Science-Spotlight: Diabetic foot ulcers causes and prevention

Foot infections and ulcers are so common in people with diabetes that they are considered the most common cause of disease-related hospitalisation for diabetics.

What does this mean? Well, the study we are examining today quotes the finding that ‘10% of all people admitted to hospital had diabetes’1*.

To put this in perspective, 10.6 million hospitalisations occurred in Australia in 2015-16*2; 10% of this number is a whopping 1.6 million with foot infections presumably responsible for the majority of these.

“[The] incidence of diabetic foot disease [and ulceration] is expected to rise…more needs to be done to reduce risk factors [of ulceration] for patients.”

Science-Spotlight

Welcome to our first Science-Spotlight where we take a look at an important piece of scientific research and unpack it for the non-scientists among us.

We’ve written before about the importance of taking care of diabetic feet and posted suggestions for simple things you can do for your diabetic skin and this week we are excited to examine a scientific report that supports these pieces.

This week: The use of urea-based creams in the prevention of diabetic ulceration. Written by Jackie Locke, Stuart Baird, & Gordan Hendry

Published in Dermatological Nursing, this paper is a review of the risk factors and causes of diabetic foot ulcers and the effectiveness of urea-based emollients (a cream that softens the skin) in preventing ulcers.

Background

So what is a foot ulcer?

In a nutshell, a foot ulcer is an open sore on the foot. It can be shallow or deep penetrating into the flesh through the skin. In severe cases, the ulcer can go deep enough to expose tendons or even bone. Open to the environment, ulcers can easily become infected. If the ulcer does become infected it can develop:

  • A pocket of puss forming under surrounding skin (forming an abscess);
  • The infection spreading to the surrounding fat (cellulitis) or the bone (osteomyelitis);
  • Gangrene - the death of the body tissue.

For anyone fortunate enough to have avoided seeing a diabetic foot ulcer there will be an image at the end of this article for awareness. Just a WARNING that it is graphic and may be confronting to some viewers.

Why is this happening?

The study identifies Autonomic Neuropathy (AN) as the “major risk factor for foot ulceration” 1*. AN is a collective name for a range of symptoms that “20-40% of people with diabetes” are very likely to develop. Just a few of the most relevant symptoms for relating to ulceration are:

  • Reduced sweating in the feet (anhidrosis or anhydrosis);
  • Skin cells not getting enough oxygen (tissue hypoxia);
  • Thickening of the skin on the feet (non-enzymatic glycation (NEG));
  • Reduced skin elasticity (NEG).

All of these symptoms are risk factors for foot ulcers- they lead to the actual 'causal pathways' (believed causes) of ulcers: Fissures and Xerosis.

Fissures

Fissures are cracks that appear in the skin and are usually found in the thickened skin on the sole and heel, and around the joint of the ankle. These cracks provide an opening to allow germs, fungi and bacterial infections into the foot. This is an intuitive explanation for infected ulcers.

Xerosis

Xerosis is the excessive drying, and 'scaling', of the skin and is caused by the loss of lipids (fat/oils) that contributes to moisture retention. These lipids also help prevents fissures. The study defines Xerosis as the “[breakdown of the] skin-barrier, moisture loss, [and exess] evaporation” it also indicates it as a causal factor to the “risk of ulceration and infection”1*

Prevention

The paper goes on to discuss prevention. Specifically, it identifies 2x areas for the most effective prevention of ulceration:

  • Screening, and education in condition awareness;
  • Application of creams that soften and hydrate the skin (emollients).

If you are unaware of the seriousness of these symptoms, or what can be done to prevent or remedy dry skin, skin cracking, and other causal factors of ulceration, a sufferer is powerless to help themselves. So, it comes to no surprise that screening and education have been accepted as some of the best methods of “reducing ulcerations and amputation rates”1*.

Following this, the report identifies the importance of using skin softening and hydration creams- 'emollients. Researchers make the clear and firm stance that “every [diabetic] patient should have [access] to simple preventative measures”1* like these ‘emollients’.

 

 

So why aren’t we utilising these creams more?

The review goes on to identify that one of the most significant barriers to diabetics not using these preventative creams is personal dissatisfaction with the product. That is, that some brands are described as unfavourably as “greasy, oil-based, [leaving] excess residue, staining clothes, [and] strong odour". That is why it is so important to choose a cream that isn't oily, that absorbs quickly and has a pleasant, or subtle, odour. It's important to shop around as there are products that tick these boxes like DIA-BALM; the specialist diabetic foot care cream.

Aside from personal dissatisfaction, there are also many options to choose from; so which is best?

The paper goes on to discuss a range of research conducted to assess what ingredient, and in what proportion, is ‘best’. According to the data, the research identifies urea as the best option reviewed. Results of further testing indicate that 25% urea is clinically and statistically more effective than 10%- and remains the best scientifically tested proportion for use by people with diabetes.

This means that the best choice you can make for diabetic feet is to choose a foot care cream has 25% urea, like DIA-BALM

The conclusion

“Incidence of diabetic foot disease [and ulceration] is expected to rise” and while diabetes foot care education has reduced ulceration and amputation rates “more need to be done to reduce risk factors for patients.” Use of an effective emollient is “paramount”1*.

Specifically, the researchers suggest that once-daily use of an emollient containing 25% urea “could significantly improve” skin function and integrity. This, in turn, helping to prevent ulceration.

 We would encourage anyone interested to review the full paper HERE

Below are two images of ulcerated feet. If you have been diagnosed with diabetes you need to be aware of the prevention, treatment and lifestyle choice that can make this as unlikely as possible.

WARNING content may be disturbing to some viewers.

Our Services and Blog posts are NOT intended to substitute any professional medical advice or treatment and are offered for informational purposes only. Remember to always work with your doctor before changing anything about your medication or diabetes management. The above information is NOT medical advice.

References:

1* The use of urea-based creams in the prevention of diabetic ulceration. Written by Jackie Locke, Stuart Baird, & Gordan Hendry. 2012, Dermatological Nursing

2* https://www.aihw.gov.au/reports-statistics/health-welfare-services/hospitals/overview

 

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