Foot Care for Diabetics

[Guest guest]

(Like Jenn says, all things in moderation. This shows Dr. Bernstein does

have some excellent advice. I especially like the bottom suggestion of a

tickler file to reread things like this every few months. I would also

suggest that include the article Harry wrote, which I will post under

separate subject, as there are a few new people on the list. At the bottom,

I will include the link where I got this article. ESS)

Foot Care for Diabetics

K. Bernstein MD, FACE, FACN, FCCWS

4 August 2008

The incidence of limb-threatening ulcerations in diabetics is very high,

affecting approximately one in six to seven patients. Non-healing " diabetic "

ulcers are the major cause of leg, foot, and toe amputations in this

country, after traumatic injuries such as motor vehicle accidents. These

ulcerations do not occur spontaneously; they are always preceded by gradual

or sudden injury to the skin by some external factor. Preventing such

injuries can prevent their sad consequences.

Virtually all diabetics who have experienced ongoing higher-than-normal

blood sugars for more than five years suffer some loss of sensitivity in

their feet to pain, pressure, and temperature. This is because prolonged

blood sugar elevation can injure and eventually destroy all sensory nerves

in the feet (sensory neuropathy). Furthermore, the nerves that control the

shape of the foot are likewise injured, with a resultant deformity that

includes " claw " or " hammer " toes, high arch, and prominent heads of bones at

the bases of the toes on the underside of the foot. The nerves that

stimulate perspiration in the feet are also affected. This results in the

classic dry, often cracked skin that we see on diabetic feet. Dry skin is

both more easily damaged and slower to heal than is normal moist skin, and

cracks permit entry of infectious bacteria.

Long-term, elevated blood sugar also may cause impairment of circulation in

the major arteries of the legs, as well as in the minor arteries and small

capillary blood vessels that supply the skin of the feet. In order to heal,

injured skin can require fifty times the blood flow of normal skin. If this

increase in flow is unavailable, the injury will probably deteriorate,

becoming gangrenous, and facilitate an infection that spreads up the leg.

This infection may not respond to antibiotics.

Blood circulation to the normal foot can readily increase one hundredfold,

if necessary, in order to conduct the heat of warm objects away from the

skin. Impaired circulation may make this impossible, and the resultant burn

may not even cause pain.

A deformed foot with bony prominences (knuckles of toes, tips of toes,

heels, and metatarsal heads at soles) may be continually rubbed or pressed

by shoes. This foot is frequently unable to perceive the extent of such

pressure and may not heal readily if injured. It can be burned at relatively

low temperatures. Impaired circulation likewise can prevent the warming of

cold feet so that prolonged exposure to cold can cause frostbite.

The following guidelines are therefore essential for all diabetics, to

prevent foot injury and the potentially grave consequences that may ensue:

1. Never walk barefoot, either indoors or out.

2. Purchase shoes or sneakers late in the day, when foot size is the

greatest. Shoes must be comfortable at the first wearing and should not

require breaking in. Request shoes with deep, wide toe boxes. Pointed-toe

shoes should not be worn, even if the tips are blunted. Some dress shoes

are now available with wide, deep toe boxes. A number of currently available

brands of athletic shoes and walking shoes are especially accommodating and

even have removable insoles so that orthotics (see below) will fit, without

making the shoe too tight. If necessary, I prescribe orthopedic or custom

oxfords for certain of my patients.

3. Inspect the insides of your shoes daily for foreign objects, torn

lining, protruding nails, or bumps. Have them repaired if you find any of

these.

4. Don't wear sandals with thongs between the toes.

5. Try to try alternate at least two different pairs of shoes every few

days.

6. Ideally, your feet should be examined daily for possible injury or

signs of excessive rubbing or pressure from shoes—blisters, cracks or other

openings in the skin, pink spots, or calluses. Be sure to check between your

toes. Inspect your soles. If necessary, use a mirror or ask another person

to check them. Contact your physician immediately if any of these signs are

found.

7. If the skin of your feet is dry, lubricate the entire foot. Suitable

lubricants include olive oil, any vegetable oil, vitamin E oil, emu oil,

mink oil, and emulsified lanolin. Many oils and lotions that contain these

products as major ingredients are available commercially. Do not use

petroleum jelly (Vaseline), mineral oil, or baby oil, as they are not

absorbed by the skin.

8. Do not smoke cigarettes. Nicotine can cause closure of the valves

that permit blood to enter the small vessels that nourish the skin.

9. Keep feet away from heat. Therefore no heating pads, hot water

bottles, or electric blankets. Do not place feet near sources of warmth such

as radiators or fireplaces. Baths and showers should feel cool—not even

lukewarm. Temperature should be estimated with your hand or a bath

thermometer, not with your feet. Water temperature should be less than 92°F,

as even this temperature can cause burns when circulation is impaired. A

bath thermometer is suggested.

10. Wear warm socks and shoes of adequate size when outside in cold

weather. It is wise for all diabetics to have the circulation in their feet

measured every few years. If circulation is impaired, do not remain in the

cold for more than twenty minutes at a time.

11. Do not soak your feet in water for more than 3-4 minutes, even if so

instructed by a physician. This causes macerated skin, which breaks down

more easily and doesn't heal well. When bathing or showering, get in, get

washed, and get out. Don't soak. Beware of rain, swimming pools, and any

environment that may wet your feet or your shoes. If you swim regularly for

exercise, before getting in the water, rub petroleum jelly (Vaseline) on

your feet to protect them from the water. After leaving the water, remove

the petroleum jelly with a towel.

12. Do not put adhesive tape or other adhesive products like corn

plasters in contact with your feet. Fragile skin might be peeled off when

the tape is removed. When applying a bandage, tape should be not be applied

to the skin, but to the bandage only.

13. Do not put any medications in contact with your skin that are not

prescribed by your physician. Many over-the-counter medications, such as

iodine, salicylic acid, and corn-removal agents, are dangerous. Iodine

products or hydrogen peroxide should never be applied to wounds even if so

directed by a physician.

14. If the skin of your feet is dry, your cardiologist should try to

avoid medicines called beta blockers for hypertension or heart disease, as

these can inhibit perspiration that moistens the feet.

15. Do not attempt to file down, remove, or shave calluses or corns.

This is dangerous. The toughened skin of a callus is the body’s way of

protecting against irritation, such as by a shoe that rubs your foot.

Filing it off removes that protection, and in my experience, this is the

most common initial cause of foot ulcers. Do not permit podiatrists,

pedicurists, or anyone else to do so. If calluses are present, show them to

your physician. Ask her or a podiatrist to arrange for your shoes to be

stretched, prescribe special shoes, or prescribe orthotic inserts. Your

physician may instruct you in the use of a shoe stretcher or a “ball and

ring,” both of which can be ordered by a shoe repair shop. By eliminating

the irritation, the callus should resolve over time.

16. Do not trim your toenails if you cannot see them clearly. Ask a

friend or relative, podiatrist, or your physician to do this for you. If the

corners of your nails are pointed, you can file them with an emery board or

have someone else trim them.

17. If you have thickened toenails, ask your physician to have clippings

tested for fungal infection. If infection is present, he should prescribe

Tincture of Fungoid. This solution must be applied twice daily to the nails

to be effective. It must be used for about twelve months to effect a cure.

It helps to first have thickened nails ground down by a podiatrist, but s/he

must be very careful not to damage skin or nail bed.

18. Don't wear stockings or socks with elastic bands that are tight

enough to cause visible depressions in the skin. Don't use garters. Don't

wear socks with holes or that have been darned, have thick seams, or are so

large that they bunch up.

19. Phone your physician immediately if you experience any injury to

your foot. I consider even a minor foot injury to be an emergency.

Procrastination can be disastrous.

Put a copy of these instructions in your tickler file so that you can

re-read them every few months. Eventually, you should know them by heart.

Copyright 2002 by K Bernstein MD, FACE, FACN, FCCWS

http://www.diabeteshealth.com/read/2008/08/04/2115.html