Diabetic Foot Care

Introduction

Although not necessarily a glamorous task, providing self-care, foot care, and proper foot hygiene education is essential for any health-related encounters concerning a patient with diabetes. Diabetic foot complications encompass a broad array of conditions, such as bunions, calluses, fungal skin infections, foot deformities like Charcot foot, ulcerative changes, and infections^.1 The presence of neuropathy and peripheral vascular disease impedes circulation to the lower extrem- ities and compounds the effects of these conditions. This further increases the risk of ulceration and amputation.²

Foot complications related to diabetes can result in significant morbidity, mortality, increased costs, and reduced quality of life.^2-5 Foot ulceration is more common in individuals with diabetes, with one study estimating prevalence at 7.7% compared with 2.8% in patients without diabetes.⁶

Furthermore, it is estimated that patients with diabetes account for more than half of all nontraumatic lower-extremity amputations.⁷ Despite these figures, the number of patients receiving an annual foot examination by a health professional remains below 100%, suggesting that there is a role for increased pre- ventive support to reduce the risk of complications.⁸ The pharmacist is well positioned to screen patients for microvascular disease and neuropathy and has opportunities to perform a monofilament foot exam. Additionally, pharmacists can regularly emphasize the importance of glycemic control and help patients achieve their glycemic targets to reduce the risk of complications related to the foot. It is critical that pharmacists educate themselves on best practices to reduce the risk of this preventable, potentially debilitating, complication.

Risk Assessment

Pharmacists and other clinicians should be vigilant and take every opportunity to educate patients with diabetes regarding proper foot hygiene prac- tices and self-care, starting with recognizing those individuals at greatest risk of experiencing complications. Table 1⁹ describes risk factors that may

contribute to diabetic foot ulcers or amputations; identifying these risk factors may present opportunities for educational intervention and counseling.⁹

The effects of uncontrolled blood glucose, peripheral vascular disease, and reduced blood flow to the lower extremities lead to consequenc- es such as skin changes, ulcerations, impaired wound healing, and nerve damage that impedes an individual’s perception of pain or pressure. These contributing risk factors to diabetic foot complica- tions must first be recognized and then adequately addressed in the clinical setting.

Mitigating Risk Factors and Patient Education

Given the multifaceted reasons for the increased risk of foot complications associated with diabetes, education should be targeted and prioritized to each individual patient. Pharmacists should emphasize to all patients that controlling risk factors can reduce the potential of developing foot complications. Even if complications arise, early intervention can reduce ulceration, amputation, and other adverse outcomes. Table 2 ^10,11 summarizes educational points to emphasize with patients inquiring about diabetes and foot complications.^10,11

Maximizing Blood Glucose Control

Poor glucose control is associated with complications, including worsened peripheral vascular circulation and development of neuropathies. Emphasizing the importance of self-monitoring blood glucose, compliance with therapeutic agents used in the management of hyperglycemia, and adherence to dietary modification recommendations or weight-loss regimens, if appropriate, may all serve to reduce the risk of diabetic foot com- plications and other microvascular complications of diabetes.

Self-Examination of the Foot

Encourage patients with diabetes to inspect their feet each day and take notice of calluses, blisters, and skin or nail changes that could require med- ical intervention to prevent them from becoming severe. A magnifying mirror, or an inspection mirror, or simply placing an inexpensive unbreakable plastic mirror on the floor near the toilet can allow for easier inspection of the soles of the feet, which should not be neglected.

Foot Protection

In a study conducted in 80 patients with diabetes who required lower-extremity amputation, investigators found that an identifiable, and potentially preventable, initial injury or minor trauma preceded 69 of 80 amputations.¹² Patients with diabetes should be educated to never go barefoot, as seemingly minor injuries may become infected and result in potentially serious complications. Wearing properly fitting socks that do not constrict the blood flow to the lower extremities, well-fitting shoes or sneakers, and slippers or footwear even inside the house is an important point to emphasize.¹⁰

Nail and Foot Care and Hygiene

Remind patients with diabetes to wash their feet in lukewarm water every day and to carefully dry feet by blotting or patting, being mindful to dry between the toes. Although it is prudent to apply moisturizer to prevent drying and cracking of skin, patients should not apply it between the toes, as fungal overgrowth could result. To reduce the chance of an ingrown toenail, patients should carefully cut nails straight across and not too short. If patients have difficulty trimming their nails themselves or are experiencing corns or calluses, then referral to a podiatrist is warranted.¹¹

Smoking Cessation

Smoking increases the risk of peripheral vascular disease and complications, including diabetic foot complications such as ulcers, infections, and amputations. For those patients inter- ested in quitting, recommending appropriate OTC nicotine replacement therapies or a medical referral for prescription-only treatments may be warranted.

Annual Foot Examination

According to the American Diabetes Association (ADA), all adult patients with diabetes should undergo an annual com- prehensive foot examination with a clinician to identify any risk factors that may be present.⁹ Specifically, as part of a comprehensive examination, clinicians should conduct a com- plete history, which may include a history of foot ulceration or amputations, presence of neuropathies or peripheral vascular symptoms, impaired vision, kidney disease, tobacco use, and foot-care practices.⁹ Visual examination and inspection of the skin, vascular assessment of pedal pulses, and a neurologic exam with the monofilament test should also be performed.⁹

Role of the Pharmacist

Pharmacists are frequently consulted for the management of both minor and more significant foot problems. As such, it is critical that the pharmacist inquire about comorbidities, includ- ing diabetes, for patients seeking advice for the management of seemingly minor foot problems, including calluses, bunions, ingrown toenails, and fungal skin infections. Additionally, by reviewing a patient’s medication profile as part of medication therapy management, the pharmacist can proactively seek out those individuals who might benefit from additional education or mitigating strategies to reduce the risk of complication. Pharmacists are well positioned to proactively reduce the incidence of the development of diabetic foot complications through education and as part of the care plan for patients with diabetes.

Additional Information

A number of different resources and patient education tools are available from the CDC, the ADA, and the National Institute of Diabetes and Digestive and Kidney Diseases. For free patient education handouts and additional materials related to foot care for patients with diabetes, visit any of these sites for additional information.^13-15

Conclusions

Patient education and understanding the relationship between hyperglycemia, peripheral vascular disease, neuropathy, and foot complications are essential to reduce the potential for foot injury, ulceration, or amputation. Pharmacists are positioned to reinforce the importance of good footcare hygiene practices, management strategies for neuropathy, and of controlling blood glucose values to ensure good foot care. Additionally, pharmacists can proactively serve to remind patients with diabetes of the importance of seeing a clinician at least annually for an examination of the feet and more frequently if neuropathy is present.

ABOUT THE AUTHOR

MARY BARNA BRIDGEMAN, PHARMD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers, the State University of New Jersey in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

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