A 76-year-old woman with type 2 diabetes of 7 years' duration, developed necrosis of her right 4th toe. She was neuroischaemic with a pressure index of 0.4, and no vascular intervention was possible. The necrosis was treated conservatively and her daughter was asked to keep the toe dry and to ensure that dressings were applied to separate the necrotic toe from its neighbours. However, her daughter allowed her to have a bath, and did not separate the toes with dressings. When she attended the diabetic foot clinic 1 week later, the necrosis was moist and necrosis was also present in an adjoining toe where it had been in contact with the necrotic toe (Fig. 6.26).
She was admitted to hospital and received intravenous antibiotics. The pressure index had not fallen. The necrosis became dry and well demarcated again and spread no further. Seven months later the toe separated to reveal a healed stump.
• Patients should not immerse their necrotic toes in the bath. Moistening necrosis may encourage infection
• Furthermore, if a necrotic toe is in direct contact with a viable toe, the necrotic toe may 'absorb sweat' and become moist. The area of moist necrosis is an excellent culture medium for bacteria which then spread from the necrotic toe to the adjoining toe
• If the interdigital area is macerated it is no longer a barrier to bacteria which may enter the viable toe and cause ulceration and necrosis
• Neuroischaemic feet with dry necrosis may remain at stage 5 for many months until the necrotic toe drops off to reveal a healed stump.
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