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This article appeared in The Home News Tribune’s 50+ section.
May 2006
Diabetes and Wounds: A Dangerous Combination
By Dr. Anthony Tonzola
It began with a sore.
The man, who is a diabetic, said he didn’t feel the sore initially, but now, after several weeks, his foot was swollen and black. He was told he needed to have it amputated.
Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States. The rate of amputation in people with diabetes is ten times higher than for people without the disease.
The high physical, emotional, and financial cost of amputation led to a focus on preventing it. Over the past decade, many different medical disciplines have come together to share perspectives on wound care. New advances in wound care, coupled with an interdisciplinary approach, now mean we can heal most wounds and, in many cases, avoid the need for amputation.
Other conditions also cause chronic wounds. These include circulatory problems, autoimmune disorders, long-term use of steroids, vasculitis, and neurologic conditions that lead to immobilization and pressure ulcers.
Diabetics are especially vulnerable to wounds because the disease can lead to a condition called diabetic neuropathy, or the gradual loss of nerve fiber and sensation. People with diabetes can develop nerve problems at any time, but the longer the person has diabetes, the greater the risk of neuropathy.
The highest rates of neuropathy are among those who have had the disease for at least 25 years, but neuropathy is also more common among uncontrolled diabetics, those with high blood lipid levels, high blood pressure, overweight people, and diabetics over 40. Control of blood sugar is the only known way to slow or prevent neuropathy’s progression.
Nerves are our body’s warning system. When we lose nerve function, we are unable to feel the “gift of pain” and take the steps needed to protect ourselves such as removing irritants, cleaning wounds and wearing protective shoes. Think about the pain you feel when there are grains of sand between your toes. Now imagine not feeling those grains of sand. With each step, those grains irritate more, causing blisters, but because you can’t feel them you don’t do anything to stop the irritation and protect yourself from further injury. If you also have poor circulation and other health problems, the stage is set for those blisters to grow deeper, get infected, and cause more serious wounds. Diabetic neuropathy with loss of protective sensation is the most frequent cause of diabetic foot ulcerations and precedes 85 percent of all amputations.
Wound care takes time and attention. Treating diabetic wounds is especially challenging because the disease affects all organ systems, especially the circulatory system, the kidneys, and the peripheral nerves. That’s why wound care specialists employ a variety of medical disciplines to assess and treat not only the wound, but the factors that led to it.
There are a number of advances in the treatment of wounds. There are new topical antibiotics, topical growth factors, which promote more rapid healing. Human skin cells grown on special mesh can provide a living dermal matrix that can be used instead of skin grafts to promote healing, as well as bioengineered skin substitutes. Thanks to these innovations, wounds that used to take six months to a year to heal can be healed in two to three months.
To prevent wounds from becoming serious, all diabetics need to be especially vigilant about their feet. They need to remove all calluses, use protective insoles and socks and not walk barefoot to avoid any trauma to the feet. They need to perform a thorough foot inspection, including between the toes, every day to make sure potential skin breakdown, ulcers or infections are detected early. They also need to schedule regular foot exams with their health care professional every one to six months.
If a foot ulcer or even a blister is present, immediate attention is needed. Patients whose wounds do not show improvement within four weeks or have not fully healed in eight weeks should be referred to a wound specialist. Treatment by a wound care specialist may include the frequent removal of all dead tissue and frequent wound inspection. The patient may also need special dressings and antibiotics. It’s also critical to relieve pressure to the wound while it heals. That generally requires special shoes, insoles, and sometimes special casts.
With the proper treatment and preventive care, more than half the amputations associated with chronic wounds in diabetecs can be avoided.
Dr. Anthony Tonzola is the Medical Director of the Wound Care Center ™ at Robert Wood Johnson University Hospital at Rahway, which is expected to open in June.
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