Complications of Diabetes
Diabetes is an increasingly common disorder in the United States and around the world. Chances are someone close to you has some form of diabetes. The United States Department of Health and Human Services has predicted that there will be over 30 million people with diabetes by the year 2020, which is now only 6 years away.
The frequency and severity of complications in diabetes is tied to the length of time with the disease as well as how controlled the blood sugar has been. On average, a person has a high blood sugar for 3 years before diagnosis and treatment.
Diabetes is a disease that, if managed well, can have few or no complications, and a person can expect to lead a full and healthy life. However, there are serious and sometimes fatal complications of diabetes when it is not well managed, and many of these issues affect the feet including wounds, infections, peripheral neuropathy, Charcot neuroarthropathy, dry skin, fungal infections of the toenails and vascular disease. Each of these complications can be encountered individually, but many times several problems are combined.
Wounds are most commonly found on the bottom of the foot in people with diabetes, but they can be found in other locations as well. Wounds on the bottom of the foot are caused by a combination of pressure, fragility of the skin and loss of proper feeling due to neuropathy. The wound occurs because there is excess pressure on an area of the foot, usually at the ball of the foot, and it is not noticed because of the decreased feeling in the foot. This pressure causes death of the living layer of skin and over the course of 1-2 days, a wound opens. There is often drainage from the wound and redness around it, and it sometimes also gets a callus (aka corn).
Often the wound is first noticed by a family member or when blood or drainage is noticed on the sock. It is very important that the wound be treated by a physician as soon as possible to prevent worsening of the condition, which includes the wound getting larger and/or deeper and infection. Redness, swelling, increased drainage, red streaks up the foot, fever, chills, nausea, vomiting and/or night sweats are the signs of infection, and if these are experienced it is important to seek immediate medical attention.
Most wounds are treated with a combination of debridement (cutting away of all the dead tissue), antibiotics to help prevent infection, and bandaging. It is very important that the cause of the wound be identified so that it can be removed. In the case of a pressure wound on the bottom of the foot, wearing a special shoe to take the pressure off is initially needed. This is followed by wearing prescription diabetic shoes to remove the pressure from all areas on the bottom of the foot, which helps to prevent new wounds in the same area of different areas.
Wounds can also occur in other areas, such as around the ankle. These wounds are usually due to damage to the blood vessels, causing the skin to become weak. There is often a lot of leg swelling as well. Damage to the blood vessels is accelerated due to high blood sugars, and it usually starts before the diagnosis of diabetes is made.
Infection is a common problem in diabetes because the immune system is affected by high blood sugar. The immune cells are damaged when blood sugars are above normal, making them slower in identifying infection and slower to attack it as well. A slow immune response also affects the time it takes to heal, since the immune system is an important part of the healing process.
As discussed earlier, wounds are a common problem in diabetes and because the immune system does not function normally, infections and poor healing can be a significant problem. Redness, swelling, increased drainage, red streaks up the foot, fever, chills, nausea, vomiting and/or night sweats are the signs of infection, and if these are experienced it is important to seek immediate medical attention. If left unchecked, deep infections can lead to severe complications which can be life-threatening, including need for amputation of the toes, foot and/or leg. If caught early, oral antibiotics and proper wound care can effectively treat most infections.
Neuropathy is a loss or decrease in sensation due to high blood sugar and compromise to the blood vessels that supply the nerves. It begins at the tips of the toes and progresses up the foot in what is called a “stocking glove” style, which means it affects all the nerves of the foot as though a sock is being put on. Not everyone with diabetes will get neuropathy, but it is very common.
The severity of neuropathy is tied to the length of time a person has had diabetes and how well the blood sugar has been controlled. Symptoms can range from a feeling of tingling, mild numbness or mild burning pain all the way to severe burning pain and complete numbness in the feet, and everything in between. These symptoms, when mild to moderate, can be somewhat reversible with better control of blood sugars. However, more severe forms are often permanent to some degree, emphasizing the importance of prevention of neuropathy.
The treatments for neuropathy are mostly geared at reducing symptoms, and including over the counter vitamins and prescription medication. Vitamins, such as Neuremedy, can help to improve the function of the nerves, reducing the neuropathic process. There are several medications that have shown some great improvement with numbness and burning pain, and these include gabapentin and pregabalin.
Because of the decrease in sensation, as discussed earlier, diabetic shoes are extremely important in preventing pressure wounds and infections that can lead to serious complictions.
This disorder, usually called Charcot for short, is caused by neuropathy and can lead to severe breakdown of the bones of the foot. This bone breakdown creates severe instability in the foot and can cause open wounds in a very short period of time. The breakdown in the bone is caused by many fractures in the bones, that are not felt because of the loss of feeling in the feet.
There are various forms of treatment for Charcot, including casting, walking boots and surgery. In many cases, surgery is necessary to stabilize the broken bones and allow for proper healing. As with neuropathy, prevention of Charcot is centered around proper blood sugar control, diabetic shoes and close monitoring by a foot and ankle specialist.
While not a serious complication of diabetes by itself, dry skin can lead to open wounds with severe cracking, which can lead to infection. Diabetes causes dry skin because it causes abnormality of the sweat and oil glands in the skin, causing them to not work correctly. In some cases this try skin can be severe and lead to fissuring and cracking that can be painful and lead to infection.
There are many treatments available for dry skin including Idonia and Lantiseptic creams.
Fungal infections are very common in diabetes because of the decreased ability to fight infection. Fungus on the foot (athlete’s foot) can cause cracking, especially between the toes, leading to bacterial infection in some cases.
More commonly the toenails can become infected with fungus, leading to thickened, discolored, cracked, brittle and painful nails. Once the fungus gets in, it can be difficult to eradicate it. Fortunately however, there are many treatments including creams, nail polishes and oral medications for treatment.
Vascular disease, or disease of the blood vessels, is a very common problem in diabetes. The high blood sugar and high blood pressure cause damage to the vessel wall, which causes narrowing and hardening of the vessels, decreasing blood flow. This damage is especially common in the very small blood vessels that carry blood to the toes and fingers. It also causes damage to the large vessels.
Unfortunately, there are no treatments currently to repair the small vessel damage, and this can lead to significant problems with wounds and wound healing. However, the large vessels can often be repaired using a variety of surgical techniques, which increase blood flow to the feet and legs. A vascular specialist evaluation is needed for proper treatment.
In conclusion there are many types of problems related to diabetes that can cause significant problems if untreated. But with treatment, most of these issues can be well managed for many years.
The doctors at Advanced Foot and Ankle Center have extensive training and experience in the treatment of diabetic complications in the foot. Call for an appointment today.
Dr. Eric Silvers, DPM
Dr. Dustin Lloyd, DPM
Dr. Christopher Witt, DPM