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Foot ulcers

1. What is the most likely disease underlying these foot ulcers?
2. Who would you manage them?

This photograph shows the typical ulceration seen on the tips of toes and on pressure bearing areas of the feet in a patient with diabetes mellitus. Such a 'diabetic foot' is seen at some time in about 5% of insulin dependent diabetic over the age of 60 years. Lower limb amputation is fifteen times more common in diabetic than non-diabetic patients.

The aetiology of the diabetic foot is multifactorial. Diabetic peripheral neuropathy results in sensory loss and undetected repeated minor trauma that predisposes to ulceration. Diabetics also have an increased incidence of peripheral vascular disease. Compared to the non-diabetic population they usually have a more peripheral distribution of this vascular disease. Microvascular disease and infection also contribute to ulceration. About 45-60% of ulcers are purely neuropathic, 10% purely ischaemic and 25-45% of a mixed neuro-ischaemic nature.

Ischaemic ulcer typically occur on the toes and heel. In the absence of significant neuropathy the feet are often cold with no palpable pulses. The ankle-brachial pressure index (ABPI) is usually reduced but it should be noted that this index can be inappropriately elevated in diabetic due to calcification of the arterial media. Neuropathic ulcers occur at sites of trauma and callus formation. As a result of an autonomic neuropathy the foot is often warm and peripheral pulses may be present.

The treatment of diabetic ulceration is multi-disciplinary. Prevention is better than cure. Prevention requires the identification of feet 'at risk' ideally in dedicated foot clinics. Patients can be educated and advised on appropriate foot care. Such an approach has been shown to reduce amputation rates. Neuropathic ulcers require pressure relief and debridement of callus. Ischaemic ulcers require vascular assessment often including angiographic assessment down to the pedal vessels. Revascularisation often involves a distal bypass procedure.

Recent papers

Jeffcoate W J,  Harding K G.  Diabetic foot ulcers.  Lancet 2003;  361:  1545-1551.

Donnelly R,  Emslie-Smith A M,  Gardner I D,  Morris A D.  Vascular complications of diabetes.  Br Med J 2000;  320:  1062-1066.

Tomas M B,  Patel M,  Marwin S E,  Palestro C J.  Diabetic foot.  Br J Radiol 2000;  73:  443-450.

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