“You have a hole in your foot!” That is usually how I start my discussions regarding Diabetic foot ulcers with a new patient. There is not supposed to be a hole in your foot. The fact is, there are things outside of our body that we want to keep out, and skin is our only line of defense in this regard. Healing a break in your skin, known as a wound or ulcer/ulceration, as fast as possible, is important to restore your defenses against the outside world.
There are more than 3000 specialized products for “wound care”. Needless to say there is a lot of confusion when it comes to choosing the most appropriate wound care dressing. Since I teach students and residents, I am forced to keep things simple. I have a way of describing wounds that is very simple, but allows me to chose a product that fits the characteristics of your ulceration in order to heal. Wounds, no matter where they are on your body, will fit into one of these three categories. A wound can be wet, moist, or dry.
Having a break in your skin will result in inflammation, which is the first step in healing. You must progress past inflammation in order to heal, but diabetic foot ulcers are well known for getting stuck in an endless loop of inflammation. With the inflammation comes fluid draining from the opening. A small amount of clear, watery or slight blood-colored drainage is normal, but when this becomes excessive there are problems. Think of your skin when you spend time in a pool. Your fingers prune, right? This is known as maceration and when it happens on the edges of an open wound you have further weakened that skin’s resistance to injury and infection. Obviously infection can cause increased drainage and antibiotics are part of the answer, but only after testing the wound for infection. Remember, no cotton swab, testing it has to be a tissue specimen (see Diabetic Ulcer Treatment).
Products used to bandage wet wounds must be able to absorb fluid to get it away from the skin edges and base of the wound. Adding more moisture is a common mistake. We do not use creams, ointments, salves, coverings that lock in moisture such as Band-aids. Foams, alginates, even gauze will absorb and move fluid away from the ulcer.
The opposite end of the spectrum is a dry wound. How often have you heard, “leave it open to the air so it will dry out and form a scab”? Would it surprise you to know that this was found to be false in 1962? It takes 100 times longer to heal a wound when scab forms, but even some naïve physicians tell patients that the wound needs air. The first concern with a dry wound is your circulation. Once I have done testing to assure that you have adequate circulation to heal or sent you to a vascular surgeon to have circulation repaired, I have to find a product that donates moisture to the wound.
Moisture donating products are creams, gels, gel sheets…basically if the product is moist then it is able to donate that to the wound. Ointments are generally not used since these are petroleum based and the petroleum has been shown to reduce the ability to heal. Science is always changing and there are rare ointments that are not based on petroleum, but just to be safe I recommend you avoid all ointments. Dry wounds have the problem of that scab forming. In order to drive the moisture through the dry wound bed, I often add a layer to keep air out. There are films, barriers, hydrocolloids, and fancy combination dressings that I often add when treating dry wounds.
A moist wound is a healing wound! Everything above has involved making a wound moist. We dry a wet wound until it is just moist, we moisten a dry wound. Keeping the wound moist involves moisture donating products such as gels, creams, and gel sheets. There is no need to lock in the moisture using a film like I do in dry wounds. Usually just a gauze covering will suffice.
That’s it. You have now been given the same information I give my students and residents minus all the fancy names of specific products. If you have a diabetic foot ulcer or wound and need care, instead of letting someone who is confused about wound care products roll the dice and choose whatever product the last drug rep brought in, come see me at Desert Foot Surgeons. Your feet matter to us!