Diabetic Foot Care: The Importance of Routine Care

Pharmacists can be instrumental in educating diabetic patients about routine skin care, especially the significance of implementing a daily foot care regimen and performing routine screenings to reduce or prevent complications.

As one of the most accessible health care professionals, pharmacists are in a pivotal position to increase awareness and educate diabetic patients regarding routine skin care, especially the significance of implementing a daily foot care regimen and performing routine screenings to reduce or prevent complications.

These complications include bacterial and fungal infections and foot ulcers which, left untreated, can lead to an amputation. Although the number of diabetics continues to escalate, according to results from a recent study, the amputation rates among diabetics are significantly declining because of early intervention and management as well as increasing patient education efforts.^1,2 Many health care experts would agree that increasing patient education and awareness about the magnitude of maintaining tight glycemic control and proper foot care are critical contributors to decreasing the incidence of foot ulcers and amputations.^{1, 2}

Diabetics, especially those with poorly controlled diabetes, are more susceptible to skin-related complications. According to the American Diabetes Association (ADA), an estimated 33% of diabetics will develop some type of skin disorder that is caused or affected by diabetes.³ In addition, in some cases, the development of skin-related problems may actually be the first clue that an individual is diabetic.³ Patients should be advised that many dermatologic conditions can be prevented or easily treated if identified early. Through patient education, early recognition, and management of independent risk factors, diabetes-related skin complications can be radically decreased or even prevented.^3-5 In general, the main goals of diabetic skin care often include a combination of preventive strategies, such as the following^3-5:

• Patient education, involvement, and compliance
• Stressing the importance of maintaining tight glycemic control
• Stressing the importance of routine skin, foot, and nail care

According to the ADA, examples of bacterial skin infections that can commonly occur among diabetic patients include styes, boils, folliculitis, carbuncles, and infections around the nails.⁵ Staphylococcus bacteria are the most common pathogens responsible for causing bacterial skin infections.³ According to the ADA, the most prevalent cause of dermatologic fungal infections among the diabetic patient population is Candida albicans.³ In addition, Tinea pedis is a common cause of athlete’s foot, and Tinea corporis is a common cause of ringworm. These types of fungal infections may present as itchy, red, moist areas on the skin surrounded by tiny blisters and scales, and they often occur in the warm, moist folds of the skin.³

Due to dry skin and poor circulation, diabetics are more prone to itchy skin.³ Foot complications such as changes in the skin (dryness and itching) and foot ulcers are common among diabetics. These conditions can often be attributed to vascular disease, neuropathy, and relative immunosuppression⁵ (Table 1).

The Importance of Diabetic Foot Care

The Centers for Disease Control and Prevention and the National Institutes of Health Diabetes Information Clearing- house report that comprehensive foot care programs, which include foot care education, risk assessment, and preventive therapy, may decrease amputation rates by 45% to 85%.⁹ According to the updated 2013 recommendations from the ADA’s Standards of Medical Care, all diabetic patients should receive an annual comprehensive foot exam. The 2013 standards regarding foot care include the following¹¹:

• All diabetic patients should obtain an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations.
• Health care professionals should provide general foot self-care education to all patients with diabetes (Table 2 and Online Table 3).
• A multidisciplinary approach is recommended for patients with foot ulcers and high-risk feet, especially those with a history of ulcers or amputation.
• Patients who smoke and/or have structural abnormalities or have a history of lower-extremity complications should be referred to foot-care specialists for ongoing preventive care and lifelong surveillance.

Table 3: Recommendations for Daily Diabetic Foot Care

• Inspect feet daily, including the tops, sides, heels, and between the toes.

• When inspecting, look for cuts, cracks, splinters, blisters, and calluses on the feet.

• Wash feet in warm, not hot, water daily; to prevent infection, make sure the feet are thoroughly dry, especially between the toes.
• To prevent drying and cracking of the skin, use lotion on the tops and bottoms of the feet, but not between the toes (lotion between the toes promotes microbial growth).

• When trimming toenails, cut them straight across and slightly round the edges with an emery board.

• Never apply a hot water bottle or a heating pad to the feet.

• To promote good circulation to the lower limbs when seated, prop up your feet and avoid standing in 1 position for long periods of time.

• Be compliant with prescribed medication.
• Monitor your blood glucose level routinely, as directed, to ensure tight glycemic control.

• Do not attempt to remove corns or calluses without seeking the advice of your primary health care provider.

• Do not use antiseptic solutions on your feet because these agents may burn or injure skin.

• To prevent foot injuries, do not walk barefoot, especially outdoors.
• To avoid injury, keep floors free of sharp objects.

• Immediately report any sores or skin changes, such as blisters, cuts, or soreness, to your primary health care provider.

• Always contact your primary health care provider if wounds show no signs of healing.

Adapted from references 5-8 and 12.

Nonprescription Products for Diabetic Foot Care

When counseling diabetic patients on their medications, pharmacists should also remind them about the various nonprescription dermatologic products on the market that address the specific skin care needs of the diabetic patient population (Online Table 4). Products for diabetic foot care include antimicrobial lotions, skin moisturizers, and antifungal and callus treatments. While assisting patients in the selection of skin care products, pharmacists can also reinforce the importance of routine foot care and inspections as well as provide patients with key information regarding diabetic foot care.^5-8 During counseling, patients should be encouraged to seek immediate medical care, when warranted, to avoid further complications. Patients should be encouraged to discuss possible diabetes skin-related complications with their primary health care provider to learn how to recognize and manage these skin conditions. Through increased awareness and patient education, patients with diabetes can take a proactive role in reducing and preventing dermatologic issues.

Table 4: Examples of Dermatologic Products Marketed for Diabetic Patients

Product Name

Manufacturer

Anastasia Diapedic Foot & Leg Treatment

Anastasia Marie Laboratories

DiabetAid Pain and Tingling Lotion

Insight Pharmaceuticals, Inc

DiabetiDerm Foot Rejuvenating Cream

DiabetiDerm Heel and Toe Cream

DiabetiDerm Antifungal Cream

DiabetiDerm Hand and Body Lotion

Health Care Products

Diabetic Basics Healthy Foot & Body Lotion

Woodward Labs

Diabet-X Callus Treatment

Diabet-X Antifugunal Skin Treatment

Diabet-X Skin Therapeutic Lotion

Diabet-X Daily Prevention Skin Therapy

FNC Medical Corporation

Eucerin

Beiersdorf

Flexitol Diabetic Foot Balm

LaCorium Health

Kerasal

Moberg Pharma North America

Neoteric Oxygenated Advance Healing Cream

Neoteric Cosmetics, Inc

ReliOn Callus Treatment

ReliOn Antifungal Cream

ReliOn Daily Skin Therapy

Wal-Mart Pharmacies

TriDerma

Genuine Virgin Aloe Corp

Zim's Crack Creme, Diabetic Formula

Perfecta Products, Inc

Zostrix Diabetic Foot Pain Cream

Health Care Products

Diabetic Foot Care Patient Resources

• Take Care of Your Feet for a Lifetime. National Diabetes Education Program website. http://www.ndep.nih.gov/publications/PublicationDetail.aspx?PubId=67&redirect=true.
• Stop Diabetes from Knocking You off Your Feet. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/complications/foot-complications/stop-diabetes-from-knocking-you-off-feet.html.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Diabetes-linked amputations declining, study finds. Medline Plus website. www.nlm.nih.gov/medlineplus/news/fullstory_138887.html. Accessed August 25, 2013.
• Belatti DA, Phisitkul P. Declines in lower extremity amputation in the US Medicare population, 2000-2010. Foot Ankle Int. 2013;34(7):923-931.
• Living with diabetes: skin complications. American Diabetes Association website. www.diabetes.org/living-with-diabetes/complications/skin-complications.html. Accessed August 26, 2013.
• Skin care. American Diabetes Association website. www.diabetes.org/living-with-diabetes/complications/skin-care.html. Accessed August 25, 2013.
• Preventative foot care. Diabetes Care. 2004;27(suppl 1):563-564. http://care.diabetesjournals.org/content/27/suppl_1/s63.full.pdf. Accessed August 22, 2013.
• Diabetic complications and amputation prevention. American College of Foot and Ankle Surgeons website. www.footphysicians.com/footankleinfo/diabetic-amputations.htm. Accessed August 23, 2013.
• Diabetes foot care. Medline Plus website. www.nlm.nih.gov/medlineplus/tutorials/diabetesfootcare/db029105.pdf. Accessed August 25, 2013.
• Foot and skin related complications of diabetes. Cleveland Clinic website. http://my.clevelandclinic.org/disorders/diabetes_mellitus/hic_foot_and_skin_related_complications_of_diabetes.aspx. Accessed August 28, 2013.
• Preventive care practices for eyes, feet and kidneys. National Institute of Diabetes and Digestive and Kidney Diseases website. http://diabetes.niddk.nih.gov/dm/pubs/statistics/#PreventiveEFK. Accessed August 28, 2013.
• Foot care. American Diabetes Association website. www.diabetes.org/living-with-diabetes/complications. August 28, 2013.
• Standards of medical care in diabetes 2013. American Diabetes Association website. http://care.diabetesjournals.org/content/36/Supplement_1/S11.full. Accessed August 28, 2013.
• Assemi M, Morello C. Diabetes mellitus. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.