Toe, Foot and Leg Ulcers

And Diabetic Sores

What is an Ulcer?

     An ulcer is basically an open wound, whether it is internal as in the stomach or on the skin as in a pressure sore. In many cases external ulcers are severe enough to go to the bone, even causing osteomyelitis (infection of the bone.) Diabetic ulcers are commonly found on the toes or on pressure points of the foot – the ball, heel, and side of the foot, especially if a person's shoes are too tight. However, ulcers can occur anywhere on the body that gets cut or injured then fails to heal properly.

     Ulcers can also be caused by bacterial infection, especially impetigo, cellulitis, ecthyma (an inflammatory skin disease characterized by large flat pustules that ulcerate and become crusted.) In rare cases they can even be caused by tuberculosis or leprosy.  Skin cancer can also be a precipitating factor in skin ulcers. Suspicious areas should be diagnosed with a skin biopsy. Other less common causes of ulcers, include systemic diseases such as systemic sclerosis, vasculitis and various skin conditions especially pyoderma gangrenosum. Ulcers may be acute, meaning they show signs of healing in less then 4 weeks, or chronic, those that persist for longer than 4 weeks. 

Infected ulcers can be identified by a yellow surface crust or green/yellow pus and may have an unpleasant smell. The surrounding area may be red and warm to the touch.    

    At any given time approximately 1% of the middle aged and elderly population have a leg ulcer.  These most commonly occur after a minor injury when there are other compromising factors.

• 45-80% occur in people with chronis venous insufficiency
• 5-20% occur in people with chronic arterial insufficiency
• 15 – 25% occur in people with diabetes

Venous Ulcers

     Venous insufficiency refers to a condition where veins in the leg cannot pump enough blood back to the heart. Ideally, the muscles and valves in the legs work together to pump blood against gravity from feet to heart. If the valves and muscles do not work properly, blood can pool in legs and ankles. This pooling of blood prevents oxygen rich blood and nutrients from getting to muscle and skin tissue, causing a stagnant environment which can easily lead to infection and more sores.

Characteristics of venous ulcers include:

• Located below the knee, most often on the inner part of the ankles.
• Relatively painless unless infected.
• Associated with aching, swollen lower legs that feel more comfortable when elevated.
• Surrounded by mottled brown or black staining and/or dry, itchy and reddened skin (gravitational or venous eczema).
• May be associated with varicose veins due to incompetence of the superficial venous system (50%).
• May be associated with lipodermatosclerosis, in which the lower part of the leg is hardened.
• Often associated with swelling, which may be caused by local inflammation. Chronic inflammation destroys underlying lymphatic vessels, causing lymphoedema. This increases the pressure in the lower leg.
• Thickened skin, hyperkeratosis (scaliness), papillomatosis (tiny rough bumps on the lower legs and feet), fissuring, oozing.

Arterial Ulcers

     Arterial ulcers are a result of arterial insufficiency (a lack of blood flow through the arteries.) Most commonly, this is caused by a condition called atherosclerosis where a build up of fatty tissues and cholesterol clog the flow through the arteries. This lack of blood flow causes the tissues of the legs to break down. Smoking can greatly increase the risk of arterial insufficiency.

Characteristics of arterial ulcers include:

• Usually found on the feet, heels or toes.
• Frequently painful, particularly at night in bed or when the legs are at rest and elevated. This pain is relieved when the legs are lowered with feet on the floor as gravity causes more blood to flow into the legs.
• The borders of the ulcer appear as though they have been ‘punched out’.
• Associated with cold white or bluish, shiny feet.
• There may be cramp-like pains in the legs when walking, known as intermittent claudication, as the leg muscles do not receive enough oxygenated blood to function properly. Rest will relieve this pain.
• Clinical assessment measures the Ankle Brachial Pressure Index (ABPI) less than 0.9. 

Diabetic Ulcers

     Neurogenic ulcers, also known as diabetic ulcers, have similar characteristics to arterial ulcers but are more notably located over pressure points such as heels, tips of toes, between toes or anywhere the bones may protrude and rub against bed sheets, socks or the shoes of persons with Type1 and Type 2 diabetes.  To protect itself from pressure, skin will naturally build up a callus; however, in diabetics, a minor injury can cause an ulcer to form instead of (or in addition to) a callous. Although most commonly occurring on the bottom of the feet, diabetic ulcers can occur anywhere on the body.                        

     Between 15-25% of people with diabetes will develop foot and leg ulcers. Serious diabetic ulcers are a precursor to over 80% of leg amputations in the US and are the number one reason for non-traumatic foot amputation. The less control of blood sugar levels a person has, the more predisposed to ulcers that person will be. "Every 30 seconds, someone in the world is losing a limb to diabetes," says David Armstrong, a podiatric medicine specialist at Rosalind Franklin University of Medicine and Science in North Chicago.

     A combination of arterial blockage and nerve damage cause diabetic ulcers. Peripheral neuropathy plays a significant role in the onset of ulcers. Neuropathy causes a loss of sensation in a person’s extremities because of nerve damage. This loss of sensation can cause a breakdown in the signals between the feet to the brain when trauma is occurring.  Charcot foot deformity can occur as a result of decreased sensation. Our bodies, when performing normally, tell us when we need to shift weight from one area of our foot to another to relieve stress. A person with extreme neuropathy looses this sensation and as a result, tissue ischemia and necrosis may occur leading to plantar ulcerations. Microfractures in the bones of the foot go unnoticed and untreated, resulting in disfigurement, chronic swelling and additional bony prominences.  

     Along with the neuropathy, diabetics have a decrease in blood circulation.  In order to heal properly, a good blood flow to the wound site is vital. Lack of blood flow can actually increase the risk of infection. Combined, neuropathy and lack of blood flow, can cause a simple cut or scrape to turn into a dangerous ulcer quickly. 

     Infections can also cause high blood sugar levels, which lower the immune system and prevent healing. Diabetics should closely monitor their blood-sugar levels at all times, and especially when dealing with ulcers.

    If you have previously had an ulcer you are more likely to get another one. Always follow the tips on prevention and decrease pressure on your feet. Try non-weight bearing exercise (swimming, rowing, cycling), consider getting cushioned shoes (your insurance may cover these) and possibly changing to a job that does not require lengths of time on your feet.

     It is important to note that smoking will greatly influence your health in regards to wounds. Smoking restricts blood flow which will slow your healing.  If you smoke, you will have a harder time getting your ulcers under control.

Treatment

• Cleanse the wound regularly with a slightly alkalizing, oxygenating cleanser such as Miracle Mist Plus Spray. Then treat with Miracle Mist Gel. If needed, call 800-217-6677 to discuss the best protocol for your wounds.
• Change the dressings often to prevent infection.
• Keep pressure off the foot ulcer to allow healing to occur. Sometimes special casts or boots can be placed on the foot to “off-load” pressure from the ulcer.
• See your doctor for any ulcers that do not show signs of improvement.

Prevention

• Inspect feet thoroughly daily. Be sure to check in between toes. Look for red spots, abrasions and mirrors.  A mirror can aid your inspection, or a caretaker can help.
• Keep toenails trimmed, but be very careful not to nick the skin.
• Wear only well-fitting shoes with cushions. Pressure-reducing hosiery can reduce the risk of injury. Check socks to insure seams will not be creating a pressure area on your feet. Avoid ill-fitting shoes, flip-flops or any shoes without socks.
• Do not go barefoot.
• Always test bath water with your hands before getting in. Your feet may not register the temperature of the water which can cause burns.

Risk Factors for Foot and Leg Ulcers:

• Diabetes
• Neuropathy (numbness, tingling, or burning sensation in your feet)
• Peripheral vascular disease (poor circulation in your legs)
• Improperly fitted shoes
• A foot deformity
• A history of smoking
• Sores, ulcers, or blisters on the foot or lower leg
• Pain
• Walking with difficulty
• Discoloration in feet: black, blue, or red
• Cold feet
• Swollen foot or ankle
• Fever, skin redness or swelling, or other signs of infection