A 52-year-old man with type 2 diabetes of 20 years' duration and profound neuropathy originally attended the diabetic foot clinic with neuropathic ulceration. This healed with regular debridement and special shoes. He was taught to check his feet every day, was careful to avoid trauma and had been ulcer free for 7 years. He attended the diabetic foot clinic at 3-monthly intervals for routine foot care and education.
He went on a business trip to Scotland and stayed in a hotel. During the night he was woken by a strong smell of cooking meat in his bedroom. On investigation he found a hot water pipe running along the wall by his bed, against which his foot had pressed in his sleep. He flew back to London the next morning for an emergency foot clinic appointment. He had a deep burn across the plantar surface of his forefoot which was cellulitic and discharging pus. He was admitted to hospital the same day for intravenous antibiotics. The burn gradually took on the appearance of a neuropathic ulcer, surrounded by heavy callus which needed regular debriding. Even when he was non-weightbearing, callus continued to develop. The foot healed in 17 weeks.
• No matter how careful patients who lack protective pain sensation are, they will sometimes injure themselves
• Patients in unfamiliar places are particularly vulnerable
• Patients should be specifically warned about the dangers of hot water pipes and radiators on bedroom walls
• Burns are hard to assess in neuropathic patients because all burns (not just third-degree burns) are painless (see Chapter 4).
Traditional remedies and alternative medicine Some traditional remedies may be hazardous, in particular for feet with neuropathy. We have seen:
• Severe burns following treatment by a traditional Chinese physician who heated eggs in a pan until they were black and charred and slapped them directiy onto the foot 'to draw the edges of the ulcer together'
• Maceration and infection following topical papaya ointment application
• 'Animal wool' wrapped around the toes to relieve pressure on interdigital corns, which absorbed perspiration, shrank and constricted the blood supply.
Patients and providers should be wary of unproved therapies.
The internet is full of details of folk remedies and new treatments. We ask patients to discuss the use of these remedies with us first so that we can establish their merits or dangers.
When traditional medicines prevent patients from seeking professional help their use is particularly dangerous.
Proprietary remedies can also be dangerous for the complicated diabetic foot. Many corn and callus removers contain salicylic acid. Many proprietary remedies contain equivocal advice which may be regarded by the patient as an indication that the products are safe. Warnings that patients with diabetes or peripheral vascular disease should not use them are frequently in a very small type which the patient with eye problems may be unable to read.
No matter how careful patients with neuropathy are, problems will sometimes occur. Without protective pain sensation it is extremely difficult to avoid and detect trauma, even if the patient takes great care.
Individualized trauma prevention programmes should take into account personal lifestyle and holiday and occupational activities.
Patients in stage 2 are usually advised to avoid walking barefoot but if this is not possible the following precautions may help:
• Walking barefoot at temple or on pilgrimage to Mecca will be safer at dawn and dusk than in the heat of the day
• Grouting of floor tiles should be smooth
• Patients should clear up spillages immediately so they do not step on spilt uncooked rice or lentils or broken dropped objects.
Holiday foot care
Patients who are in unfamiliar places are at particular risk.
We remember a patient whose toes were crushed when a bus driver in Greece unfolded a seat onto his foot trapping his toes, but he was unaware of this until he tried to get up at the end of his 50-mile journey.
Trauma occurrence is particularly common in people on holiday. The reasons include the following:
• Unfamiliar environment exacerbates problems caused by poor vision or unsteady gait
• Lack of easy access to professional help
• Holidays regarded as a carefree time, when one can escape from the usual pressures
• Usual shoes discarded
• Increased alcohol consumption. Dangers of the beach include:
• Cuts from sharp rocks, sea shells and broken glass
• Abrasions from sharp corals and sand or putting shoes on sandy feet
• Puncture wounds
• Not drying feet properly, leaving skin soggy and susceptible to trauma
• Insect bites and stings
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