The principal factors for ulcer development are the loss of sensation on the feet and peripheral vascular disease. Peripheral neuropathy, apart from loss of sensation, can also cause anatomic deformities on the feet, since it causes atrophy of the small foot muscles (claw toes, protrusion of the metatarsal heads, shifting of the subcutaneous protective fat pads from the metatarsal heads towards the bases of the toes) and instability when walking. These disturbances, combined with the anatomic deformities, result in an increase of the applied pressure on some areas of the sole (metatarsal heads, plantar surface of the big toe, heel). Peripheral neuropathy of the sympathetic nervous system brings about dryness of the skin in the feet. This, together with the increased pressure on the sole, is responsible for callus formation. The presence of calluses significantly increases the chance of foot ulceration, whereas their frequent removal dramatically decreases the pressure applied on the foot and protects it from ulcer formation.
Other risk factors for ulcer development are long DM duration, the presence of other - microvascular - complications, oedema and non-compliant behaviour of the patients regarding advice given to them for foot care and application of appropriate preventive measures. Also, people living alone or in nursing homes are at increased risk of ulcer development.
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