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The Diabetic Foot: The Art of Wound Care

Wounds in general pose a big problem in our current health setting.  The general physician as a primary care provider sees a wide variety of wounds, either acute or chronic. It is of utmost importance that the general physician assess the patient as a whole in formulating a wound management strategy.  Questions abound in the general physician’s mind regarding factors which contribute to poor wound healing.
It is because of certain illnesses such as diabetes and cancer? Is it because of certain medications such as steroids, anti-hypertensive medications (e.g., beta-blocker), or pain meds such as NSAIDS?  Is it because of reduced mobility or nutritional status, or simply because of aging?

Focus is on the management of diabetic foot disease.  Diabetic foot disease is estimated to affect 15% of all people with diabetes.  So why does it take long for a diabetic wound to heal?  What contributes to its abnormal wound healing? There are 3 main causes for diabetic foot disease: pressure, infection and circulation (PIC).  Diabetics usually are “numb” especially in the foot.  They do not feel anything and sometimes the wound has already been there for a long period of time.  Diabetics are particularly susceptible to infection especially those with poor sugar control.  Poor sugar control also affects their blood to combat infection.  Diabetics also have problems with their circulation resulting also in poor wound healing.

Over the last 40 years, there have been significant advances in the understanding of wounds and wound management. Wound care now becomes an art. There has been great complexity of the diabetic foot disease. There is a paradigm shift in the treatment of chronic wounds. The art of wound care requires holistic care of the diabetic foot. It is now a virtual necessity at this time, but evidence-based science continues to evolve. The most significant is the concept of “moist wound healing”. There are certain “tissue factors” that help wounds to heal in a moist environment. With a moist wound environment, epithelialization (skin growth) occurs in the surface at a more rapid rate. A dry wound environment tends to deplete the tissue factors. This also encourages dehydration of the wound and this promotes dead tissue formation.

Since we are advocates of moist wound healing, the wound should be cleaned by a simple natural saline solution. Saline is the solution of choice. Wound cleansing and irrigation are used to remove surface debris and exudate, allowing for proper assessment of the wound and facilitating wound healing. The use of tap water is controversial especially if you are not sure that it is “clean”. In immunocompromised patients (diabetics with poor sugar control), it is contraindicated because of the possibility of introduction of unwanted pathogens (bacteria).

We do not advocate the use of alcohol and any other solutions that tend to dry the wound. Agents that dry the wound are topical steroids, liquid detergent, cetrimide, chlorhexidine, povidone-iodine solution, hydrogen peroxide, hypochlorite solutions, and mercurochrome. Do not overdo the cleaning because too much irrigation with water or NSS will also “macerate” the surrounding tissue.

Do not self-medicate with antibiotics. If you think the wound is infected, consult your doctor. Self-medication with antibiotics promotes bacterial resistance and you might not be hitting the real cause of your wound and worse, you might get the side effects of the antibiotics.

In the art of wound care, there are lots of questions rather than answers. The best way to treat diabetic foot disease is to prevent its development. Educating the patient is one of the keys to prevention. People with diabetes should learn to examine their own feet. They should recognize the early signs and symptoms of a diabetic foot problem. They should know when to seek medical care. Diabetics should seek medical care for the following reasons:
• There is a break in the skin (significant trauma) of the feet or legs. No matter how minor, it still needs medical attention. Even minor injuries can result in serious infections.
• Constant pain in the feet or legs is never normal.
• There are new areas of redness, warmth or swelling on the feet. These are early signs of infection or inflammation.
• A simple ingrown toe nail with signs of infection.
• There is constant itching (sign of dryness or a sign of fungal infection).
• There is a new or constant numbness.
• All calluses or corns should be professionally removed.

Bottom-line, the best way to treat diabetic foot disease is prevention.

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Comments:1

  1. Joyce yagoda Reply
    10/09/13

    Diabetic wounds, next to impossible to heal, mostly do to infections.

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