any patient with diabetes have their feet checked at least annually by a doctor. Patients who have neuropathy or a lack of feeling in their feet then are at a substantially increased risk of complications and need to be screened more often. If a patient has diabetes and neuropathy, they should be checking their feet daily. One easy way to do that is just by applying lotion to their feet after show. That way you run your hands over your feet, and you'll feel with your hands if something new is going on in. I also recommend taking a handheld mirror like you use when you're checking the back of your hair and setting that on the floor in the restroom or the bedroom. Then patients can hold their foot up and be able to visualize the bottom of their foot and watch for problems as well. Again, as far as patients with diabetes and neuropathy goes as soon as they see something abnormal—whether it’s a blister, a cut, wound, bleeding—they really need to be seen as soon as possible. In my office, we have a policy where if a patient with diabetes calls in and says they’ve got a concern about a new wound or infection, one of our physicians will work them in immediately even that day because it’s so much easier to catch those problems early than have them wait and turn into something that’s much more problematic.
Host: Absolutely great advice. Thank you so much, Dr. Wienke, for coming on and sharing your incredible expertise with us today on good foot care and foot wounds. Thank you to our Bryan Foundation partner In Patient Physician Associates. That concludes this episode of Bryan Health podcast. Please visit our website at bryanhealth.org for more information and to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Bryan Health podcasts. I'm Melanie Cole.
Diabetic Foot Wounds: Myths, Care & Healing
Melanie Cole, MS (Host): Welcome to Bryan Health podcast. I'm Melanie Cole and today we’re discussing foot care and wound care. Joining me is Dr. Jeffrey Wienke. He’s a podiatrist at Capital Foot and Ankle. Dr. Wienke, it’s a pleasure to have you join us today. So tell us what type of wounds you see in the wound clinic.
Jeffrey Wienke, Jr. DPM, CWSP (Guest): We really see a wide range of wounds there. Being a podiatrist, primarily the wound that we see most common is the diabetic foot ulcer. We also see wounds related to chronic venous insufficiency or swelling, surgical wound dehiscence, and even traumatic wounds.
Host: Why are diabetics at particularly higher risk of foot wounds and foot wounds that don’t heal?
Dr. Wienke: Well, that’s a great question. So most of the patients that we see that have foot wounds or foot ulcers at are at increased risk because they have what’s called diabetic peripheral neuropathy. So extended periods of elevated blood sugars will cause patients with diabetes to lose sensation in their feet. When that happens, if they were to step on an insulin needle or something sharp, stand on a hot piece of concrete, have a rock in their shoe, something like that they aren’t able to sense that and continue to walk or continue to stand there. Eventually the skin will break down. This can happen even from high pressure points in shoes. If a patient with diabetes has a pressure point underneath a spot in their foot and they can't feel that, they’ll continue to walk until the area becomes calloused or blistered and eventually breaks down and becomes an open ulcer. As far as the healing goes, elevated blood sugars also impede healing by a number of ways. Most commonly we see it with issues with the circulation.
Host: Well thank you for that answer. So let’s talk about some of the other wounds and some myths surrounding them when people see these wounds. I also would like you to tell us how often you want people to check their feet for these kinds of wounds, and what that means when you say check their feet. Speak about whether we’re soaking them or if alcohol disinfects them or if small wounds don’t always require treatment. Give us some of those myths and tell us how to properly check our feet.
Dr. Wienke: Well, excellent. This is one of the things I'm most passionate about and one of the things I get to lecture on most often are common myths and misconceptions involving wound healing. So you’ve hit on a couple of them. First involving alcohol or hydrogen peroxide. Those are both excellent first aid tools, but they really don’t have any place as far as wound care or wound healing goes. If you were to get a road rash, alcohol or hydrogen peroxide will disinfect the skin. Prolonged use of either of those is actually cytotoxic. So it kills both unhealthy cells and healthy cells and will slow would healing. So if you get a wound, especially a traumatic wound, it’s okay to rinse it off with hydrogen peroxide or alcohol, but then that should get put back in the cupboard. One of the other big ones you touched on is soaking. Soaking an open wound does a couple of things. Number one, it predisposes it to bacteria. Even if you put Epsom salts or something in your soak solution, you're still increasing your risk of infection.
The other issue actually goes to one of the third big wound myths we see in patients often believe that wounds need air to heal. I think we’ve been told that from our grandparents for generations and generations. What studies actually show is that a moist wound will heal up to five times faster than a dry wound. So soaking your foot or soaking a wound will dry it out, just like if you're washing dishes and you get those dishpan hands. It will suck the moisture out of the wound. So showering is great for wounds. It will rinse bacteria off and make it tough for bacteria to stick to the wound bed, but we don’t want to soak. Then as far as wound cares go, it’s important to talk to your doctor specifically about what they recommend. In general for a diabetic foot wound, we would want to donate moisture by applying some sort of topical medication. Then keeping that dressing on and covered 24 hours a day unless you're bathing or changing because, again, we want to keep that wound bed moist.
One of the other kind of last real big wound care myths is that diabetic foot wounds or open wounds need an antibiotic. The Infectious Disease Society of America came out with a position statement back in 2010. If there's no infection, we don’t want to take a culture of the wound. We don’t want to treat that with antibiotics. Patients with diabetes are already at increased risk of developing resistance with antibiotic. So we want to save those antibiotics only if and when the ulceration becomes infected.
Host: Very comprehensive approach and answer, Dr. Wienke. Does a scab mean the wound is healing?
Dr. Wienke: So a scab should be formed or is useful to form when we have what we call kind of a partial thickness wound. So, again, if you get a scrape, if you get road rash, if you get a wound that causes some bleeding but doesn’t break all the layers of the skin then a scab is great. It will protect the tissue underneath there and you want to leave that in place. The wounds that we’re talking about here are more chronic in nature. They're much, much deeper. If we allow a scab to form, the scab is going to contribute to drying of the wound bed. Again, that’s been shown to slow down wound healing. So part of what happens during a checkup with a wound expert is that the wound will likely be debrided. So we’ll use a scalpel or a tissue nipper or a curette and we will debride or remove and eschar or scab material, even callous material, from the top of the wound in order to allow the medication to penetrate and to keep that wound bed moist.
Host: Earlier you mentioned shoes and the pressure that they can put on. Tell us about shoes and socks and how they can contribute or help if somebody has a non-healing foot wound.
Dr. Wienke: So in general, if a patient does have a wound on their foot we actually more often than not would like them not to be wearing shoes at all. That may involve crutches or a wheelchair. It may involve a special walking boot. It may involve a cast, but in general in order to get a foot wound to heal we have to remove the pressure that caused the wound in the first place. Diabetic shoes are fantastic, but shoes—even custom inserts and custom diabetic shoes—have been shown not to be real effective at getting wounds to heal. Now, once we have healed a wound successfully then shoes are extraordinarily important. We want a very custom well-balanced insert to offload the high pressure areas of the foot. We want to pair that with a shoe that controls motion and is appropriate fitting in length, width and depth. So for most of my patients, once we’ve got a diabetic foot ulcer that was successfully healed we will transition a patient to custom inserts and custom offloading diabetic footwear in order to keep the wound healed. Again, patients with diabetes who have some neuropathy or decreased feeling can't sense if there's areas of pressure. They will likely re-ulcerate. In fact, 81% of the time they’ll break back open in the first two years. It’s imperative that we are very careful with the shoes and inserts that we wear in order to remove areas that are high in pressure, so the ulcer doesn’t come back. As far as socks go, patients with diabetes do need to be careful with their socks also. We want to try to avoid socks that have seams, again, that could rub on their feet or toes when they aren’t able to feel that. We want to be careful that we’re using a sock that’s going to help with removing any moisture from excessive sweating.
Host: Dr. Wienke, before we wrap up, when we’re thinking about what we want to keep on hand, do you prefer gauze or Band-Aids? Do you like Bacitracin or Neosporin? Do any of these kinds of things really matter in the big picture of taking care of our foot wounds so that they don’t become something that can really get dastardly?
Dr. Wienke: Yeah, absolutely. Until you see your doctor, if you have an open wound Bacitracin, Neosporin, a triple antibiotic ointment, all of those are going to be equally effective at donating moisture to the wound which is our goal. So any of those are fine. In the long term setting, I actually prefer a hydrogel which is just a normal saline like you get in an IV in a gel form. That way there’s nothing to react to, nothing to become allergic to, and nothing to become resistant to. As far as your question of having gauze or Band-Aids on hand, gauze is now a little bit outdated. We found that gauze will stick to the wound and will promote an inflammatory reaction which slows wound healing. So for most of my patients, I actually recommend an antibiotic ointment or a wound gel with a non-stick dressing like a Band-Aid. Any of those options are great until you get in to see your doctor and give the doctor a chance to evaluate the wound. Then maybe tailor the wound care depending on the ulcer. As far as having on hand, antibiotic ointment and a Band-Aid is a great first line treatment.
Host: So now summarize it for us with your best advice about foot wounds, checking out feet, the importance of checking our feet, and blood sugar levels even, and how we know when it’s time to see a professional to check that foot wound.
Dr. Wienke: So as far as the American Diabetic Association goes, they recommend any patient with diabetes have their feet checked at least annually by a doctor. Patients who have neuropathy or a lack of feeling in their feet then are at a substantially increased risk of complications and need to be screened more often. If a patient has diabetes and neuropathy, they should be checking their feet daily. One easy way to do that is just by applying lotion to their feet after show. That way you run your hands over your feet, and you'll feel with your hands if something new is going on in. I also recommend taking a handheld mirror like you use when you're checking the back of your hair and setting that on the floor in the restroom or the bedroom. Then patients can hold their foot up and be able to visualize the bottom of their foot and watch for problems as well. Again, as far as patients with diabetes and neuropathy goes as soon as they see something abnormal—whether it’s a blister, a cut, wound, bleeding—they really need to be seen as soon as possible. In my office, we have a policy where if a patient with diabetes calls in and says they’ve got a concern about a new wound or infection, one of our physicians will work them in immediately even that day because it’s so much easier to catch those problems early than have them wait and turn into something that’s much more problematic.
Host: Absolutely great advice. Thank you so much, Dr. Wienke, for coming on and sharing your incredible expertise with us today on good foot care and foot wounds. Thank you to our Bryan Foundation partner In Patient Physician Associates. That concludes this episode of Bryan Health podcast. Please visit our website at bryanhealth.org for more information and to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Bryan Health podcasts. I'm Melanie Cole.