How frequent are the ulcerations of the feet and what is their significance

The prevalence of feet ulcerations in diabetic persons is in the order of 4-10 percent, whereas their incidence is 2.2-5.9 percent per year. Ulcer frequency is lower in younger persons aged less than 45 years (1.7-

Figure 17.2. Neuroischaemic painful ulcer on the lateral surface of the heel. A second smaller ulcer is observed on the head of the 1st metatarsal. The base of the ulcer is necrotic. The presence of skin cracks is evident due to neuropathy and anhidrosis.

3.3 percent) and higher in persons older than 60 years (5-10 percent), regardless of the type of DM. Many studies have shown that around 5 percent of diabetic people have a history of foot ulceration, while around 15 percent will have an ulceration in their lifetime.

The significance of the ulcers lies in the fact that about 85 percent of leg amputations in diabetic persons have foot ulceration as their underlying cause. These ulcers are difficult to heal. Infections of both soft tissues as well as deeper tissues (abscesses, osteomyelitis) are a frequent complication of chronic ulcerations and are the cause of amputations in 20-50 percent of cases. For this reason, detection of high risk people for development of foot ulceration is of paramount importance as well as their education and the application of measures that decrease the chance of ulcer development. It has been proven that with education and

Figure 17.3. Neuroischaemic painful ulcer on the lateral surface of the foot caused by trauma from new shoes. The base of the ulcer is necrotic and the periphery of the lesion is red.
Figure 17.4. Ischaemic ulcer on the dorsum of the second toe in a patient with critical ischaemia. Discoloration of the toe distally to the lesion, the loss of hairs and onychodystrophy of the big toe are also seen.
Figure 17.5. Dry gangrene on the periphery of the toes. The precise demarcation of the ischaemic skin necrosis up to the ankle joint is seen.

Table 17.1. The differential diagnosis of ulcers





Hyperkeratosis Base

Periphery of ulcer Findings of peripheral neuropathy Findings of peripheral arteriopathy


In points of increased pressure in the plantar surface (metatarsal heads, heel, plantar surface of big toe) Abundant around the ulcer Healthy granulomatous tissue* Hyperkeratosis Yes


In the peripheral borders of the foot and in the dorsal surface


Necrotic (yellow or gangrenous tissue) Redness No

*When neurotrophic ulcers are complicated by infection, pain may be present and their base be dirty.

Arterial pressure



Arterial pressure



Figure 17.6. Pathogenetic mechanisms that lead to ulcer formation. Modified from: Boulton A.J.M(2000). The pathway to ulceration. Aetiopathogenesis, in A.J.M, Boulton H., Connor PR. Cavanagh (eds), The foot in diabetes (3rd edn). Wiley, Chichester, p 21.

application of preventive measures, the rate of amputations in diabetic persons can be decreased by at least 50 percent.

Apart from amputations, treatment of ulcerations per se implies a great financial burden. The cost of treating an ulcer in the USA in 1997 was $16,850. The psycho-social burden on the patients should be added on this financial cost, since these persons need the continuous care of other people, transiently stop working and significantly restrict their social activities.

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