Wounds are prevalent, and include mechanisms that cause a break in the skin such as cuts, punctures, scrapes, and scratch

es. Most wounds are minor, and do not require medical intervention. However, when a wound persists, an ulcer may develop. Nonhealing ulcers, categorized as arterial, diabetic, or venous, are particularly concerning. These ulcers contribute to a decrease in a patient’s productivity and quality of life, and increase health care costs.

1,2

Diabetic ulcers are the most prevalent of the nonhealing ulcers. In the United States, diabetes affects more than 20 million people, with a diagnosis more likely as the general population grows older.

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Health care costs related to patients with diabetics are close to $200 million yearly, and ulcer costs account for nearly 30% of those expenses.

3,4

RISK FACTORS

Potential complications from diabetes include integumentary problems and cardiovascular, neuropathy, and renal disease.

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The likelihood that a patient with diabetes will develop an ulcer in their lifetime is about 15% to 25%, with equal disbursement in both type 1 and type 2 diabetes.

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Typical characteristics for patients with diabetic ulcers include having the disease for 19 years or more, being male gender, having poor glycemic control, and prior evidence of comorbidities. Additional risk factors are individuals who lack health insurance, and being of a certain ethnic or racial background, such as African American, Latino, or Native American.

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CLINICAL PRESENTATION

Completion of a thorough history and physical exam for a patient who presents with a diabetic foot ulcer are obligatory for assessing the issue, guiding appropriate treatment, and minimizing complications. A comprehensive history includes a detailed review of any recent complications, blood glucose

history, current glycated hemoglobin (A1C), and how the diabetes is controlled. Other factors to consider are allergies, comorbidities, health maintenance (eg, last dilated eye exam), immunization status, and medications. A review of systems should be pervasive, but may focus on the classic symptoms of diabetes (polydipsia, polyphagia, and polyuria), any hypoglycemic episodes, signs of infection, and additional questions on known or potential comorbidities (eg hypertension, neuropathy, etc).

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Key systems for a comprehensive diabetic foot examination consist of integumentary, musculoskeletal, neurologic, and vascular. Skin status should be assessed for any color changes, cracking, dryness, or thickness.

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Patients may come in with a wound that has not healed or pain at the location of a pressure point, callus, or other bony prominence. Signs usually associated with infection or inflammation, such as drainage, redness, tenderness, or warmth may not be present or reduced.

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Therefore, evaluate the feet for signs of deformity, how well the patient’s shoes fit, and muscle wasting. Besides the ability to recognize pressure from a standard-sized monofilament, a patient needs to be able to feel vibration with a pinprick sensation, positive ankle reflexes, or a tuning fork. The final component of the vascular exam is to measure foot pulses and the ankle-brachial index, if necessary.

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TREATMENT

Treatment should focus on healing the wound and reducing the chance of complications. Several classification scales exist to categorize the wounds, including the 2 most prominent: the Wagner Diabetic Foot Ulcer Classification System, and the University of Texas Wound Classification System.

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A few of the most serious potential complications include amputation, gangrene, and osteomyelitis.

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Lab work may include a complete blood count to assess for signs of infection, comprehensive metabolic

panel, lipid panel, and A1C to evaluate the patient’s diabetes and comorbidities.

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Standard treatment for ulcers often includes a combination of the following: blood glucose management, control of infection, foot care education, infection control, limb elevation, mechanical compression and offloading, necrotic tissue debridement, or revascularization surgery.

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Approaches to treatment have changed drastically over the past decade, with current recommendations including less frequent dressing changes, less aggressive debridement to the wound bed, limited revascularization versus none, topical antibiotics instead of systemic, and self-adaptive dressings as opposed to

wet-to-dry dressings.

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When wounds do not adequately heal with standard treatment, advanced wound

care therapies need to be considered.

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Hyperbaric oxygen therapy has received much attention in recent years. Advocates contend that wound healing occurs through antibacterial, antiedema, and neovascularization efforts.

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CONCLUSION

Wounds within the general public tend to require minor or no treatment, but individuals with diabetes face heightened risk factors for potential skin problems, including ulcers. Treatment of wounds for this population includes prompt recognition and action to heal the wound, decrease the chance of complications, and reduce health care costs.

Jenna Herman, DNP, APRN, FNP-BC, is the family nurse practitioner program coordinator and an assistant professor at the University of Mary in Bismarck, North Dakota. Her clinical practice includes the emergency department of a level II trauma center, correctional medicine, and locum tenens in primary care clinics, nursing homes, and hospitals across rural North Dakota.

REFERENCES

1. Greer N, Foman NA, MacDonald R, et al. Advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers.Ann Intern Med.2013;159(8):532-542. doi: 10.7326/0003-4819-159-8-201310150- 00006.
2. Wolcott R. Economic aspects of biofilm-based wound care in diabetic foot ulcers.J Wound Care.2015;24(5):189-190, 192-194. doi: 10.12968/jowc.2015.24.5.189.3.
3. Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team.J Vasc Surgery.2010;52(suppl 3):17S-22S. doi: 10.1016/j.jvs.2010.06.003.
4. Hicks CW, Selvarajah S, Mathioudakis N, et al. Trends and determinant of costs associated with the inpatient care of diabetic foot ulcers.J Vasc Surg.2014;60(5):1247-1254,1254.e1-2. doi: 10.1016/j. jvs.2014.05.009.
5. Hanft J, Suprenant M, Buttita O. Improving diabetic wound care outcomes: a practical guide.Podiatr Manage.2012;31(5):117-119. scholarlycommons.baptisthealth.net/se-all-publications/2499/.
6. Kalish J, Hamdan A. Management of diabetic foot problems.J Vasc Surg.2010;51(2):476-486. doi: 10.1016/j.jvs.2009.08.043.
7. Brownlee M, Aiello LP, Cooper ME, et al. Complications of diabetes mellitus. In: Sholmo M, Polonsky KS, Larsen PR, Kronenburg HM, eds.William’s Textbook of Endocrinology.13th ed. Philadelphia, PA: Elsevier Saunders; 2016.

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