Relieving Pain in Patients with Diabetic Peripheral Neuropathy

Given the limitations of pharmacotherapy options for treating painful diabetic peripheral neuropathy, practitioners are also considering the merits of cognitive therapy, orthotic management, and combination therapies to relieve patients’ pain.

Diabetic Foot Ulcer Treatment: Taking the Confusion out of the Wound Care Products

“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.

Wet Wounds:

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.

Dry Wounds:

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.

Moist 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!

Dress Your Feet – Selecting Proper Socks

You probably don’t even think about them unless you lose one in the wash.  They are left balled up in a drawer.  Half asleep, you reach in blindly and grab the first pair you make contact with.  You give more consideration to them when you use them for dusting rather than when you wear them.

Socks!  What other particle of clothing has so many uses?  They help to keep your feet clean, warm, and dry, fight dry skin, cushion and protect your soles.  Some people use them as a form of expression and others just an accessory.  Even when they are worn out and no longer suitable for your feet you can use them to polish furniture, shine shoes, wash your car, cover your golf clubs, or make a puppet.

At Desert Foot Surgeons, our talk about socks is not limited to just patients with diabetes.  Socks can make a difference and help in your treatment.  Dr. Geller talks about the fibers used to make the sock, thickness of the material and padding.

The fibers used to make socks are either natural fibers or man-made (acrylic).  Natural fibers are cotton and wool.  You didn’t have to grow up in New Jersey, like Dr. Geller, to know that wool is itchy.  Socks made of cotton and wool are criticized for being too tight and the seams too rough, in other words uncomfortable.  When it comes to keeping your feet dry, natural fibers are not as good as man-made materials.

Acrylic materials are combinations of polyester, nylon, and elastic fibers.  When these types of socks are made with increased cushioning, they are better at keeping moisture away from your skin compared to natural fibers.  The material is softer and the seams easily hidden.  Padded socks made of man-made materials have been shown to lower the pressure on your feet.  Elastic can be increased so that the socks can be used to help prevent swelling.

No matter what material they are made from socks cannot replace shoes.  Walking in socks does not provide the support or protection that a shoe does.  Especially for those of you who have diabetes with loss of feeling in your feet, you cannot walk inside or outside in socks alone.

At Desert Foot Surgeons, Dr. Geller does the shopping for you.  We carry special diabetic socks.  These are high quality, padded acrylic socks especially good for our patients with diabetes.  Even if you don’t have diabetes, these socks are good for people who are athletic or work in areas where your feet are exposed to moisture.  Please give your socks the consideration they deserve and dress your feet.

Arterial Ulceration

Of adults over 40 years of age in the United States, about 4.5% have peripheral arterial disease (PAD). This is a lack of circulation to your legs and feet.  Healing an ulceration where there is a lack of circulation is very challenging for you and your doctor.  The most important part of healing these open sores is bringing blood into the foot.  Dr. Geller works with vascular surgeons, interventional cardiologists and radiologists who can help with this part of your care.  The actual care of the open wound is determined by Dr. Geller.  This will involve something to keep pressure off the sore and medication applied to the wound.  At Desert Foot Surgeons you will find a physician with the expertise and experience needed to develop a program that best suits your needs.

Those of you who have healed an arterial ulceration have suffered a great deal of pain and possibly even undergone surgical correction of the poor artery circulation.  If this is not enough reason to quit smoking I don’t know what is. Part of your recovery will be walking for exercise to increase circulation even if you had surgery. Since most arterial ulcerations are on the feet you will need protection of the scar by shoes and possibly inserts. Your heels may need to be protected while lying in bed. Moisturizing dry skin using specific foot creams is also recommended to help prevent new or recurrent ulcerations.

Dr. Stephen Geller, AZ Podiatrist

Venous Ulcerations

Swelling in the legs can be caused by bad veins with valves that no longer work, injury from prior blood clot or phlebitis, weak muscles that pump the blood up the leg, or increased pressure in other organs such as your heart.

In order to heal your wound you were placed in some form of compression wrap. Once your scar was mature enough to handle pressure from socks you were prescribed support hose. Even though we live in Phoenix where temperatures often exceed 100ºF the compression is needed to fight the swelling. Surgery is often used for bad veins, but even so support hose are a required part of this treatment. There is no way around it, you will have to wear some form of compression garment.

Dr. Stephen Geller, AZ Podiatrist

Diabetic Foot Ulcers and Peripheral Neuropathy

Between 30-50% of patients with diabetes have peripheral neuropathy. This is a nerve injury that prevents you from protecting your own skin by losing feeling. In addition, the nerve damage interferes with your muscles leading to deformities and difficulty walking. Pressure increases over these prominent areas leading to callus formation from repeated injury. Damage from the callus or injury leads to open sores or ulceration.

Your wound care treatment has included some form of “off-loading” by padding or casting. This is how we remove pressure from the open sore to allow the body to heal. Under the care of Dr. Geller you also had to remain in this cast or padding 4 weeks after healing to allow the scar to mature. To prevent return of the ulceration you will need protection from pressure on prominent areas.

You should be very proud of yourself. You have accomplished what more than 90,000 Americans failed to do this year. You saved your leg from amputation due from diabetic ulcer.

More than 90,000 people lost a major part of their foot or the entire leg to complications beginning as a wound on their foot. Some of these were not avoidable, but it is estimated that 64% of these could have been prevented with advanced wound care such as you have done.

Now our focus switches to prevention. You and your physician do not want you to experience anything like this ever again. You have most likely been treated using some form of cast or padding to keep the pressure off your foot and swelling down. Since this was necessary to heal the wound it should be no surprise that something will be needed to keep the wound healed.

Prescription shoes with custom-made inserts are used to cushion and protect the feet. You will have to wear these shoes with inserts everyday for quite some time. Every year your insurance will pay for new shoes. You should receive three pairs of inserts for these shoes to be changed every four months. The longer you stay healed and the better you control the callus formation the more flexible your shoe selection will become.

In some patients surgery was performed to correct deformity and decrease pressure. Even these patients have to wear the prescription shoes with insoles.

Dr. Stephen Geller, AZ Podiatrist