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Remember, harmful bacteria that can cause serious infections are normal inhabitants of the foot. This can begin with a small skin break. They are abundant and are very prominent between the toes, especially between the 4th and 5th toes. These areas should be cleaned on a daily basis.
Diabetes is a multi-system, multi-organ disease. Simply put, it affects just about every part of our bodies, especially the feet, kidneys, and eyes. Your best way to fight back is to limit your intake of sugar to 4 grams per hour. ( This is the amount of sugar in a teaspoon ! )
This is the amount of sugar your pancreas can handle. Any more than this causes problems. A can of soda has 11 teaspoons of sugar!
Of all the complications that result from Diabetes, including heart disease, kidney disease, and eye disease, ( that are mostly unpreventable ) the number one reason a diabetic is hospitalized is a foot infection, and this is preventable 85% to 90% of the time!
Proper shoe fit is extremely important for the Diabetic patient. Buying shoes according to your "size" is often inaccurate. This is because shoes come from all over the world and this makes the quality control regarding shoe sizing poor at best.
I recommend that you follow the " rule of thumb " when trying shoes on. You should be able to press down and get a thumb nail (one inch) between the end of the shoe and the tip of your big toe. Do this when standing or have someone assist you. If you can do this, the shoes generally will be long enough and wide enough. This is a more accurate way to find your correct shoe size.
Dry skin in the Diabetic is a very common problem. This is especially true in the winter. Diabetes affects the sweat glands and interferes with the normal oil secretions the keep the skin moisturized. Also, the dryness leads to cracking. This then gives the bacteria a window to enter the body that can then lead to infection. The best defense is to moisturize your feet once or even twice a day with a good skin moisturizer.
Fungal infections ( athlete's feet) are very common in the Diabetic patient. It is important to note that there are different kinds of fungal infections that look and behave differently. This is because there are different fungal organisms that attack the foot and they all look different.
The infection may present with acute fluid filled blisters, cracking between the toes, or a chronic scaly flaking skin on the bottom surfaces of the feet. This is often confused with dry skin and in my experience, is the most common type. Often, patients treat this condition with all types of moisturizers and become frustrated because moisturizers will not work. An anti-fungal daily for one month is required because it takes 28 days to get a new epidermis - the outer layer of skin.
Dr. Joslin, who was the first doctor to specialize in diabetes over a hundred years ago, was the founder of today's Joslin Diabetes Center.
Among his many accomplishments, probably the most important one was developing the strategy of Patient Self -Management for reducing complications in the Diabetic Patient.
There is a Self -Management program for every complication of Diabetes.
Self-Management involves two critical aspects:
- Patient education
- Patient involvement In the foot, Patient Involvement has three key components - Daily Inspection, Daily Hygiene, and regular sensory testing.
The next several foot bits will go into more depth on Self-Management for the Diabetic Foot which has been time tested and the proven strategy to prevent 80 to 90% of foot complications when practiced on a daily basis.
The first component of patient involvement is daily inspection of the foot. In my opinion this is as important as checking your blood sugar on a daily basis.
Check the feet daily for cuts, redness , blisters, or any break in the skin. Remember, these openings are the doorway for harmful bacteria, and this is how an infection usually begins.
Use a long handled mirror if you cannot easily see your feet. Please check ALL areas of your feet, including between the toes. Having a spouse or family member do this as part of a daily routine is certainly acceptable, especially if your vision is poor.
If a wound is discovered, clean with warm soapy water, dry gently, apply a topical antiseptic, and covering with a dressing or a bandaid is a good idea. It is always a good idea to have even the most minor wounds evaluated by your podiatrist as soon as possible.
Remember inspection is to be done DAILY!
The second component of patient involvement is daily cleansing. This is no less important than daily inspection. Some people tend to ignore their feet when it comes to daily hygiene. A diabetic patient can never and should never do this. Daily hygiene is extremely important in preventing foot complications especially infections. If hygiene cannot easily be done when bathing or showering, one must address this in other ways.
The simplest approach is to soak the feet daily in a warm soapy solution. This can be assisted with a long handled brush or sponge. ( Please refer to our education videos.)
It is very important to not bathe in water that is too hot. The problem with the Diabetic patient is numbness in the feet ( neuropathy ) and not being able to sense temperatures properly. The safest way to check water temperature without a thermometer is to make sure one tests the temperature with their hands. This is good as long as they do not have neuropathy in the hands. A thermometer can be used and a safe temperature is not to exceed 100 degrees fahrenheit.
Cleansing the sides and soles of the feet removes dirt, bacteria, and dead skin; all of which can cause an infection. Cleansing between the toes is especially important because disease causing organisms thrive in these areas. This includes bacteria as well as fungi. Daily hygiene keeps the number of organisms to a minimum. Dry thoroughly with a clean towel. If dry skin is a problem as it often times is, this is the perfect time to apply a skin moisturizer.
The third component of patient involvement is regular sensory testing for neuropathy. There are several different types of diabetic neuropathy. However, the type that needs to be tested for is that of numbness. After 5 years most diabetics have some degree of numbness.
Patients often ask for my opinion on exercise. My answer is; that there may be something that comes along in the future that surpasses it, but for now exercise is truly as close to the "fountain of youth" that we can get.
Depending on your age, your physical condition, and your preferences, the choices are plentiful and healthy. However, if you are limited for whatever reason, but you can walk, then by all means make walking your exercise choice. This, in my opinion, is an excellent choice for everyone.
Walking helps us mentally as well as physically! I encourage patients work up to walking two miles per day, five days per week. If one chooses to exercise on the two other days, I encourage non-weightbearing forms of activity. This can be, biking, machine work , yoga swimming, or anything that may be of interest.
As for footwear, I recommend a running shoe that one finds comfortable. Running shoes generally provide the most shock absorption. I am very liberal in prescribing Diabetic running shoes. I recommend these if a patient has neuropathy or a bone deformity that may be irritated by a shoe that does not fit properly .
Talk to your doctor if you are having problems. Remember, exercise alone cannot lead to weight loss, but when combined with proper dieting - you have an unbeatable combination!
There are many toenail disorders that affect the patient with diabetes. However, by far, the most common condition is onychomycosis; the medical term for fungus toenails.
This is often the presenting problem of the patient with diabetes. The nails are often too difficult to manage for the patient. Furthermore, a patient is at risk for self-injury trying to treat these on their own. Please let your podiatrist manage the problem.
Most insurance plans encourage and cover this treatment every 61 days. Treatment ranges from professional debridement to medications to treat the problem. As far as medications, topical medicines are poor at best. I tell my patients they are usually safe but generally ineffective.
What works best in my experience is oral medications. I start with Lamisil (terbinafine) if the patient is medically able to take it. However, I give a mini/pulse dose, and not the 90 day course. I have found this to be 70% to 80 % as effective as the full dose. Blood work is usually not necessary. Either way, this is a well-tolerated and safe medication, especially when given in an abbreviated form.
Talk to your podiatrist or internist to see if you are a candidate .
Corns and Calluses:
Corns and calluses are hard, thickened areas of skin that result from excessive pressure, usually to an underlying bone. The difference between the two is location. Corns are on or between the toes, and calluses are on the bottom or sides of the foot. Corns and calluses are pressure problems and not a skin disorder.
Thus, the treatment is reducing the abnormal pressure more than applying creams and medications. This is accomplished with wearing shoes that fit properly, and at times surgery to correct the underlying bone problem. In the patient with diabetes, this abnormal pressure combined with a lack of sensation (neuropathy), is probably the leading cause of a diabetic ulcer.
This is the beginning of the chain of events that can lead to amputation. This is why it is crucial for a patient with diabetes to inspect their feet daily, or even twice a day. Any areas of redness, irritation, or simple breaks in the skin should be checked by a physician immediately. This is true even if there is no pain because with neuropathy pain sensation is lacking. It is always better to error on the safe side!
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