feet on the ground

What are diabetic foot ulcers (DFUs)?

A diabetic foot ulcer (DFU) is an open sore or wound that occurs in the feet of patients with diabetes. According to the American Podiatric Medical Association (APMA), 15% diabetic patients tend to develop DFU.

These are commonly caused by repetitive mechanical stress over an area that is subject to high vertical or shear stress. The common factors contributing to the development of DFU include, peripheral neuropathy (causing lack of sensation) or peripheral artery disease (resulting in poor circulation in the foot).

Who is affected?

As the term "Diabetic Foot Ulcer" suggests, DFU affect people with Diabetes Mellitus, primarily type 2. It is important to know that certain risk factors for developing DFU exist, so additional focus can be devoted to prevention. DFU occur in both men and women but men seem to be affected more often older people with DM are also at higher risk of developing DFU compared to younger people. People who experience altered sensation, known as neuropathy, are at a higher risk for developing DFU. Having a chronic illness such as hypertension, peripheral vascular disease or other complication from DM such as diabetic retinopathy or diabetic nephropathy may put people with DM at higher risk of developing a DFU. People who already had one DFU or have foot deformities are at higher risk of developing DFU. Finally, smoking cigarettes may increase the risk of DFU and is generally associated with poor health outcomes.

What do DFU look like?

  • Stage 1 ulcers are characterized by a reddening over bony areas. The redness on the skin does not go away when pressure is relieved.
  • Stage 2 ulcers are characterized by blisters, peeling or cracked skin. There is a partial thickness skin loss involving the top two layers of the skin.
  • Stage 3 ulcers are characterized by broken skin and sometimes bloody drainage. There is a full thickness skin loss involving subcutaneous tissue (the tissue between the skin and the muscle.)
  • Stage 4 ulcers are characterized by breaks in the skin involving skin, muscle, tendon and bone and are often associated with a bone infection called osteomyelitis.

How are DFU prevented and treated?

Blood sugar control is the first step in preventing complications such as a DFU. If you have numbness, tingling or burning sensation in your toes/feet, you should have your feet evaluated by a podiatrist to assess for poor circulation and peripheral neuropathy (nerve damage to the feet). If you have any cuts, blisters, or wounds in your feet, it's important to see a podiatrist as soon as possible in order to prevent an ulcer from developing.

Once an ulcer develops, we need to make sure that the there's adequate circulation to the foot and that there's no infection present. If there's adequate circulation and no infection, the treatment typically involves wearing appropriate offloading shoe/brace and keeping the ulcer clean with a wound dressing.

Who treats DFU?

The treatment of diabetic foot ulcers in patients with diabetes can be performed by many doctors. Your primary care physician may refer you to a specialist. Podiatrists, plastic surgeons, wound care specialists, vascular surgeons, and nurses all play a role in your care. They will work together as a team to help heal your wound. If you have questions, please speak with you doctor.

When will my wound heal?

How long it will take your wound to heal depends on a variety of factors, such as wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels, wound care, and what is being applied to the wound. Healing may occur within weeks or require several months.

What are biomarkers?

Biomarker” is short for biological marker and is defined as a measurable indicator of a biological process. Examples of types of biomarkers are cells, chemicals, and molecules. Biomarkers can be associated with the presence and severity of a disease, as well as an indication that a particular treatment is working.

Why are biomarkers important in DFU?

Biomarkers can be used to predict, diagnose, or monitor a disease state. They can help clinicians by providing a useful, objective adjunct to clinical signs and symptoms.

Why do DFU recur?

A closed DFU may reopen for many reasons. If the quality of wound closure is poor such that health of the repaired skin is poor, that wound is likely to reopen. Lack of proper care of the foot with the closed wound is a major reason responsible for reopening of DFU. Even mild trauma, such as hitting the edge of the door, can easily open the closed wound. Other reasons include stress on the foot because of deformity. Yet other reasons could be chronic disorders of the foot such as poor blood supply or lack of sensation.

Why is it important to investigate DFU?

Diabetic foot ulcers are the leading cause of limb amputations. The risk of death at five years for a patient with DFU is 2.5 times as high as the risk for a patient with diabetes who does not have a foot ulcer. Other than the social burden there is also an economic cost associated with the disease. In the US, an estimated $176 billion is spent annually on direct costs of diabetes care and a third of this expense is for lower extremity associated complications. Investigating DFU will help care for such wounds with better outcomes such as fewer amputations. Importantly, DFU research can help prevent DFU formation. This would be a great relief to the individual patient and increase their productivity. This would lead to more workforce and lower healthcare cost helping our national economy.