Dr Nkemjika (Kemji) Abiakam
THE MORTALITY OF DIABETIC FOOT ULCER: AN UNDERESTIMATED SOCIO-ECONOMIC THREAT
Diabetes represent a huge burden both for the healthcare systems as well as for the society. Its implications are well known and have been extensively reported in scientific literature.
It has been estimated that almost 3.5 million people in UK are affected by diabetes and the prevalence of this disease is expected to raise up to 5 million by 2025.
Diabetes is divided in 2 categories namely Type 1 and Type 2.
Type 1 diabetes, also known as insulin-dependent diabetes, is due to the destruction of pancreatic cells, which are responsible for the production of insulin. The latter has the duty to regulate glucose blood level.
Type 2 diabetes, instead, is caused by the resistance of the body to insulin, which results in accumulation of sugar in the blood. About 90% of people with diabetes have Type 2 diabetes.
Diabetes could lead to several skin conditions which can be a major discomfort for patients and a significant drain on resources for health care providers. Diabetic foot ulcers (DFUs) are amongst the most prevalent chronic skin injuries in many countries, including UK. It is estimated that 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives. DFUs precede more than 80% of amputations in people with diabetes and after a first amputation, there is a high probability to have a subsequent second amputation. In addition, there is an increase up to 70% in mortality rate of DFUs patients following amputation.
COST FOR TREATING DIABETIC FOOT ULCERS
The mean cost of treatment over 12 months for diabetic foot ulcers have been estimated by UK’s National Health Service (NHS) to be £7800 per patient (Guest, Fuller et al. 2018). This cost includes dressings, community nurse visits, compression systems, bandages, GP visits, prescriptions, amputations, laboratory tests and specialist visits. NHS has reported the cost of health care for ulceration and amputation in diabetes for the population in England to be between £837 million and £962 million (Kerr, Barron et al. 2019).
SYMPTOMS AND DIAGNOSIS
Early symptoms of DFUs are redness, unusual swelling, irritation, and odours from one or both feet. There could also be stains on the patient’s socks as a result of the ulceration leakage. A visual sign of ulceration is called “eschar”, a black tissue surrounding the compromised site. The formation of eschar is due to the absence of blood reaching the area around the ulcer.
It is important to highlight that signs of an ulcer occurring under the feet might not be clear initially until the ulcer become infected. It is, therefore, of vital importance for people affected by diabetes to have a regular skin check, especially under their feet.
DIABETIC FOOT ULCER RISK FACTORS
Anyone affected by diabetes is at risk of acquiring DFUs. However, some factors can increase the probability of this skin condition occurring. These include:
- Kidney disease
- Poor hygiene
- Poorly fitted shoes
- Use of tobacco and alcohol consumption
- Heart disease
PREVENTING DIABETIC FOOT ULCERS
In order to reduce the escalating foot amputations as well as reducing the mortality rate due to DFUs, the adoption of appropriate prevention strategies is of crucial importance. It is necessary for the individuals affected to manage properly their blood sugar level as this reduces the chances of complications happening. Also important is to include rigid skin healthcare regime in one’s lifestyle.
Wash and check your feet every day, wear appropriate footwears following your doctor’s instructions, keep your feet dry and moisturized, adequately trim toenails and often visit the podiatrist for callus and corn removal.
THE NEED OF DIABETIC FOOT ULCER EARLY DETECTION
At present, clinicians assess the risk of DFUs occurring using visual means, monofilaments and tuning forks. These represent qualitative measures and do not adequately capture the risk status of ulcer development. Laboratory measurements, such as erythrocyte sedimentation rate (ESR), procalcitonin (PCT), C-reactive protein (CRP), aid in the diagnosis of diabetic foot ulcers when there are misleading visual signs. However, these biological markers are still not detectable at an early enough stage to prevent the initiation of the ulcer. In the past decade, there has been considerable interest in research on detection of diabetic foot ulcers using thermal imaging. Neuropathic feet have an elevated temperature and the resulting thermal gradient has been employed as a detection parameter by various research groups with thermographic measurements used to identify feet at risk. Despite its detection potential, this method suffers from low specificity. There is, therefore, a compelling need for novel medical technologies that can detect DFUs at early stage in order to enable clinicians to adopt the best preventive strategies. More research in future is necessary for this to happen.