Illustrated Prevention and Management

1. Is one of the most significant and devastating complications
of diabetes .
Foot affected by ulceration that is associated with
neuropathy and/or peripheral arterial disease of
the lower limb in a patient with diabetes.
Diabetic Foot Disease

2. Diabetic Foot Ulceration ..
3 Great Pathologies
Neuropathy :
Poor sensation makes
patient
unaware of foot injuries.
Vasculopathy :
Premature “PreSenile”
atherosclerosis and
microangiopathy.
Immunopathy :
Compromized both
humoral and cellular
immunity = Infection.

3. Presentations include :
Neuropathic Ulcer
Diabetic Foot Infection
Diabetic Vasculopathy
Mixed Type
Gangrene

4. Diabetic Foot Ulcer :
Neuropathy & MicroAngiopathy can result in two sets of what
superficially appear to be contradictory problems:
* Pain, burning, pins and needles or numbness which lead to
discomfort
( Neuropathic Pain ) .
* Loss of ability to feel pain and other sensation which leads to
neuropathic ulceration .

5. Lost Protective Pain sensation.
A lot of Pressure at One spot
Building up a Callus without causing discomfort.
Pressure becomes so high
Breakdown of tissues and ulceration.
The Patient Hardly notices any Pain.

6. So, Typical Neuropathic Ulcer is :
- Painless
- Deep :: may reach Bone
- At Pressure Sites :: Heal, Ball of Big Toe
- Surrounded by callus
- May be ; good foot pulses (because the circulation is
normal)

7. 45 % of diabetic foot ulcerations are purely Neuropathic
in origin .
10 % are Purely Ischemic Vasculopathic ulcers .
45 % are Mixed , NeuroIschemic origin .
DFU in Numbers

8. one or more of the following
:
* Severely Swollen Limb, Red, Hot, Tender .
* Persistent Non-Healing Ulcer .
* Pus Loculus, Dark tissue & Sloughs .
* May Spread :
Locally : OsteoMyelitis
Systemically : Septicemia & Septic
Shock .

9. Wagner’s Classification

10. Grade 0
-PreUlcer Stage
-Bone Deformity
-Intact Skin
-Red Skin
-It can be Prevented
-It needes to be Re-assessed frequently.
• One of signs of Charcoat Joint.
• It results from a dorsal and lateral
dislocation of the talonavicular joint.
• Remember these 2 Bone 

11. Grade 1
-Superficial Shallow Ulcer
-Should be Re-Assessed every 3 months

12. Grade 2
-Deep Ulcer .
-Visible Tendon or Bone in the wound .
-Aggressive ttt is a must .

13. Grade 3
-Deep Ulcers + Osteomyelitis + Joint Sepsis or Abscess .
-Increased chances of losing leg .

14. Grade 4
Limited Gangrene : necrosis of the forefoot or heel .

15. Grade 5
Gangrene of entire foot or leg
Treated by Amputation .

16. Our Main Topic ..,
Medical Treatment of DF
Prophylaxis is Better than Treatment .
Time is Money .

17. Prevention becomes Cost effective , if we reduce
incidence of foot ulcers and amputations by 25% .
Boulton et al ;
Lancet Nov. 2006

18. How to Prevent !?
Risk
Identification
Foot Examination
Patient
Education

19. :1) RISK IDENTIFICATION
- Previous amputation
- Previous history of DFU
- Peripheral neuropathy
- Peripheral Arterial Disease
- Poor glycemic control
- Diabetic Retinopathy = Impaired Vision
- Diabetic Nephropathy specially ESRD
- Foot deformity
- Smoking.
- Obesity

20. 2) FOOT EXAM :
Assessment of :
- Protective sensation
bone deformities:- Foot structure
- Vascular status
- Skin integrity : especially between the toes and
under the metatarsal heads.
- History for claudication

21. :3) PATIENT EDUCATION
Regarding
- Risk factors and appropriate management
:- Foot monitoring on a daily basis
proper care of the foot, including nail and skin care,
and the selection of appropriate footwear.

22. Management can be easily
kept in ur Memory as follow
:
Care of Patient
Care of Foot
Some Drugs

23. :
Strict Control of Diabetes Mellitus :
Diet
Excersise
Loss of Weight
Oral HypoGlycemic Drugs
Insulins “Various types”
Stop Smoking
Correct Vision errors

24. Care of Foot :
DOs :
* Do Inspect your feet daily.
Look for redness, pain, blisters, cuts, scratches, or
other sores.
If you can't see your feet, use a mirror or ask a family
member or caretaker for help.

25. * Do Wash your feet regularly.
Dry them carefully,
Powder them, especially between toes.
‫سل‬‫غ‬‫ا‬..‫ف‬ّ‫ش‬‫ن‬..‫د‬َ‫ب‬‫ر‬

26. * Do use Lubricants or Moisturizers to keep your skin
from getting dry or cracking.
These also prevent calluses from forming.

27. * Do Cut your nails straight across, and avoid
cutting into the corners of the nails.
If the edge of your nail is sharp, make it smooth.
If you can't feel your toes, don't cut your own nails. A
special foot doctor called a Podiatrist should check
your nails regularly.

28. * Do Avoid extremely Hot or Cold temperatures.
Always test the temperature of the water before you take a bath
or
shower.
* Do Treat any infections as Taenia Pedis infection
* Do visit your Podiatrist right away if you find anything wrong
with your feet.

29. * DoWear comfortable shoes.
Make sure to check the inside of your shoes and feel around
for anything that could rub against your feet.
Avoid walking Barefoot .

30. Small Hints
About Orthotic Handling of DF

31. Fore-Foot
Orthosis
Ankle-
Foot
Orthosis

33. (Pressure Relief Ankle Foot Orthosis)

34. Prophylactic :
Care of Patient
Care of Foot
Some Drugs
Be Alert ..
Remember the Headlines 

35. Some Drugs
:
V V V A A A
VasoDilators
VasoModulator
Vitamins
AntiPlatelets
Analgesic
Aldose Reductase Inhibitors

36. VasoDilators
Trivastal (Piribedil) 50 mg : Circulatory disorders
The recommended dose is 150-250mg daily in 3-5 divided doses.
Trental (Pentoxifylline) 400 mg : Chronic PAD , Claudications ,
Trophic ulcers
The recommended dose is 400mg 3 times per day with meals

37. VasoModulator
Doxium (Ca Dobesilate) : Vasoprotective, antioxidant
effects, Circulatory disorders
Vitamins
B1,6,12 as Neurovit, Biovit, Vitamax,
Thiotacid = Alpha Lipoic Acid
Thioctacid 300 mg (antioxidant)

38. Analgesic:
- NSAIDs
- Topical Capsaicin

39. - AntiConvulsants :
Gabapentin (Neurontin 400mg t.d.s)
Begin at 400 mg taken 2 hours
before bedtime ..
4800mg daily can be reached
Carbamazepine (Tegretol 200mg tab twice)
Pregabalin (Lyrica 75 twice .. 150mg twice)

40. Duloxetine (Cymbalta , 60 mg daily)- SSNRIs:
- SSRIs: Paroxetine (40 mg/day)

41. Aspirin 150 mg once daily:AntiPlatelets
Antiplatelet / Platelet aggregation inhibitor

42. Aldose Reductase Inhibitors : Sorbinil
First step in Polyol pathway of Reduction of
Glucose to Sorbitol

43. Management can be easily
kept in ur Memory as follow
:
Care of Patient
Care of Foot
Some Drugs

44. Remember Drugs :
V V V A A A
VasoDilators
VasoModulator
Vitamins
AntiPlatelets
Analgesic
Aldose Reductase Inhibitors

45. Refrences
• Medscape
• PubMed
• Prof. Doctor Hassan Elwan Of Illustrated
Neurology for Undergraduates
• Cairo Uni. Department of Surgery Official
Surgery Book

46. Thank You
Dearest,
Prof. Dr.
Hussein Khairy

47. Thank You
for your
Attention