Diabetic foot: prevention, care and treatment of ulcers in Tashkent

Why does the wound appear unnoticed?

Long-term elevated blood sugar damages nerve fibers and small vessels. As a result, several protective mechanisms are violated at once. Pain and temperature sensitivity disappears - the foot does not report an injury. The small muscles of the foot weaken, the toes become deformed, and the load is redistributed to several points, where calluses form, and ulcers form underneath them. The work of the sweat glands is disrupted, the skin becomes dry and cracks. If atherosclerosis of the leg arteries is added to this, the tissues also receive little oxygen, and any wound stops healing.

• Numbness, burning, tingling, or cottony feeling in the feet, often worse at night
• Decreased sensitivity to touch, temperature and pain
• Dry skin, cracked heels, calluses in pressure areas
• Deformation of the toes, change in the shape of the arch of the foot
• Thickening and discoloration of nails, fungal infections
• The absence of pulsation in the arteries of the foot and chilliness are a sign of a vascular component

It is important that neuropathy develops gradually and a person gets used to it. Almost no one notices the loss of sensitivity as an event: there is no day when the foot “stops feeling.” Therefore, you cannot rely on your own impression - the doctor checks sensitivity objectively, usually with a thin nylon thread and a tuning fork. If the test shows that protective sensitivity is lost, the person automatically goes into the high-risk group, even if he has no complaints at all.

Three Shapes: Why It's Important

1. Нейропатическая форма — преобладает повреждение нервов. Стопа тёплая, розовая, пульс на артериях сохранён, чувствительность снижена. Язва образуется под мозолью в точке максимального давления, чаще под головками плюсневых костей или на пятке, и обычно безболезненна.
2. Ишемическая форма — преобладает нарушение кровотока. Стопа холодная и бледная, пульс не определяется, есть боль в покое. Некроз возникает на кончиках пальцев и по краям стопы, лечение обязательно начинается с восстановления кровотока.
3. Смешанная форма — сочетание обоих механизмов, самая частая у людей с большим стажем диабета и наиболее сложная в лечении.

It is important to distinguish between forms because the tactics are fundamentally different. With a neuropathic ulcer, the main thing is to remove the load from the affected area, and the wound will heal. With ischemic, no bandages will help until blood flow is restored, so assessment of the arteries is mandatory for any long-term non-healing wound on the foot.

Daily inspection: what and how to look

This simple procedure replaces lost pain: since the body no longer reports damage, the eyes must report. It takes about a minute and is superior to any medicine in its ability to prevent ulcers. The point is regularity - a wound found on the day it appears is treated on an outpatient basis and heals in a matter of days; the same wound two weeks later often requires hospitalization.

1. Осматривать стопы каждый вечер при хорошем свете, включая подошву и промежутки между пальцами. Подошву удобно рассматривать в зеркале, положенном на пол, или попросить помощи у близких при плохом зрении.
2. Искать: покраснения, потёртости, пузыри, трещины, мозоли, вросшие ногти, изменения цвета, участки, которые стали теплее или холоднее остальной стопы.
3. Мыть ноги тёплой водой не дольше нескольких минут, обязательно проверяя температуру воды рукой или термометром, а не стопой.
4. Тщательно высушивать, особенно между пальцами; наносить увлажняющий крем на кожу стопы, но не в межпальцевые промежутки.
5. Ногти подпиливать или стричь прямо, не срезая уголки; мозоли не срезать лезвием и не пользоваться мозольными пластырями с кислотой.
6. Каждый день менять носки — бесшовные, of натуральных материалов, без тугой резинки.
7. Перед тем как надеть обувь, проверять её изнутри рукой: камешек, задравшаяся стелька или загнувшийся шов не будут ощущаться стопой.

Shoes: the main source of problems

Shoes are the cause of most diabetes ulcers. New shoes, a narrow toe, a hard inner seam, an accidental pebble - all this would cause immediate pain in a person with intact sensitivity and would be eliminated in a minute. With neuropathy, the same episode lasts for hours and ends with a wound, which the person learns about in the evening by a stain on the sock.

• Buy shoes in the afternoon, when the foot is a little swollen, and be sure to try on both
• No “breaking in”: shoes should be comfortable right away, because pain from rubbing with neuropathy will not be felt
• Wide toe box to prevent pinching of toes, soft upper without rough inner seams
• Stable sole, heel no higher than 3–4 cm; a completely flat sole is also undesirable
• Closed toe and heel: Flip-flops and shoes with a toe bar are not suitable.
• For foot deformities - individual orthopedic insoles and special shoes as prescribed by a doctor
• Do not walk barefoot anywhere: neither at home, nor on the beach, nor in the bathhouse. Hot sand and floors cause burns that a person cannot feel

What do doctors do if an ulcer has already appeared?

1. Оценивают глубину раны, наличие инфекции и вовлечение кости; при подозрении на остеомиелит выполняют рентген или МРТ.
2. Проверяют кровоток: пульсация, лодыжечно-плечевой индекс, дуплексное УЗИ артерий. При значимом сужении обсуждают ангиопластику или шунтирование — без кровотока рана не закроется.
3. Обеспечивают разгрузку поражённого участка: специальные разгрузочные повязки, ортопедическая обувь, костыли или кресло. Это главный лечебный фактор при нейропатической язве, а не дополнение к мазям.
4. Проводят обработку раны с удалением омертвевших тканей и подбирают повязки, поддерживающие правильную влажность.
5. Назначают антибиотики при признаках инфекции, ориентируясь на посев, а не «на всякий случай».
6. Добиваются целевого уровня сахара крови: при высокой гликемии заживление резко замедляется, а инфекция развивается быстрее.

Ulcer healing is not the end of the story, but the beginning of a period of prevention. After the wound is closed, the risk of a new ulcer developing within a year remains high: neuropathy, deformation, and the point of excess pressure remain. Therefore, healing is necessarily followed by the manufacture of orthopedic insoles or shoes, regular examination by a specialist and the same daily home monitoring. People who have already had an ulcer are at highest risk and are the ones who benefit most from prevention.

Household habits that lead to trouble

A significant part of severe cases begins not with the disease itself, but with household actions performed with the best intentions. Below are habits that, if sensitivity is preserved, are harmless, but with diabetic neuropathy regularly lead a person to the operating table.

• Warming your feet with a heating pad, near a radiator, or in a hot bath is the most common burn mechanism for loss of sensitivity.
• Cut calluses with a blade or razor, use caustic callus plasters
• Fill the ulcer with iodine, brilliant green or alcohol: this damages the tissue and makes it difficult to evaluate the wound
• Cover the wound with a band-aid and wait for it to “go away on its own” for weeks
• Walk barefoot at home, wear shoes on bare feet, wear tight socks with a tight elastic band
• Treat nail fungus and cracks yourself without showing your feet to a doctor
• To assume that with normal sugar levels today, the feet are no longer in danger: neuropathy, which has developed over the years, does not disappear anywhere