Ulcerations are a result of a breakdown of the skin with diabetic ulcers being an especially common cause, along with ischemia (poor circulation) and venous stasis (varicose veins).
Diabetic ulcerations are by far the most common form of ulceration of the feet. These ulcerations occur in areas of the foot that are exposed to excessive pressure or irritation from the rubbing of the shoes on the skin. Calluses and corns develop as a result of excessive pressure over bony areas of the foot. Over time the thickened callus that forms can act as an irritant that breaks down the skin under the callus, forming ulceration. This is more likely to occur if the person with diabetes also suffers from diabetic neuropathy. Diabetic neuropathy is a condition that most commonly affects the nerves of the hands and feet. Diabetic neuropathy causes a loss or alteration in the ability to perceive pain associated with excessive pressure, heat or cold, sharp and dull, vibration, and position sense. As a consequence, corns and calluses which would normally be painful do not cause pain and over time, breaks down the skin causing ulceration. Quite often, an infection will also occur which can result in bone infection (osteomyelitis) or deep tissue infection. If the person also has poor circulation, gangrene can develop as a result of the diabetic ulcerations.
Treatment is geared toward prevention. People with diabetes must learn to inspect their feet daily and obtain medical attention as soon as they notice anything suspicious or an ulceration forming. Calluses that have a black or blue appearance are in the early stages of ulceration. Corns and calluses should be treated regularly by a podiatrist. These areas should be protected from pressure by using pads and/or cushions. Over-the-counter corns removers must be avoided. These home treatments have acid in them, which can burn the skin and cause infection. Once an ulceration has started, every effort must be made to reduce the pressure on the area or it will not heal. Special shoe inserts, called orthotics, are useful in reducing abnormal pressure on the bottom of the foot in areas of calluses or ulcerations. There are also several different topical medications that are used for the treatment of ulcerations. Treatment should be guided and supervised by a physician.
- Ischemic ulcerations occur in areas of poor circulation. Commonly they form on the feet, ankles, and lower legs. As the circulation gets worse, the skin begins to thin and is less resistant to pressure and friction forces. Spontaneous breakdown of the skin can occur. These ulcerations tend to be painful, with a whitish or light-pinkish base. Treatment is focused on keeping the ulceration clean and free from infection. By-pass surgery may be indicated to improve the circulation to the area. Hyperbaric oxygen treatments may also be useful. It is important not to use bandages that can cut off the circulation, or adhesive tape, which can tear the skin when removed.
- Venous stasis ulcerations occur in areas where the venous circulation is poor. Venous circulation is the blood flow that returns to the heart in the veins. Varicose veins are abnormal veins that do not allow normal blood flow back to the heart. As the veins become more and more damaged, there is a pooling of fluid that accumulates in the feet and ankle. This swelling of the tissue, over time, will cause damage to the skin and can result in open sores or ulceration. These ulcerations tend to weep a clear fluid, have a reddish base, and become infected easily.
Treatment is geared toward prevention by reducing the swelling in the legs with the use of support stockings, medications to reduce the swelling, and elevation of the legs. Once ulcerations have developed, treatment consists of keeping the ulcerations clean and free from infection. This often requires the long-term use of oral antibiotics. A common form of treatment consists of wrapping the legs with a dressing called an Unna boot. This dressing is a gauze wrap that has zinc oxide impregnated in it. This dressing helps to keep the bacteria that is in the ulceration from growing and also adds compression to help reduce swelling.
