Guidelines for doctors

Examine every diabetic patient's feet on diagnosis and annually. On examination check:

♦ Skin—colour, ulcers, rubs, blisters, corns, calluses, etc.

♦ Foot and toe shape—hammer or claw toes, bunions, missing toes, surgery, deformities

Sunset Foot Ischaemia

Fig. 14.1 The diabetic foot: warning signs during exami- Infection nation

♦ Pulses—dorsalis pedis and posterior tibial

♦ Sensation—light touch, Monofilament, vibration, position

Danger signs

Colour change Red foot (infection or 'sunset' ischaemic foot); white (no circulation); blue/black (gangrene). Refer to hospital immediately.

Infection Any foot infection in patients with neuropathy or vascular disease should be treated by staff used to such problems. This is usually the hospital diabetes team. If you suspect any infection is major or extends below the immediate subcutaneous tissues refer the patient to hospital immediately. Superficial infected areas should be cleaned and dressed (see Table 14.1) and seen daily by a nurse or doctor until healed. Any infection which is not healing within three days should be referred to hospital. Refer patients with worsening foot or leg infection to hospital immediately.

Swelling This may mean infection, autonomic neuropathy, Charcot joints, cardiac failure, or nephrotic syndrome. It is often a danger sign in people with diabetes. Consider referral to a diabetologist.

Previous surgery

Table 14.1 Look after your feet: guidelines for patients

1. Look at your feet every day. Use a mirror or ask someone else to help if you have difficulty seeing.

2. If you have any of the following see your doctor (or chiropodist or diabetic clinic) within 24 hours:

any colour change any new pain or unusual feeling any sore places (corns, blisters, cracks, calluses, ulcers, bunions) swelling anywhere any break in the skin (ulcers, cracks, blisters) a strange smell from your feet

3. Treat any skin break by washing with dilute antiseptic (follow the instructions on the container), drying gently with sterile gauze, and covering with a dry dressing (e.g. N-A dressing). Use non-allergic tape (e.g. Micropore) and never wind it round a toe. Then contact help.

4. Wash your feet daily in lukewarm water. Dry carefully, especially between the toes.

5. If you have dry skin use a moisturizing cream or emollient lotion, but not between the toes.

6. Cut toenails in a gentle curve without leaving sharp edges to dig in to that or other toes.

7. Wear clean socks, stockings, or tights every day.

8. Buy shoes which do not squeeze your foot, and which do not hurt or rub anywhere the first time you try them on. Low-heeled lace-ups with plenty of toe room are best.

9. Do not walk bare foot.

10. Do not use corn cures, or cut corns or callus.

11. Do not use a hot water bottle.

12. Do not use vibrating foot massagers or baths.

13. Do not smoke.

14. See a state registered chiropodist regularly (SRCh).

This table may be photocopied for use by patients only. ©2002 Dr Rowan Hillson. From Practical diabetes care, Oxford University Press, 2002.

Pain This requires urgent investigation. It may represent an easily treatable problem, tight shoes for example. Or it may represent major trouble such as infection. Remember that neuropathy may blunt pain but that it can also cause pain. Furthermore, although Charcot joints develop in neuropathic limbs, they may be painful while evolving. Repeat X-rays in diabetic neuropathic patients with persistent pain, swelling, or heat after an injury.

Heat A hot area may indicate infection or an active Charcot joint. Such 'hot spots' should always be investigated.

Cold A cold foot or leg strongly suggests vascular insufficiency. Rapidly developing coldness indicates acute vascular block and the need for urgent action (see p. 143).

Absent foot pulses (See p. 143).

Neuropathy (See p. 131).

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