Diabetic Foot Care: Prevention and Management

Diabetes and high blood sugar levels can affect the feet in various ways. Over time, it can cause damage to:
1. Blood vessels, causing peripheral vascular disease
2. Nerves, causing neuropathy

Together, these conditions increase the risk of foot wounds.

High blood sugar levels cause blood vessels to narrow, reducing blood supply to the feet and legs. This causes the feet to be deprived of oxygen and nutrients, and makes it harder for any wounds to heal.

Neuropathy
About 50% of people with diabetes will develop neuropathy that can affect their feet in various ways such as:
- Pain
- Burning sensation
- Numbness
- Muscle cramps
- Loss of foot sensation
- Foot deformities

What can I do to protect my feet?
It is important to check your feet regularly for any injuries, wounds, blisters and skin thickening (callus). You should also attend an annual diabetic foot screening with your healthcare provider to check for any reduced sensation and blood flow to your feet.

Early diagnosis and treatment of hard skin and wounds reduces the risk of complications (including amputations).

Diabetes can cause many undesirable complications in the feet and lower limbs, so it is important for people with diabetes to have a correct foot care regime to keep their feet healthy.

In a person with diabetes, foot conditions like hard skin, ingrown toe nails, blisters or cuts can often lead to wounds, which can easily deteriorate if no proper care is taken. Thus, it is important for people with diabetes to check their feet daily to avoid foot complications.

How to check your feet
It is important for a person with diabetes to check his or her feet daily. Diabetes can damage the nerves in the leg and lead to a loss of sensation in the feet. As a result, you may not be able to feel pain even when there is something wrong with your feet.

1. Check the top and bottom of your feet and behind your heels.

2. Look in between your toes for whitish skin or breaks in skin.

3. If you are unable to bend down, use a mirror or get your family member or caregiver to do it for you.

Cleanse any skin breaks with an antiseptic solution such as iodine and dress with a sterile dressing. Do not burst blisters.

1. Use a callus foot file to gently file any hard skin or corn sites.

2. Do not file with too much force as it can cause a skin abrasion.

3. If the amount of hard skin or corn builds up quickly, you may have to increase the frequency of filing.

Do not use scissors, knives, blades or nail clippers to remove the hard skin or corn as it may cut the skin and injure it, resulting in a wound.

Do not use corn plasters or liquid corn/callus removers. They can cause the skin to break down and create wounds.

If you are concerned or unsure about how to do it, please seek advice from your doctor or podiatrist.

Avoid cutting the sides of your toenails as this could lead to ingrowing toenails and possible infections. Instead, file to smoothen out nail edges.

When choosing a pair of shoes, always ensure that the shoes are appropriate with supportive features and are a good fit.

Footwear should ideally have removable insoles and sufficient depth to allow insertion of orthoses, if required.

What to look out for when choosing a supportive shoe:

1. Wide and deep toe box
Allows for sufficient room for toes and prevents skin abrasion from occurring.

2. Laces or buckles
Secures feet firmly in shoes and prevents slippage and risk of falling.

3. Firm and rigid heel counter
Holds your heel in place when you are walking.

4. One thumb's width spacing
Allow for one thumb's width spacing from the longest toe to the front of the shoe to ensure adequate space for your feet when walking.

5. Flexible toe box
Shoe should be flexible only at the balls of the feet so as to encourage efficient toe-off when walking.

6. Midsole
Midsole should not be too flexible to maintain stability of the mid-foot.

What to remember when buying a pair of shoes
1. Before buying, it is best to try on the shoes to ensure a proper fit.

2. Avoid having someone else buy the shoes for you or even buying them online without trying them on.

Foot care tips to remember at home
Do not: walk barefoot at home.

This is to prevent injuring your feet when:
1. An object accidentally drops on your foot

2. You accidentally hit your foot against an object

3. You accidentally step on a sharp object

Do: Always wear protective cushioning slippers at home to protect your feet.

1. Avoid exposing feet to high or low temperatures
Do not use heat pads, a hairdryer, light therapy or hot foot soaks to warm your feet, and ice packs or cold foot soaks to cool your feet. They can result in skin burn injuries.

Why:
It is common for people with diabetes to develop a loss of sensation in the feet. When this happens, they are not able to sense the change in temperature as a person with normal sensation would be able to.

Thus, it is dangerous for people with diabetes to use heat pads, a hairdryer, hot foot soaks or light therapy to warm their feet as they may burn their feet.

Likewise, the usage of ice packs or cold foot soaks is also not recommended. The skin tissue gets damaged when the skin comes into contact with very cold objects, which may lead to an ice burn.

Avoid soaking the feet for prolonged periods of time as this could cause the skin to wrinkle and break down.

Foot basins can also contain germs which can enter skin breaks in the feet and cause infections.

What you should do:
If your feet are cold, wear a pair of thick cotton socks to warm them up.

For foot soaks, check the temperature of the water with your elbow or get your family member/caregiver to test, and ensure that the water temperature is lukewarm prior to placing your feet into it.

2. Avoid walking barefoot or wearing slippers

Why:
This exposes your feet to sharp objects in the surrounding environment, increasing your risk of getting cuts or injuries. Germs can enter through the skin breaks and cause an infection.

This is especially so for those with a loss of sensation in their feet as they are unable to feel the cut or injury and may leave the skin break untreated.

What you should do:
When going out, it is important to always wear a pair of covered shoes. Shoes should be worn together with cotton socks to absorb sweat. Ensure that socks are changed after each use for hygiene purposes.

At home, wear cushioning home slippers to protect your feet. Also, check your feet with a mirror daily to ensure there are no cuts, injuries or changes from the norm.

3. Avoid walking on pebble foot reflexology paths or going for foot reflexology or massages.

Why:
On a hot day, the pebbles on the foot reflexology paths readily absorb heat and can cause severe burns to your feet. The uneven ground and any sharp objects in between the pebbles can also cause a foot injury.

The pressure exerted on the foot during foot reflexology or massage sessions may cause injuries to your foot as well.

4. Avoid cleaning foot wounds with seawater and/or going for a fish spa.

Why:
Seawater and fish spas are not sterile and contain many harmful germs and foreign particles. The risk of foot infection is high if wounds are washed with seawater.

Fish in the fish spa nibble on the dead skin of people's feet, and germs from one person can easily spread to another.

What you should do:
Wounds should be cleansed with sterile water or saline prior to applying dressing on the wound.

5. Avoid leaving wounds exposed to air-dry

Why:
This exposes the wound to germs and even flies in the environment.

Drying the wound with a fan or hairdryer will not help heal the wound faster and may instead cause further complications.

The longer a wound is left uncovered, the higher the chances are of developing an infection at the wound site.

What you should do:
Wounds should be covered with sterile dressing at all times to prevent infections from occurring.

6. Avoid use of traditional remedies for wound care

Why:
There is no scientific evidence to prove that traditional medicated ointments are beneficial for wound care. In fact, some of the ingredients may even cause wound deterioration and delay wound healing.

What you should do:
If you get any superficial wounds or cuts, cleanse them with an antiseptic solution such as iodine and cover with a dry dressing. if the wound fails to heal or worsens, please seek medical advice from the polyclinic, GP or hospital. 

1. Cleanse any new skin tear, blister or foot wound with an antiseptic solution like iodine, and cover with a dry sterile dressing. Monitor for any signs of infection or deterioration.

2. If you notice any signs of infection, pus discharge, changes in skin colour or swelling in your feet, contact your GP, polyclinic doctor or podiatrist within 24 hours.

3. Go to the A&E (Accident & Emergency) Immediately if you get any severe foot pain or sudden cold foot, or if your doctor or podiatrist is not available.

4. Remember, any delay in seeking advice or treatment could lead to severe complications.

Ref: F26