Play PodcastPlay Download PodcastDownload

Transcription:

Melanie Cole, MS (Host): Minor foot problems such as blisters or cuts can cause complications if left unattended, and even more so in people with diabetes. Welcome to The GW HealthCast. I'm Melanie Cole. Today’s topic is the prevention and treatment of foot wounds in diabetic patients. My guest is Dr. Michael Stempel. He’s the chief in the division of podiatry and the director of the podiatry center at the George Washington Medical Faculty associates and he’s an assistant professor of surgery at the GW University School of Medicine and Health Sciences and is affiliated with The George Washington University Hospital. Dr. Stempel, I'm so glad to have you with us today. What a great topic. Tell us what foot problems can be caused by diabetes and why do diabetics have this special issue?

Michael Stempel DPM, FACFAS (Guest): The issues that diabetics run into are usually related to a loss of sensation in their feet. They can often start off as the same type of foot issues that the general population would have. However, as a side effect of poorly controlled blood sugar over time, they lose sensation in their feet and are unaware of the extent of the damage that’s occurring to their skin. So small issues, such as an ingrown nail or a blister or a cut, can turn into a deep wound or infection that threatens their limb.

Host: So they lose that ability to feel these things. Then what can they do? Before we get into some of the treatment for these wounds, tell us about your best advice, really, for prevention and healthy feet in diabetics.

Dr. Stempel: Well what we emphasize right away with any opportunity to meet, speak, or examine a diabetic patient is that they develop a routine of preventive management. Of course, we also encourage them to do the best they can to work with their doctors to control their blood sugar because that’s ultimately what’s going to determine how at risk they are over time. But daily practices such as checking your feet in good light, being careful about what shoes you wear, avoiding walking barefoot especially in areas like such as outdoors or in the yard is the general advice that we give every diabetic patient even when they're just newly diagnosed without any particular risk or loss of sensation.

Host: You mentioned shoes. Let’s kind of start there and socks. Give us some of the dos and don’ts. I mean are there certain shoes that you don’t want diabetics wearing? Or socks? Any particular material that can hold in moisture and possibly cause more problems?

Dr. Stempel: Well, the advice that I give to diabetics and especially diabetics who have lost sensation isn’t necessarily that different than the advice I would give to the general population, which is that they should get their feet measured, make sure that they're actually in the correct shoe. It’s amazingly common that patients will be wearing the same shoe size that they were when they were 21 when they’re in their 50s. It’s commonly seen that their foot size will increase by one or two sizes, especially if there’s been a gain of weight or other foot deformities. So people wear the incorrect size. Especially if they’ve lost some sensation in their feet, they may not even perceive that the shoe is too tight at all.

Also that the shoe be well designed for what they're using it for. So if you're doing a lot of walking or standing such as at work or as a form of exercise that the shoe should be designed for that and in good condition. Another issue that I often will see that patients love their pair of shoes to death, wearing them out excessively. As the shoe wears out unevenly, it causes pressure points and rubbing. It also sets them up for just more common foot issues, such as tendonitis and heel pain and things like that.

Also, the issue of avoiding high heels and shoes that are just ill considered in general. Nobody wants to hear that they shouldn’t wear their cute shoes anymore, but the reality is that shoes that are excessively narrow, pointy, a heel height greater than an inch or so is going to put more and more pressure on the front part of the foot. That’s the area where patients with neuropathy are most likely to develop wounds.

You also mentioned in terms of socks. There’s this traditional advice of cotton white socks. With modern dyes and the like, as long as the sock is well made the color isn’t really the issue. Socks that are designed to wick moisture off of the skin, that have extra padding in the area of the heel or the toe, that doesn’t have seems across the toe where they can cause pressure or rubbing are general advice. In general, thing nylons and things like minimally thick socks that cause extra friction or pressure and don’t wick moisture off the skin can be an aggravating factor, especially in tight dress shoes.

Host: So before we talk about treatment options, what should we be on the look out? When you say examine your feet, what do you really want them to look out for and what are some red flags of a wound that is not healing properly?

Dr. Stempel: Yeah, that’s a very good question. Patients ask what is it that they're looking for. The first thing would just be anything that they haven’t seen before. So if there was a blister, a red spot, an area that looks like there's been drainage—like a crusted spot of blood on the skin—those are obvious red flags. Certainly if there’s something that’s bleeding or open. But it may be more subtle than that, especially in patients who have lost protective sensation or have diminished blood flow to their foot. Small injuries often are more significant than they appear. The best advice that I can give somebody is that if they're not sure what they’re looking at, get it looked at. That they should see their primary care provider. That they should see their podiatrist. That they should call and say, “I am diabetic, and I see something on my foot and I'm not sure what’s going on.”

Short of that, if there’s a blister, if there’s kind of puffiness under a callous, if there’s redness or discoloration or even more alarming would be a bruise or dark appearance underneath a corn or a callous. Basically anywhere where there’s a corn or a callous is a pressure point in the foot. So if the toe is rubbing against the shoe, if the side of the joint is rubbing against the shoe, if there’s a callous on the ball of the foot, those all represent pressure points. So in a patient who has lost sensation, those are the most likely spots to first cause trouble just from daily walking and activity.

There's also the things that people will induce in themselves such as sitting on the edge of their bathtub with a razor blade or using cuticle scissors to carve out callouses and corns. Stuff that they may have done for years before they had diabetes might not have been the wisest things, but now has become a very dangerous. A lot of times these issues are self-inflicted.

In terms of the presence of an actual wound—so if there is an open area of skin—that’s something that should be professionally valuated right away within days. If you clean the area with peroxide and put some topical antibiotic ointment and cover it with Band-Aid and clean it up, that’s fine. In terms of getting it checked or evaluated, especially if you’ve had a history of wounds in the past or you know that you're having issues with numbness or poor circulation in your feet, don’t even hesitate to get it checked.

Host: Then let’s talk about what happens when you get it checked. What treatment options do you use? You mentioned clearing it themselves and using antibiotic ointment and covering it. What would you do first if you get one of those wounds? Tell us about some of the treatment options that you have available.

Dr. Stempel: Well, a lot of times what patients initially will do—or for months on end sometimes on their own—is that they’ll treat a skin ulcer—and that’s what we’re referring to. These wounds are an actual loss of skin. There's a whole in the skin. It’s not a scrape or abrasion. What I’ll explain to patients is it’s not like when you were a kid and you skinned your knee. You don’t let it dry. You don’t let it form a scab. It’s not going to heal that way. These wounds are a complete hole through the skin. They're only going to heal from the edges, and they will only heal from the edges when there is healthy, clean tissue that can support growth of skin. So it’s a very fragile wound that’s vulnerable to pressure, first and foremost, but also any harsh chemicals. So once you clean the wound, you don’t keep putting peroxide on it. You don’t keep putting iodine on it. You don’t use strong astringents or let it sit open to air. What happens is the wound that’s trying to generate new skin and blood vessels is actually going to kind of shrink and die in response to that, and especially if there’s poor circulation to begin with.

So when I see a patient with a wound, the first thing we do is to immediately evaluate for the presence of infection. We’ll often get an x-ray to see if there’s any changes underneath the skin involving the bones or the joints and check the circulation and blood flow. If there isn’t adequate blood flow, the body will not be able to clear infection and won't be able to heal the wound. Once we've checked for these things—and assuming that there isn’t something more serious going on that requires immediate hospitalization, such as if there was an abscess or a deeper infection—we’ll then focus on getting pressure and weight off of the wound.

So once we clean up the wound, we try to keep it clean and keep it protected. Because it’s the foot, putting that foot back into a tight shoe or walking on it repeatedly throughout the day will cause the wound to rapidly worsen. Much of what we focus on when treating patients in our wound center is basically choosing the appropriate therapy to keep the wound moist, clean, healthy, free of infection, and to limit any weight and pressure.

Host: Tell us about some of those therapies. People have heard the term HBOT. Tell us about some of the therapies available.

Dr. Stempel: Well HBOT, which is hyperbaric oxygen therapy, is one of our more advanced treatment modalities. We start with the mainstay, as I was just describing, of basically first assessing the wound and dealing with any immediate risk for infection and excessive pressure. But when wounds are more complex, then we use other things to help facilitate the healing process. So we have devices such as a negative pressure dressing, which is commonly called a wound vac that puts suction and deforming stress on the skin to help tissue grow faster.

We have hyperbaric oxygen therapy, which is an hour to hour and a half treatment in a pressurized oxygen chamber. It increases the amount of oxygen available in the blood and that can facilitate healing and facilitate treatment of complex infections. We have tissue grafts that are grown in the lab as well as various types of collagen grafts and other high tech dressings that basically wick moisture off of the wound and have antibiotic properties without being excessively harsh or topic to fragile wound tissue.

Host: Dr. Stempel, with all these treatment options available and so much of your good advice—and no diabetic wants to hear this—but when does surgery become that discussion?

Dr. Stempel: Well, you know, the sad thing is is that often I've had patients—way too often—I've had patients who are afraid to come in because of advice that they’ve heard in their community or from family. “Don’t let them start cutting on you because once they start cutting on you, then you're just going to lose your leg.” They don’t understand that they're creating their own reality that is guaranteeing the worst case scenario. If there is an infection, it needs to be drained. That involves surgery. If there is advanced destruction of bone that’s threatening the rest of the foot or the leg, then that’s a case where we need to do surgery.

I liken it fighting a forest fire. Sometimes you have to sacrifice one part of the forest in order to save the rest of the forest. So if the fire is burning out of control in one area, it’s only going to spread. So I will explain to patients that we need to eliminate the infection where it is right now because if it’s left to it’s own devices, it will continue to spread. Separate from infection, sometimes wounds just need to be debrided. What debridement is is basically using surgical instruments to clean away tissue that’s unable to heal. Basically tissues that’s been damaged or is unhealthy or doesn’t have adequate blood flow. So by removing what’s unhealthy, we’re allowing the healthy tissue to recover. So I try to break it down in terms of taking steps along a path that while the immediate step that we’re taking may seem scary, we’re trying to avoid the more dangerous and truly scary things such as amputation that would come from neglect of care.

Host: Wow. What great information. So well put. Dr. Stempel, wrap it up for us. Your best advice for diabetic patients and good foot health. It’s so important. Tell them what you tell everybody every single day and what you’d like them to know.

Dr. Stempel: Well, the number one thing is actually not to do with the feet. It’s to learn and know what your hemoglobin A1C is and keep track of that number. Patients often will rely on doing random blood sugars, and a lot of times they’ll just kind of lull themselves into a false sense of security. I’ll say how are you doing. They'll say, “Oh, I'm doing fine. My numbers have been pretty good lately.” Then we get their hemoglobin A1C and they have a value that’s several points above normal. So even though they thought they're doing well, they weren’t. Patients with elevated A1Cs, above eight, above nine, are destined to losing sensation in their feet and having poor blood flow. Ultimately when I see patients that are in that category, quite often they're already deep in a whole that makes it harder for me to help them.

So first and foremost is diabetes control. Being honest with yourself, working with your doctors. Number two would be basic preventive management of your feet. Seeing a podiatrist, getting your feet screened, checking your feet on a regular basis, and reporting anything that becomes out of the norm. anything unusual. Certainly any redness, any swelling, any drainage that this is an emergency. Someone else’s eyes should be on it. If it’s nothing, they’ll be happy to tell you it’s nothing.

Host: Thank you so much Dr. Stempel for coming on with us today, sharing your expertise. What great information. So important for diabetics to hear and for their loved ones to help them keep track and keep healthy feet. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Stempel or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. Until next time, this is Melanie Cole.