Diabetic foot ulcer

Diabetes is a disease in which patients have high level of sugar in blood. a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood.

• Type I diabetes: It appears when the body is not able anymore to produce the right quantity of insulin. The insulin is the hormone that reduces the level of glucose in the blood, so the patient has to use the artificial insulin.
• Type 2 diabetes: It alters the use of insulin in the body. It means that cells are not responsive to insulin action. It is often linked with obesity.
• Gestational diabetes: it occurs in women during pregnancy when the body can be less sensitive to insulin.

Long-term complications of diabetes can be retinopathy, kidney disease (nephropathy), neuropathy and macrovascular problems.

Diabetic foot is one of the most important complications of diabetes mellitus. Diabetic patient may have peripheral neuropathy (sensory and motor).  With the loss of sensation in the foot and in the leg, the patient doesn’t feel pain and if he has a cut, ulcer, trauma or a wound, it can go completely unrecognized for days. The motor neuropathy causes foot deformities, having inappropriate weight redistribution on the plantar area. With the diabetic angiopathy the patient has poor circulation due to calcification of the arteries (macroangiopathy) and the thickening of the small capillary basement membranes (microangiopathy). The neuropathy and angiopathy can determinate diabetes foot ulcers. Moreover, the high level of glucose in blood modifies the normal steps of the wound healing, prolonging and increasing the inflammation period of the diabetic wounds and ulcers. It reduces the availability of nutrient and oxygen of the cells. It alters the normal function of the immune-system that is involved in the wound healing process. All these factors increase the risk to have infected wounds with a delayed wound healing process. If the diabetic ulcer is not treated properly, the infection can spread to deepest tissue, involving muscle and bone (osteomyelitis) and causing gangrene that is the most commune reason of amputation. The worst clinical cases need hospitalization to have intensive care treatment due to sepsis

For the management of the diabetic patient a multidisciplinary assessment is required, involving surgeon, diabetes specialist, specialized nurse, vascular surgeon, podiatrist and so on. Patients have to check their feet daily, detecting new small lesions that must be treated immediately.

The scope of the treatment of the diabetic ulcers should include:  blood sugar control, offload shoes (the overload usually delay the healing process), one to several sessions of debridement using advanced wound dressing and removing the dead tissue from the wound, surgical procedures using dermal substitutes (bioactive tissue matrix allograft composed of dehydrated human amnion/chorion membrane (dHACM), hyaluronic acid ester matrix, naturally-occurring urinary bladder matrix (UBM), a porous matrix of fibres of cross-linked bovine tendon collagen and so on); sometimes it is necessary for performing dermal/epidermal skin graft). Sometimes the Hyperbaric Oxygen Therapy may help to treat the patients.