Wet necrosis with rapid onset

A 73-year-old Afro-Caribbean woman with type 2 diabetes of 30 years' duration, peripheral vascular disease and a previous below-knee amputation attended the diabetic foot clinic with a 2-cm broken blister on her left heel. She was obese and confined to a wheelchair. She did not want to take antibiotics and said she would prefer not to have visits from the district nursing service as her daughter, with whom she lived, would look after the foot. Her daughter was carefully taught to clean and dress the foot, and advised to check it every day. We emphasized the need for immediate return to the diabetic foot clinic if any deterioration occurred. The patient returned to clinic 1 week later, for her routine appointment, with a discharging, malodorous ulcer and extensive deep necrosis. She was admitted to hospital and given intravenous antibiotics. She had angiography but there was severe infrapopliteal disease and no distal arterial run-off. No vascular intervention was feasible and she underwent a second below-knee amputation.

Keypoints

• Ischaemic foot ulcers can become infected rapidly and deteriorate to wet necrosis with alarming rapidity

• Detection of deterioration was rendered more difficult because the patient had very heavily pigmented skin and did not want home nursing visits

• We encourage our patients and their families to be 'critically observant'. At the first appearance of a break in the skin, no matter how small and shallow, they are advised to seek help the same day.

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