diabetic wound care

• Thick Skin
• Scleroderma diabeticorum
• Yellow Skin
• Xerosis
• Necrobiosis Lipoidica (shin spots)
• Bullosis diabeticorum (Diabetic Bullae)
• Granuloma Annulare
• Acanthosis Nigricans

• *increased thickening from 8- 50%
• *Commonly has a shiny appearance
• *May lead to limited joint mobility and conjectures
• *Involving the finger and hands may range from pebbled skin to scleroderma changes
• *diabetic hand syndrome...thickened skin over dorsum of digits and limited joint mobility (especially interphangeal joints.

• Consists of thickened skin over the dorsum of digit and limited joint mobility, especially interphalangeal joints.
•      *Difficulty in tenting the skin
•      *Pebbled or rough skin on knuckles
•        or periungual region
•      *Decreased skin wrinkling following 
•        immersion in water

collagen bundles in the dermis are thickened and disorganized as a result of irreversible non-enzymatic glycation, cross-linking and "browning" of protein.

• No Treatment
• Strict glucose control may be beneficial

Dermal thickness on the posterior back and upper neck occasionally extending to the deltoid and lumbar regions

In middle aged, overweight, poorly controlled type 2 dm

a peru to orange appearance of skin can occur, often with DECREASED SENSITIVITY TO PAIN AND TOUGH

Thickened dermis with large collagen bundles that are separated by wide, clear spaces

• Cause: collagen is irreversibly glycosylated and rendered resistant to degradation by collagenase, leading to excess accumulation.
• No treatment is available other than tight glycemic control which might decrease skin thickness

• Yellow nails and skin are a benign condition
• Cause: 1)May be due to nonenzymatic glycosylation of dermal collagen or elevated levels of carotene
• 2) May be result of accumulation of 2-(2-furoyl) 4(5)-(2-furnayl)-1H-imidoazole, and end produce of glycosylation that has a yellow hue.
• Yellow color on palms of hands, soles of feet, and distal nail plate of the hallux
• No treatment!

• Neuropathic: DO NOT HAVE PAD
• Neuro eschemic: Neuropathy and Ischemia.  Have PAD
• Ischemic:Presence of ulceration, gangrene, or pain at rest.

• Neuropathy
• Deformity
• Truma
• All 3 are present in almost 2/3 of patient with foot ulcers

Neuropathy!

It is irreversible and cannot be cured

• Sensory
• Motor
• Autonomic - sympathic alteration

• (alters tactile sensation)
• loss of protective sensation, numbness, impaired tempt perception
• pain, parasthesias
• Loss of vibration and position sensation

• (alters biomechanics and muscles)
• Contributes to wasting of intrinsic muscles of foot: muscle imbalance
• Motor loss (gait alteration, tripping, ect)
• Muscle weakness and atrophy
• Structural foot deformity such as claw toes

• Decreased vasomotor activity
• vasodilation, edema
• Increased atherosclerotic plaque formation
• Reduced circulation and loss of sweat and oil gland function, which leads to dry, scaly skin that easily cracks and splits

• Peripheral ischemia resulting from proximal arterial Dx is recognized as a component cause in pathway to ulceration in approximately 1/3 OF ALL CASES
• In patients with DM, for every 1% increased in A1C there is a corresponding 26% increased risk of PAD

• Inappropriate footwear is most common source of trauma
• Poorly fitting shoes - low-pressure injuries that are asoociated with prolonged or constant pressure
• Ulcers on weight-bearing areas - repetitive moderate pressure and shear forces on the sole
• Penetrating injuries from puncture wounds or other traumatic events (high-pressure injuries with a single exposure of direct pressure)

• Duration of DM - greater than > 10 yrs
• Diabetes control - A1C > 7%
• History of previous ulceration or amputation (36.4 x greater risk for another ulcer)
• Male Sex
• DM with cardiovascular, retinal, or renal complications
• Peripheral neuropathy with loss of protective sensation
• Distal symmetric polyneuropathy is one the most important predictors of ulcers & amputation
• Smoking (vaso constriction)
• Obesity
• Age
• Visual impairment
• Rigid foot deformity
• Callus
• Peripheral vascular Ds
• Severe nail pressure
• Elevated planar pressure

• Category 0 = No LOPS, no PAD, no deformity
• Category 1 = LOPS + deformity
• Category 2 = PAD + LOPS
• Category 3 = History of ulcer or amputation

Yearly assessment

Every 3 - 6 mths

every 1 - 3 mths

every 1 - 2 mths

No LOPS, NO PAD, no deformity

LOPS + deformity

PAD + LOPS

History of ulcer or amputation

• Hypoesthesia or complete loss of sensation of light though, pain, temp, and vibration
• Absence of Achilles tendon reflexes
• Abnormal vibration perception threshold, often above 25 v
• Loss of sensation in response to 5.07 monofilaments

• Borders of the Dorsal aspect of feet
• Toes or between toes
• Over phalangeal heads

• Yellow or black necrotic tissue
• Redness at borders of the ulcer

• Thin, shinny, dry skin
• Absent or diminished pulses
• TBPI < 0.7
• TcP02 < 30 mmHg (Hypoxic, 5 -70 is norm) Skin cool to touch, pale, or mottled
• No finding of peripheral neuropaty
• Hair loss on ankle and foot
• Thick Nails (dystrophic)
• Pallow or elevation and dependent rubor
• Cyanosis

thick nails

• Neuropathic ulcer
• ischemic foot ulcer
• Neuroischemic Ulcer

• Absence of Pulse
• Presence of resting pain
• Pallow
• Paresthesia (pins and needles)
• Paralysis

• Dry Gangrene
• Wet Gangrene
• Gas Gangrene