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JAMA Patient Page
January 1/8, 2019

Diabetic Foot Ulcers

JAMA. 2019;321(1):114. doi:10.1001/jama.2018.18323

Foot ulcers are common complications of diabetes.

Why Are People With Diabetes at Risk of Ulcers?

Foot and lower leg ulcers are one of the many problems caused by poorly controlled diabetes. Ulcers that do not heal can lead to amputations of toes, parts of the foot, or the lower leg. Diabetes damages blood vessels throughout the body. Tiny blood vessels that supply the nerves in the legs may be affected, resulting in burning pain or numbness in the feet (peripheral neuropathy) and reduced pain sensation. Calluses, blisters, cuts, burns, and ingrown toenails can all lead to diabetic foot ulcers. A patient may not be aware of these minor injuries due to peripheral neuropathy, so ulcers may develop and enlarge before they are noticed. Larger blood vessels in the legs may also be affected by diabetes, resulting in poor circulation (peripheral artery disease). Ulcers may heal slowly due to peripheral artery disease. High blood glucose levels also delay healing. Daily foot inspection is an important part of diabetes management and can help prevent foot ulcers.

Infection and Diabetic Foot Ulcers

Diabetic foot ulcers may become infected. If there is pus draining from the ulcer and the surrounding skin is warm and red, the ulcer is probably infected. A clinician will often need to cut away callus and dead tissue from an ulcer; if the ulcer appears infected, tissue sample testing in a microbiology laboratory may be helpful in identifying the type(s) of bacteria causing the infection and choosing an appropriate antibiotic. An infected ulcer is usually treated with an oral antibiotic for 1 to 2 weeks.

The bone underlying an ulcer may become infected if the ulcer is deep. Bone infection is called osteomyelitis and can cause bone to die. Antibiotics have no effect on dead bone. Once bone is dead, it should be removed, usually by amputation of the affected part of the foot or leg. Many amputations in patients with diabetes are due to osteomyelitis. If the bone has been infected only for a short time or if removing the dead bone is not possible, a patient may be prescribed a long course of antibiotics. If a patient needs 4 to 6 weeks of intravenous antibiotics, a long-term intravenous line called a PICC line is placed. The patient will also need blood tests once a week to monitor for signs of infection and antibiotic side effects.

Treatment

  • Removal of callus and dead tissue by a podiatrist

  • Good wound care

  • Reducing pressure on the ulcer (“off-loading”)

  • Good blood glucose control

  • Good nutrition

  • Evaluating the circulation in the legs

  • Antibiotics if the ulcer is infected

Prevention

  • Keep feet clean, dry, and well moisturized.

  • Wear shoes that fit well.

  • Inspect feet daily.

  • Never walk barefoot.

  • See a podiatrist for calluses, minor injuries, or ingrown toenails.

  • Schedule clinical foot examinations at least once a year.

  • Maintain good blood glucose control.

  • Do not smoke.

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Article Information

Source: Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012:54(12):e132-e173.

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