Diabetic Ulcers

Diabetic Ulcers

Also called: Diabetic Bullae, Skin Ulcer & Diabetes, Bullosis Diabeticorum, Diabetic Ulcer


Ulcer can refer to any open wound or sore. A diabetic ulcer usually involves the foot or leg, and serious medical problems can result.

Improper foot care or injury can cause foot ulcers that become dangerous if not treated early. Most leg amputations in the United States and other developed nations happen to people with diabetes, and foot ulcers occur before the majority of these amputations. However, foot ulcers are preventable, and prompt treatment often prevents serious consequences.

Prevention of foot ulcers includes:

  • Daily foot inspections and hygiene
  • Regular examinations by a physician
  • Proper footwear and toenail care
  • Control of glucose (blood sugar) and blood fats
  • Avoiding smoking

Treatment options include wound care, medications such as antibiotics, skin substitutes and sometimes surgery.

People with diabetes are also at increased risk of developing pressure ulcers (bedsores). A pressure ulcer is the breakdown of skin and underlying tissue that can occur if a person stays in one position too long without shifting weight. As with foot ulcers, prevention and early treatment are key to reducing future complications.

Other ulcerative disorders associated with diabetes include a mouth infection called thrush and several obscure skin conditions. There is little evidence linking diabetes to the most familiar kind of ulcer, the peptic ulcer that affects the stomach, but diabetes may complicate recovery from peptic ulcers.

About diabetic ulcers

An ulcer is any open sore or wound. Most people first think of a stomach condition when they hear the term “ulcer,” but it is also commonly a disorder of the skin. People with diabetes are at higher risk of skin ulcers, especially on the feet and legs.

Foot ulcers may be caused by injury or improper foot care. People with diabetes face increased risk of foot trauma because of numbness due to nerve damage (diabetic neuropathy) and impaired circulation. Foot ulcers are so common and serious with diabetes that they are often used as a synonym for diabetic ulcers.

People with diabetes account for 7 percent of the population yet undergo more than 60 percent of foot or leg amputations in the United States, according to the Centers for Disease Control and Prevention (CDC). Of those diabetic amputations, 85 percent are preceded by a foot ulcer. The CDC also reports that among American adults with diabetes, about 12 percent have had a foot ulcer. Diabetic foot ulcers are most common among individuals who:

  • Smoke
  • Are obese
  • Use insulin
  • Have had diabetes for two decades or more
  • Are white or Hispanic
  • Are male

A pressure ulcer is damage to the skin, and in more serious cases the underlying tissue, caused by impaired circulation due to pressure on a specific area. The skin begins to die when the supply of blood is stopped for more than a couple of hours. Pressure ulcers most commonly occur in individuals who spend most of their time in a bed or chair without repositioning. Pressure ulcers also may occur from straps, splints, a cast or ill-fitting clothes.

Diabetes is one of several chronic diseases that elevate the risk of pressure ulcers because of neuropathy, impaired circulation and the increased possibility of impaired mobility. Poorly controlled glucose (blood sugar) also contributes to the development of pressure ulcers. People who are confined to a bed or a wheelchair because of severe diabetes or other debilitating conditions are at highest risk.

Parts of the body most likely to develop pressure ulcers are bony areas beneath the skin and areas in contact with a bed or chair. These body parts include elbows, shoulders, back, buttocks, hips, ankles, heels and the back of the head.

Pressure ulcers often heal on their own when caught early and the source of pressure is resolved. However, serious cases can lead to infection of the underlying muscle and even of the bone (osteomyelitis). These infections can lead to gangrene (tissue death) that may require amputation of a limb.

Diabetic conditions, such as high blood glucose (hyperglycemia), impaired circulation and nerve damage, increase the risk of infection and impede the healing of wounds. Thus the presence of slow-healing skin ulcers may be a sign of diabetes that has not yet been diagnosed.

Types and differences of diabetic ulcers

The two forms of ulcers most closely linked with diabetes are foot ulcers and pressure ulcers. Other ulcerative conditions seen among people with diabetes include:

  • Thrush. A yeast infection of the mouth. Thrush causes a thick white coating of the tongue, a dry mouth, and ulcers on the tongue or elsewhere inside the mouth. It results in discomfort or pain and can lead to inflammation of the esophagus (esophagitis). People with diabetes are at increased risk of thrush because their saliva can contain extra sugar. The increased sugar causes overgrowth of fungus that naturally exists in the mouth and throat.

Thrush is usually not serious but can become dangerous and hard to control with people who have weakened immune systems. It is treated with antifungal medications. Good oral hygiene and control of glucose (blood sugar) help prevent thrush.

  • Necrobiosis lipoidica diabeticorum (NLD). An irregularly shaped rash, usually on the lower legs. It often appears with a reddish-blue raised border and a red center that turns yellow-brown and can ulcerate. It is rare, but more common among people with diabetes, women and white people. The cause is unknown. Treatment options for NLD ulcers may include anti-inflammatory drugs, topical corticosteroids, ultraviolet light and antibiotics.  
  • Diabetic bullae (also called bullosis diabeticorum). A bulla is a fluid-filled blister. Diabetic bullae are spontaneous blisters on the hands, feet, forearms and lower legs. The lesions contain clear liquid and are not surrounded by redness. Diabetic bullae are uncommon but are seen most often among men with severe, long-standing diabetes. Diabetic bullae usually disappear once the glucose level is under control.
  • Peptic ulcer. An ulcer of the stomach (gastric ulcer), lower esophagus or duodenum, the upper part of the small intestine.  This is what people typically think of when the term “ulcer” is used. Research is not conclusive on whether people with diabetes have an increased risk of developing peptic ulcers. Peptic ulcers are generally considered uncommon with diabetes and have little association with the disease, according to the National Institutes of Health (NIH). However, recent research suggests that the risk of death from bleeding or perforated peptic ulcers may be greater in diabetic patients than in nondiabetics. Possible reasons for this difference may include diabetic vascular problems (diabetic angiopathy) and the increased diabetic risk of infections.

A peptic ulcer often has no symptoms in the early stages. With time, symptoms may include heartburn, brief periods of gnawing pain, painful digestion, nausea and vomiting. Treatment with antacids and ulcer drugs usually averts any need for surgery. Some symptoms of peptic ulcers are similar to those associated with a stomach condition called gastroparesis, a form of autonomic neuropathy that people with diabetes are at higher risk of developing. 

Risk factors and potential causes of diabetic ulcers

Factors that influence the development of foot ulcers involve damage to the nerves, blood vessels and structure of the foot. They include:

  • Diabetic neuropathy. Nerve damage resulting from high glucose(blood sugar). Types of neuropathy that contribute to foot ulcers include:
    • Peripheral neuropathy. Damage to the peripheral nerves, including those serving the legs. The nerve damage eventually impairs sensation, which can make a person unaware of puncture injuries (e.g., stepping on a nail), pressure injuries (e.g., abrasion caused by tight shoes) or thermal injuries (e.g., scalding bath water).
    • Autonomic neuropathy. Damage to the autonomic nerves that control involuntary functions, such as heart rate and blood pressure. This condition can cause decreased sweating, which can dry and crack the skin, resulting in ulcer formation or infection.
    • Focal neuropathy. Nerve damage that develops quickly and affects one body part, such as the legs.
    • Proximal neuropathy. Nerve damage that affects the hips, thighs and buttocks.
  • Peripheral arterial disease (PAD). Restriction or blockage of the peripheral arteries (those outside of the heart and brain), including the tibial and peroneal arteries that serve the lower leg. PAD is a type of atherosclerosis, which is a hardening and narrowing of the arteries due to buildup of plaque. PAD is four times more common among people with diabetes. It is exacerbated by high blood pressure, smoking and hyperlipidemia (too much fat in the bloodstream). The main symptom of PAD is claudication (pain in the legs when walking).
  • Structural abnormalities. Problems with the structure of the foot, which can cause high-pressure areas of skin more prone to ulcer development. They include:
    • Callus. Area of hardened skin.
    • Corn. Horny thickening of the skin due to friction or pressure.
    • Bunion. Painful swelling of the bursa (a sac that contains friction-reducing fluid) at the big toe’s first joint, with that toe displaced toward the other toes.
    • Hammertoe. A claw-like bending of the toe joints.
    • Charcot foot. A joint damaged and deformed by repeated injuries due to impaired sensation. This condition is often caused by diabetic neuropathy.

  • Incorrect footwear. Research has demonstrated that many people who developed diabetic foot ulcers were not wearing their appropriate shoe size.

In addition, rates of diabetic ulcers are higher among smokers than nonsmokers, among men than women, among longtime patients than people who have recently developed diabetes, among the obese than the thin, and among whites and Hispanics than people of other races.

A pressure ulcer can occur when the tissues of the body are damaged from continued contact with a contributing factor. Conditions that may cause pressure ulcers include:

  • Immobility, whether from weakness, paralysis or positioning devices sometimes used in nursing homes or hospitals.
  • Inappropriate mattress, cushion or bedding for a patient.
  • Neuropathy. People with nerve damage cannot sense discomfort or pain causing the tissue breakdown.
  • Exposure to moisture such as urine or sweat.
  • Malnourishment. Lack of protein, vitamins and other nutrients impairs skin integrity and slows healing.
  • Poorly fitting clothes or footwear.

Symptoms and diagnosis of diabetic ulcers

Foot ulcers and pressure ulcers can cause pain. However, people with both types of ulcer often feel no symptoms because neuropathy has caused nerve damage that reduces or eliminates sensation.

Regular self-monitoring and appointments with a physician play important roles in containing ulcers. Visual inspection is crucial for detecting foot and pressure ulcers in time to prevent complications.

Diagnosis of an ulcer usually involves a physician’s visual inspection. In the case of a pressure ulcer, the physician also diagnoses the severity by examining the site and noting the extent of damage. There are six stages of ulcers (decubiti):

  • Stage 1: Skin is red but unbroken.
  • Stage 2: Skin is swollen, often has blisters.
  • Stage 3: The sore has ulcerated, revealing deeper layers of skin.
  • Stage 4: The sore extends into muscle.
  • Stage 5: Muscle is destroyed.
  • Stage 6: Bone is exposed, damaged, possibly infected.

In addition, physicians may perform one or more tests to identify an underlying condition that might be contributing to ulcer formation, including:

  • Monofilament test. A fast and painless check of sensation that can be used to diagnose peripheral neuropathy. It uses a device consisting of a nylon filament mounted on a holder. The physician touches the filament to the patient’s sole with just enough pressure to bend, which is a force of 10 grams. Nerve damage is apparent if the individual cannot feel the strand of nylon.
  • Ankle-brachial index (ABI). An easy-to-use, noninvasive office test that can indicate insufficient circulation. A blood pressure cuff on the arm is inflated until a handheld Doppler ultrasound device cannot detect a pulse in the brachial artery. The cuff is deflated until the Doppler device can detect a pulse (systolic pressure). The procedure is repeated on the leg, with the cuff on the lower calf. The Doppler is placed over the posterior tibial artery or dorsalis pedis, which gives the ankle’s systolic pressure. ABI is the ankle’s systolic pressure divided by brachial systolic pressure. A result of less than 0.8 is abnormal and indicates impaired blood flow in the legs.
  • X-ray. Standard x-rays can reveal structural deformities, demineralization and possibly osteomyelitis (bone infection). The physician may order a bone scan, a type of radionuclide imaging, if osteomyelitis is suspected.

Scientists are refining technologies that can find early signs of diabetic foot ulcers and that may one day become standard tools for diagnosis. Medical hyperspectral imaging (MHSI) and magnetic spectroscopy are able to detect diabetic skin changes (reduced oxygen and diminished muscle energy reserves) before ulcerative foot disease develops. Development of these tools could identify at-risk individuals and help prevent ulcers.

Treatment options for ulcers

Foot ulcers and pressure ulcers can cause serious complications for people with diabetes. However, they are easily treated with early detection.  Treatment of ulcers varies with the type and severity of the wound. Physicians can offer the best information regarding the cause of the ulcer and appropriate treatment. Common treatment methods for ulcers include:

  • Wound care. Dressings range from ordinary bandages to antibacterial and antiviral coverings. Therapy may included debridement (removal of dead tissue) by chemicals, scalpel or whirlpool treatments. Casts may be applied during healing. Researchers have found that nonremovable casts can increase compliance and allow faster recovery.
  • Antibiotics. These medications can control bacterial infections at the early stage to prevent worsening of the condition and spreading of the infection in the body.
  • Skin substitutes. A dissolvable mesh containing a product made from the human cells that make connective tissue is placed on the wound. The skin substitute is absorbed, replaces the damaged area and closes the lesion.
  • Topical human growth factor. Gel containing a genetically engineered platelet-derived growth factor is applied to the ulcer. The gel attracts and fosters the spread of the cells that repair wounds and create tissue.
  • Diet. Meals high in protein, vitamins and other nutrients can speed repair of damaged tissues.
  • Exercise. Walking, muscle strengthening, and physical therapy for positioning issues can help resolve pressure ulcers. Some research has found that active people are less likely to develop diabetic foot ulcers than nonexercisers. However, some types of exercise, such as running or other high-impact activities, may be harmful for those who have or are at risk of foot ulcers. Patients are advised to get their physician’s approval before starting an exercise program.
  • Infrared light therapy. The U.S. Food and Drug Administration (FDA) has approved a light-emitting device that features a pad strapped to the foot or other injured area. Dozens of diodes in the pad send painless infrared light into the body. The light may dilate (widen) the blood vessels and encourage new blood vessels to grow. Increased circulation improves sensation and wound healing.
  • Skin grafting. Transplants of skin may be necessary in severe cases.
  • Surgery. Surgery on the blood vessels to improve circulation to the legs might be necessary if blockage is severe and unresolved by noninvasive procedures. Consultation with a vascular surgeon would be a necessary first step. For people with nonhealing foot ulcers and osteomyelitis, surgical removal of dead tissue and restoration of circulation sometimes prevents extensive amputations.

Individuals with poor sensation due to diabetic neuropathy are sometimes offered an Achilles tendon lengthening (ATL) to increase the ankle’s mobility and prevent pressure points on the foot. Another surgical treatment for neuropathy, nerve decompression, may help heal ulcers and prevent amputations.

Ongoing research

Researchers are developing many potential treatments for diabetic ulcers. Some recent highlights:

  • Cuban bioengineers report using human growth factor to create an injected medication called Citoprot-P. They claim that in human clinical trials it has often cured severe diabetic Foot ulcers and prevented amputations. Additional research would be needed before this drug may become available internationally.
  • Some research has found that tretinoin (Retin-A), a topical form of vitamin A used to treat acne, may help diabetic foot ulcers heal.
  • Additional clinical trials are planned in Europe of a medication called SBG (soluble beta-1,3/1,6-glucan) after early results indicated drug enhanced the immune system’s healing of diabetic ulcers.
  • South Korean researchers report creating a protein called COMP-angiopoietin-1 that has promoted healing of ulcers when injected into diabetic laboratory animals. Clinical trials on humans are planned in the near future.
  • The U.S. Food and Drug Administration (FDA) has approved trials, and is considering additional trials, of advanced dressings and topical wound-healing agents.
  • Emu oil is being studied as a potential treatment for diabetic wounds, burns and other conditions.

Prevention methods for ulcers

Prevention is always important with diabetic conditions, and it is especially crucial with foot ulcers and pressure ulcers. Foot ulcers and foot and leg amputations could be reduced by up to 85 percent through foot care, skin care and other preventive measures, according to the U.S. Centers for Disease Control and Prevention (CDC). Steps to prevent ulcers and further complications include:

  • Daily foot inspections. People with diabetes should check their feet daily, including between the toes, for cuts, blisters, sores, heel cracks and other problems. A long-handled mirror or a mirror on the floor can help. Patients should immediately notify their physician if a problem is present. Researchers have found that checking the soles with a handheld infrared thermometer can reveal a risk of foot ulcers if the reading is several degrees Fahrenheit above normal.
  • Daily foot hygiene. The feet should be gently but thoroughly washed and patted dry. A physician can recommend whether to use balms, lotions or powders to protect the skin. Generally creams and oils should not be used between the toes because the moisture can result in infection and skin breakdown.
  • Proper toenail care. Nails should be trimmed along the contour of the toe and any sharp edges filed, according to the American Medical Association. People with diabetes who have peripheral neuropathy, impaired eyesight or other conditions that complicate foot care are advised to see a specialist, such as a podiatrist, for their foot care.
  • Proper footwear. Some researchers have found that special double-layer socks may reduce the risk of foot ulcers. Studies differ on whether special diabetic shoes are more effective than standard shoes. Correct fit of special or regular shoes appears to be the most important factor. Buying shoes late in the day can ensure a better fit because the feet tend to be less swollen in the morning. Having at least two pairs of shoes and alternating them every other day reduces the risk of pressure in the same location on the foot. It is important to avoid walking barefoot and using shoes without socks. For more information, see Athletic Shoe Choices.
  • Comprehensive foot exams by a physician. Patients at high risk, including those with diabetes, are advised to have a complete foot examination at least once a year to identify conditions that may lead to ulcer development. These risk factors include peripheral neuropathy, peripheral arterial disease, foot deformity and a history of ulcer or foot or leg amputation.

Early detection and management of people with high-risk foot conditions. According to the National Institutes of Health (NIH), studies have shown that patient education reduces foot ulcers and amputations.

The following measures can help prevent pressure ulcers as well as foot ulcers:

  • Control of glucose (blood sugar). Hyperglycemia damages the nerves and impairs the immune system’simmune system’s ability to fight infection. Close control of glucose results in better skin condition and a reduced risk of medical complications.
  • Prevention or cessation of smoking. Smoking increases the risk of ulcers and slows healing because it impedes circulation.
  • Control of hyperlipemia. High levels of cholesterol and other fats in the blood increases the risk of atherosclerosis, the hardening of the arteries that is a risk factor for ulcers.
  • Interventions to improve facilities’ care. These steps include careful examination of patients and monitoring of the skin’s condition.

Prevention of pressure ulcer also includes:

  • Keeping the skin clean and dry
  • Teaching the patient  how to shift weight in a wheelchair or bed
  • Repositioning frequently, generally every two hours, by lifting rather than sliding the patient
  • Use of special mattresses or wheelchair cushions
  • Protection of prominent bony areas with padding

Questions for your doctor regarding ulcers

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about ulcers:

  1. Do I have or am I at risk of developing foot ulcers?
  2. Do I have or am I at risk of developing pressure ulcers or any other kind of ulcers?
  3. What dangers do diabetic ulcers pose for me?
  4. Do I need to undergo any diagnostic tests?
  5. What treatment do you recommend for my diabetic ulcer?
  6. Can I help treat or prevent ulcers through diet and exercise?
  7. Are there any exercises I should avoid?
  8. What sort of foot care and skin care should I do at home?
  9. How often should I have doctor assess my feet and skin?
  10. What should these checkups include?
  11. How can the risk of pressure ulcers be reduced for my loved one who is in a nursing home?
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