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ABSTRACT
Many patients with diabetes can lead a full life without developing
diabetic lesions in their feet. This is because these patients have
avoided the precipitating factors of which the most important is
mechanical trauma and infections.
We present five cases of diabetic patients who, out of ignorance,
listened to bad advice by using hot therapy to treat their
peripheral neuropathy. This resulted in burns and secondary
infections. All of them required large surgical debridement and
prolonged costly hospital stay to treat their condition.
Fortunately, none of them required amputation.
This paper hopes to highlight the dangers of self treatment and
medication in diabetic foot lesions.
Keywords: diabetes mellitus, neuropathy, burns
INTRODUCTION
The complications of diabetes mellitus predispose to the development
of foot lesions(9). These complications are largely irreversible and
the onset is unpredictable. When they occur, it may result in a limb
threatening or even life threatening situation. If avoided, however,
patients may live for many years and may eventually die of another
vascular complication such as myocardial infarction(2). This is
because these patients have managed to avoid the precipitating
factors of complications of the diabetic foot, of which the most
important is mechanical trauma. Minor wounds or infections in a foot
with normal sensation and blood supply are recognised by the pain
they cause so that they are treated early and heal rapidly. In the
neuropathic foot, however, a small lesion may progress and
deteriorate because it is not recognised early and the source of
injury not eradicated. Rapid progression of minor foot disorders may
result in gangrene and amputation(5). Impairment of blood supply may
result in delayed healing. Infection is an important aggravating
factor that may cause extensive tissue damage.
In this series, we look at the extreme range of thermal injury to
the diabetic feet coupled with infection.
Effects of diabetes
Diabetes mellitus is a disease with multi-systemic complications
causing retinopathy, nephropathy, dermopathy, neuropathy and
arterial disease. An important group of these patients would be
those with feet problems(12). These feet complications are
aggravated by the presence of peripheral neuropathy, arterial
disease, skeletal deformity and an increased tendency toward sepsis
for patients with diabetes(9). Unrecognised repeated trauma or
worsening infection in a neuropathic foot may result in marked
progression of the disease before it is even detected by the
patient. This is worsened by poor blood flow and hence healing
potential in diabetic feet.
An unfortunate but surprising common cause of foot problems in
Singapore is due to burns, often self induced out of ignorance(1).
Below are five cases seen and treated at (the former) Toa Payoh
Hospital within one month. They all resulted from burns, peripheral
neuropathy and our unique cultural beliefs.
Case I
Mr TKH is a 67-year-old Chinese gentleman with diabetes mellitus for
eight years and peripheral neuropathy involving both hands and feet.
On the advice of his friends, he poured "almost boiling hot" water
over his feet in an attempt to evoke sensation from his anaesthetic
feet.
Unfortunately, all that resulted was an ulcer 6 cm in diameter that
was complicated by pseudomonas infection and required intravenous
antibiotics and prolonged wound cleansing. This was compounded by a
compromised circulatory status [ankle brachial index (ABI): 0.6].
Hospitalisation totalled 27 days and healing took nearly 48
1/2
months.
Case 2
Mr GCS is a 57-year-old man with long standing diabetes mellitus of
25 years, with end stage renal failure on dialysis and a previous
right below knee amputation. He also had peripheral neuropathy and
wanted to improve the circulation of his numb feet. On the advice of
his wife, he soaked his remaining foot in a basin of hot water
This resulted in large infected ulcers on the dorsum and plantar
aspects of his remaining foot. His ankle brachial index was 0.7, and
the capillary refill was only fair. He required intravenous
antibiotics therapy and surgical debridement. Skin grafting was not
performed and the total hospitalisation was 43 days.
Case 3
Mr TKL is a 54-year-old man with newly diagnosed diabetes mellitus
of three months also with the problem of peripheral neuropathy. He
was told that massaging his foot would help improve the circulation
to his foot and decrease his symptom of numbness. An electrical
massager was used to massage his foot. Unfortunately, the metal
portion of the massager overheated and burnt his foot.
He developed a right sole ulcer which was subsequently infected.
Wound cultures grew both pseudomonas and methacillin resistant
staphylococcus aureus. He required a prolonged hospital stay (34
days) and treatment to eradicate the infection.
Case 4
Mr TH is a 57-year-old Indian gentleman with diabetes for nine years
who also suffered from peripheral neuropathy. He is a devout Hindu
and one hot day, he walked one kilometer barefoot to the temple. He
only realised that his feet were burnt when his friends pointed it
out to him. He too required hospitalisation.
Case 5
Mr KCC is a 59-year-old man with diabetes mellitus for four years.
He burnt his left foot with hot water in 1994. Despite long term
antibiotic treatment and repeated surgical interventions, which
included repeated debridement and excision arthroplasties of his
left second and third metatarsal head of the foot, his wound refused
to heal and he has had repeated admissions to hospital for recurring
foot infections. This was again compounded by a poor vascular supply
to the limb (weak dorsalis pedis and posterior tibial pulses and
slow capillary refill). He was still suffering from ulceration of
the foot six months after the initial injury.
DISCUSSION
Limb or life threatening complications in patients with diabetes
mellitus can be prevented with an integrated and multi-disciplinary
approach(5). Peripheral neuropathy is a common and well documented
complication of diabetes mellitus, of which the most common form is
that of distal symmetric polyneuropathy. Glycaemic control retards
the progression of neuropathy, which is the most important risk
factor for ulceration(5). Distal symmetric polyneuropathy results in
varying involvement of sensory, motor and autonomic nerve fibre
function. In general, the sensory deficits predominate over the
motor component. It arises first distally and progress proximally,
resulting in a "glove and stocking" distribution of paraesthesia.
All five cases presented suffered from distal symmetric
polyneuropathy secondary to diabetes mellitus. The neuropathy
resulted in insensate feet and the loss of protective sensation.
This would explain why such patients were more prone to repeated
injury (whether mechanical, thermal, chemical or otherwise) of the
feet without either realising it or recognising the severity of the
injury until the later stage of the disease, with resultant
ulceration and infection. The problem is compounded owing to the
poor healing potential of such patients secondary to poor peripheral
circulation and poor glycaemic control.
The best approach socially and economically therefore, is to aim for
prevention rather than seeking to treat these problems as they
arise(4,7). Good patient education would go a long way in helping to minimise these problems(8). The better informed patient would
generally be one who would take a more active and responsible part
in the management of their own diabetic foot. All five patients
above developed their foot lesions largely because of
misinformation.
If one would seek to soak one's foot in warm-water, then one should
follow guidelines of the human experimental skin temperature-tone
scald burn curve shown in Figure 1 measured by Hennques and
Moritz(13) to minimise the risk of foot burns.
The problems were aggravated in some because of delay in seeking
proper treatment, again largely due to their ignorance of the
condition.
We would like to propose that the following
be included in patient education:
1. An understanding of diabetes mellitus with its associated
complications and the need for good glycaemic control;
2. Patient counselling for specific problems that each patient may
face;
3. Printed instruction with pictorial illustrations be made readily
available in addition to verbal instructions.
Specifically for the care of the diabetic
feet:
1.The importance of the regular use of other means (visual and
tactile) together with the lack of reliance of foot sensation to
detect early diabetic foot lesions;
2. Instruction for the care and regular cleaning
of the feet;
3. The protection of the feet with appropriate footwear that will
not cause excessive pressure on the feet's pressure points; to be
strictly adhered to when going out and to be seriously recommended
even at home;
4. The need for early consultation with the relevant medical
personnel for early diabetic foot lesions. |
