Posts Tagged ‘diabetic wound assessment’

Dry Skin Alert: Foot Xerosis in Diabetic Patients

Thursday, January 14th, 2016

Diabetic wound management requires awareness, including knowing the signs and progression of xerosis – an abnormal dryness of skin.

Xerosis in Diabetic Patients

Patients with diabetes are prone to dry skin, particularly when blood glucose levels are running high. And as a clinician, one of the most common types of skin conditions you will see in your diabetic patients is xerosis, which is an abnormal dryness of the skin. This is just one reason why clinicians should routinely inspect the feet of diabetic patients.

According to research, 82.1% of patients with diabetes had skin with dryness, cracks or fissures, which serves as a predictor of foot lesions. In addition, an unpublished survey of 105 consecutive patients with diabetes revealed that 75% had clinical manifestations of dry skin. This serves as further evidence that xerosis in diabetic patients is a threat to foot ulcers, and the more we know about the condition, the better we can treat and heal our patients.

The Signs

The most common characteristics of xerosis include excessively dry, rough, uneven and cracked skin. Other signs include:

  • Possible raised or uplifted skin edges (scaling), desquamation (flaking), chapping, and pruritus.
  • Excessive dryness and scaling on the heels and feet.
  • Possible fissures (linear cracks in the skin) with hyperkeratotic tissue.

Progression and Patterns

The progression of xerosis follows a defined pattern that begins when the skin becomes dry and rough, with pronounced skin lines. As the condition progresses, you’ll see the development of superficial scaling, with fissuring and erythema. In severe cases, a crisscrossing pattern with superficial scaling is present. The skin becomes less elastic and loses both its flexibility and its ability to withstand trauma, which may result in skin breakdown and subsequent infection.

Causes

A number of conditions contribute to the onset of xerosis in diabetic patients, including the loss of natural moisturizing factors and moisture from the stratum cor­neum and intercellular matrix of the skin. Additionally:

  • Sebaceous and sweat glands normally maintain skin lubrication and control the oil and moisture in the foot, but they become atrophied when autonomic neuropathy occurs.
  • Corneocytes (cells that make up the top layer of epidermis) are aligned parallel to each other in normal skin; xerosis causes structural changes to these cells and disrupts the surface, resulting in a rough epidermal surface.
  • The dryness is due to the redistribution of blood flow in the soles of the feet by persistent and inappropriate dilatation of arteriovenous shunts. This activity diverts blood away from the skin surface. When this occurs in combination with alterations in the elasticity of the skin (due to nonenzymatic glycosylation of structural proteins and glycoproteins), the skin splits, creating portals for bacteria to enter.

Treatment

Once you see initial signs of xerosis in your patients, what should you do? Start by applying an agent to the feet every day in order to maintain skin moisture, such as an emollient lotion or cream. Use moisturizers that contain urea or lactic acid.

  1. Urea works by enhancing the water-binding capacity of the stratum corneum. Long-term treatment with urea has been demonstrated to decrease transepidermal water loss. Urea also is a potent skin humidifier and descaling agent, particularly in 10% concentration.
  2. Lactic acid (in the form of an alpha hydroxy acid) can accelerate softening of the skin, dissolving or peeling the outer layer of the skin to help maintain its capability to hold moisture. Lactic acid in concentrations of 2.5% to 12% is the most common alpha hydroxy acid used for moderate to severe xerosis.
  3. Examples of products with urea or lactic acid include Atrac-Tain Cream, Eucerin 10% Urea Lotion, Lac-Hydrin 12%, and AmLactin Foot Cream Therapy.

Additionally, it’s important to avoid:

  • Products that contain alcohol – because they evaporate, and their drying action compounds the original problem.
  • Petroleum-based products, because they seal the skin surface and prevent what little lubrication is made from evaporating. These products don’t penetrate the surface of the skin and don’t replace skin moisture.

Patient education

As always, part of our job is to continuously educate patients and their family members or caretakers. When it comes to your patients suffering from xerosis, make sure they know to:

  • minimize bathing to no more than once a day (or even every other day)
  • use cool or lukewarm water
  • pat – don’t rub – to dry the skin
  • avoid harsh soaps
  • avoid lotions with dyes or perfumes
  • ensure skin moisturizers are applied appropriately and at the right frequency

What do you think?

Knowing the signs of xerosis and how to treat it is crucial for diabetic patients. Have you had experience with this condition, and are there any specific techniques, treatments or products you find most effective? And what are the biggest challenges you face when it comes to this particular type of wound management? We would love to hear about and learn from your experiences! Please share your stories below.

 

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

Urgent! Risks and Diagnosis of Diabetic Foot Infections

Friday, January 8th, 2016

For effective diabetic wound management, clinicians must know the risk factors for foot infections, and be able to diagnose them properly – and as soon as possible.

Diabetic Foot Infections

Wound care clinicians deal with foot infections all the time, but when the patient is also diabetic, an infection can progress rapidly to a critical state. In fact, it is estimated that around 56% of diabetic foot ulcers become infected, and an infected foot wound precedes about two-thirds of amputations.  Being able to treat diabetic foot infections promptly – before they progress too far – helps prevent amputations, which is why your role is so crucial to a patient’s well-being.

What are the risk factors?

If you are treating a diabetic patient with a foot infection, there are a number of risk factors to consider. These include:

  • 30-day-old wounds
  • Wounds that go down to the bone
  • Recurrent foot infections
  • Peripheral vascular disease
  • An etiology from trauma

In particular, be on high alert with your diabetic patients for what they call an occult (hidden) infection. A diabetic foot ulcer could clearly have an infection, but fail to show any of the classic signs and symptoms that you traditionally look for, like erythema, heat, pain and purulence.

Because a diabetic patient’s immune system is compromised, you might be on the lookout for typical signs but not see any of them at all. This does not mean that an infection isn’t there; only half of diabetic foot ulcer patients will show classic signs, which means we also need to work our patients up for infection.

The best approach? Be persistent and keep looking for more signs, like:

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  • Serous exudate (thin, clear, watery)
  • Delay in healing
  • Friable (fragile) granulation tissue
  • Discolored granulation
  • Odor
  • Pocketing in the wound bed

How do we diagnose infection?

Diagnosing infection in any wound, particularly with diabetic patients, is a clinical one (versus a lab diagnosis). So if you ever hear a colleague say, “We’re going to wait for the lab results to see if our patient has a wound infection,” it’s time to stand up and emphatically say, “No!” Why? Because lab results, specifically the swab cultures that are most commonly used, are often inconclusive in the presence of biofilm. Instead of waiting for the results, you need to act immediately.

That’s not to say that lab results aren’t useful. They can sometimes help us confirm infections and target which antibiotic we want to use. But again, most infections are polymicrobial (containing more than one kind of bacteria), and swab cultures don’t pick up everything. We need to use our clinical judgment and supplement with lab and cultures.

The Final Word

As wound care professionals, prevention is obviously our first line of defense against any wound complications from infections. But when caring for diabetic patients, clearly understanding the risk factors for foot infections, and then being able to diagnose conditions as soon as possible, are crucial for effective treatment.

What do you think?

Have you had experience in treating diabetic patients with foot infections? Have you been able to identify the infection in a timely manner? Is there a particular case that was exceptionally challenging or difficult? Please tell us about it, and leave your comments below.

Really, How Important is that Monofilament Test?

Monday, January 26th, 2015

Neuropathy is one of the most common risk factors for lower extremity complications in our diabetic patients. With sensory neuropathy the patient has a loss of protective sensation that leads to a decrease in the ability for our diabetic patient to sense pain and temperature changes. This loss of protective sensation puts the patient at an increased risk for plantar foot injury. Unfortunately the patient may not feel the injury until significant complications have occurred.

The American Diabetes Association set up guidelines for us as healthcare professionals, these guidelines recommend screening in diabetic patients for neuropathy to check for loss of protective sensation on an annual basis, one way this can be done by doing the Semmes Weinstein Monofilament test. If the patient is found to have decreased sensation and is found to be at high risk the monofilament test should then be done quarterly.

The Semmes Weinstein 10g Monofilament is a test that checks for protective sensation in the diabetic foot.  It uses a 5.07 monofilament that exerts 10 grams of force when bowed into a C-shape against the skin for one second.  We don’t apply the filament directly to the ulcer site, callous, scar or necrotic tissue. Ask the patient to close their eyes during the exam and tell them to reply “yes” when the monofilament is felt, repeat without touching skin occasionally to be sure of patients response. Be sure to use random order on successive tests.

Areas to be tested include the dorsal midfoot, plantar aspect of the foot including pulp (fleshy mass on the distal plantar aspect) of the first, third, and fifth digits, the first, third and fifth metatarsal heads, the medial and lateral midfoot and at the calcaneus.  Record the results on the screening form, noting a “+” for sensation felt and a “-” for no sensation felt. The patient is said to have an “insensate foot” if they fail on retesting at just one or more sites on either foot.

Those patients who cannot feel the application of the monofilament to designated sites on the plantar surface of their feet have lost their “protective sensation”. Without this protective sensation the diabetic is now at increased for injury or ulceration. Neuropathy is usually noted in the first and third toes and then progresses to the first and third metatarsal heads.

Injury is much more likely to occur in the diabetic insensate foot at these areas and interventions must be implemented to protect the diabetic foot that is at risk for ulceration. Patient education and good “shoe fit assessment” will be part of our plan of care to protect the diabetic neuropathic patients foot.