Increased activity levels in patients with diabetes may help protect them from developing diabetic foot ulcers. Clinicians have long believed that increased pressure on the foot, combined with stress from activity, led to the development of ulcers; however, a recently published study found that the opposite might be true. Foot complications are the leading cause of lower-extremity amputations in people with diabetes, and are a frequent cause of hospitalizations. Patients with diabetes have a 15- to 40-fold higher risk of lower-extremity amputation than nondiabetics.

The study included 100 patients and examined the relationship between activity level and development of foot ulcers. Study subjects, who averaged 68.5 years of age, wore computerized activity monitors to measure the number of steps taken over a period of time. Patients were followed for a minimum of 25 weeks or until ulceration occurred. Eight percent of patients developed ulcers. The subjects who developed ulcers had a much lower level of activity than those who did not develop ulcers. Further analysis of the data showed great variability in activity patterns in the group with ulcers. The pattern was characterized by short bursts of activity in an overall sedentary lifestyle. This pattern was most prominent 2 weeks before ulcer development. The researchers concluded that vulnerable skin might be at high risk for damage if stress patterns are not consistent and that awareness of this finding might help patients modify their activity to make it more consistent.

The majority of foot complications in patients with diabetes begin with formation of ulcers. Risk factors for development of ulcers include peripheral arterial disease, diabetic neuropathy, foot deformities, improper footwear, uncontrolled blood glucose, poor vision, and obesity. Early detection and early treatment are key factors in preventing amputations. Routine foot inspection is one of the easiest, least expensive ways to prevent foot ulcers, but it may be overlooked in routine physician office visits. Noninvasive vascular and sensory tests may be used in conjunction with physical examination to identify patients at highest risk for complications.

Minor foot injuries such as cuts, scrapes, blisters, and athlete's foot may be cautiously self-treated. Patients should be counseled to avoid hot foot soaks, heating pads, and topical agents such as peroxide, iodine, and witch hazel, as these remedies may impede wound healing. Wounds should be cleaned with a gentle cleanser and moisturized with a topical antibiotic. Patients should be referred to their physician for any wound that does not heal rapidly.

Despite careful foot care, many patients with diabetes may eventually develop foot ulcers. These ulcers are typically painless, as they are most likely to develop in patients with neuropathy. Treatment generally begins with removal of dead tissue and surrounding calluses. X-rays may be taken to rule out infection of the underlying bone. Cultures may not be useful since most diabetic foot ulcers have multiple bacteria present. Broad-spectrum antibiotics are usually given, usually for an extended period of time if the bone is infected.

Pharmacists can play a significant role in helping their diabetic patients prevent foot complications. Patients (or caregivers) should be counseled to inspect the feet on a daily basis. Feet should be cleaned with soap and water and dried carefully, especially between the toes. Moisturizer should be used to prevent skin breakdown. Patients with chronically wet feet should use cornstarch and absorbent socks to absorb moisture. Shoes should be examined for any areas that might cause friction on the patient's foot. Pharmacists can also perform monofilament tests to identify peripheral neuropathy.

Medicare covers the cost of diabetic shoes, and patients should be referred to the appropriate source for special footwear if indicated.

Diabetic foot ulcers can be prevented with careful maintenance and counseling. New information about risk factors continues to be published. Advice about levels of activity, in addition to more traditional counseling points, may help patients avoid complications that may result in limb amputation. Pharmacists are uniquely positioned as the most accessible health care providers to guide people with diabetes in the care and maintenance of their feet.

Dr. Garrett is a clinical pharmacist practitioner at Cornerstone Health Care in High Point, NC.

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