Check out these best practices for trimming your diabetic patient’s toenails to help prevent foot ulceration.

Did you know that a whopping 10-25% percent of all patients with diabetes ultimately develop a foot ulcer – a diagnosis that brings a five-year mortality rate of nearly 50%? Consistent foot care, such as regular screenings, footwear assessment and nail maintenance can help prevent ulceration.

You can help diabetic patients with nail maintenance by taking extra care to preserve the integrity of the toenails. This includes keeping the cuticles and surrounding skin intact, and following best practices when trimming the nails. That’s why we’ve put together our top tips for proper trimming.

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Five clinical tests for diagnosing loss of protective sensation in the diabetic foot, plus tips on inflammation assessment.

How serious are diabetic foot ulcers? The statistics are sobering:

• It is estimated that between 10 and 25% of patients with diabetes will develop a foot ulcer in their lifetime.
• Diabetic foot ulcers precede 84% of all lower leg amputations.
• The five-year mortality of patients with newly diagnosed diabetic foot ulcers (DFUs) is nearly 50%, and carries a worse prognosis than breast cancer, prostate cancer, or Hodgkin’s lymphoma.

In addition, DFUs are at increased risk for infections and other complications, and continue to be a major cause of hospitalizations and additional healthcare expenditures.  So while patients suffer greatly from DFUs, these chronic wounds are also a huge financial burden on healthcare systems. This is because these same patients spend more days in the hospital, and experience more visits to the emergency room and outpatient physician offices than other patients with diabetes.

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Detecting neuropathy in the diabetic foot is crucial for patient care, which is why the 10-step monofilament test is a must when it comes to injury and ulceration prevention.

Healing patients and helping them get on the road to recovery are always at the top of any wound clinician’s list. We are always on alert and in constant assessment mode, looking for ways to prevent further complications or possible injury. So when a patient also happens to be diabetic, our assessment mode goes into overdrive.

One of the most common complications of diabetes is neuropathy, or nerve damage of the extremities. With sensory neuropathy, the patient loses protective sensation and the ability to feel pain and temperature changes. Without protective sensation, the diabetic patient is at an increased risk for foot injury or ulceration, and may not realize anything is amiss until there are serious complications.

Neuropathy Screening

This is why testing your diabetic patients for neuropathy is so important. In fact, the American Diabetes Association recommends that we screen diabetic patients for neuropathy annually, at minimum. Once we note any diminished sensation, we should check quarterly.

One way to assess protective sensation in the diabetic foot is to perform a Semmes Weinstein 10g Monofilament Test across designated sites on the foot.  The test uses a 5.07 monofilament that exerts 10 grams of force when bowed into a C-shape against the skin for one second.

How to Perform the Semmes Weinstein 10g Monofilament Test

The test procedure is as follows:

1. Use the 10gm monofilament to test sensation.
2. Have patient close his or her eyes.
3. Apply the filament perpendicular to the skin’s surface.
4. Be aware that the approach, skin contact and departure of the monofilament should be approximately 1.5 seconds in duration.
5. Apply sufficient force to allow the filament to bend. (Figure 1).
6. Do not apply to an ulcer site or on a callous, scar, or necrotic tissue.
7. Do not allow the filament to slide across the skin or make repetitive contact at the test site. Randomly change the order and timing of successive tests.
8. Ask the patient to respond, “Yes,” when he or she feels the filament.
9. Document response when felt, and test for sensation (Figure 2).
10. Be aware that neuropathy usually starts in the first and third toes, and progresses to the first and third metatarsal heads. It is likely that these areas will be the first to have negative results with the 10gm monofilament. Repeated testing can demonstrate vividly to the patient the progression of the disease.

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. Injury is much more likely to occur in these insensate areas and we must take protective measures. Provide patient education verbally and in writing, such as these materials from the American Diabetes Association, and be sure to do a good shoe fit assessment as part of your care plan.

Do you administer the Monofilament test?

Are you familiar with the Semmes Weinstein 10g Monofilament Test, and do you administer it on a regular basis to your diabetic patients? Has monofilament testing produced significant results in terms of prevention and assessment? We are interested to know about your experiences in diabetic foot testing, so please leave your comments below.

Click to download this easy-to-use resource for performing foot examinations.

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

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.

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.

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 of diabetic foot infection?

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:

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

How do we diagnose diabetic foot 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.