People with diabetes are prone to serious foot infections, ulcers and other foot conditions that can begin with a scratch or bunion. Most of these problems, however, are easy to prevent. Following a regular program of diabetes care, foot care and hygiene can promote good health and can prevent hospitalizations, amputations and other drastic measures.
Diabetes increases the risk of foot problems for many reasons:
- Diabetic neuropathy (nerve damage)
- Suppressed immune system
- Hyperglycemia (high blood glucose)
- Impaired circulation
- Hyperlipidemia (high levels of fat in the blood)
- Peripheral arterial disease
- High blood pressure
These risk factors create a cycle that make the feet susceptible to infections and complicate healing. For example, diabetic neuropathy impairs the ability to feel pain. An individual may not be able to feel a blister caused by tight shoes. Ignored, this blister can become an open wound that allows infection to enter. Excess sugar in the blood aids the spread of the infection. Hyperlipidemia and peripheral arterial disease worsen circulation. The reduced blood flow adds to suppression of the immune system by hindering infection-fighting white blood cells. The compromised immune system fails to stop the infection. The infection worsens into a system-wide problem that weakens the body, further impairs the immune system and sets the stage for another cycle.
A program of diabetic foot care, however, can help a patient avoid these complications. Such a program should include:
- Controlling glucose, blood pressure and cholesterol
- Skin care including daily hygiene and inspection
- Toenail care to prevent ingrown nails and other problems
- Proper footwear to avoid blisters and other potentially serious injuries
- Control of risk factors such as smoking, diet and lack of exercise
- Routine medical care to catch problems early and avoid complications
About foot care and diabetes
Individuals with diabetes account for more than 60 percent of nontraumatic foot or leg amputations, according to the U.S. Centers for Disease Control and Prevention (CDC). Most of these amputations stem from minor wounds and could have been prevented.
Diabetic foot care focuses on routine tending to the feet and prompt treatment of minor but potentially catastrophic injuries. Common problems that may lead to infection but that foot care can prevent include:
- Athlete’s foot. A contagious, itchy fungal infection that causes cracks in the skin. People with diabetes are prone to fungal infections, including nail fungus, ringworm, thrush and yeast infections. Athlete’s foot can spread to the toenails and make them thick and difficult to trim. It is treated with antifungal medication and may be prevented by wearing shower shoes in locker rooms and common bathing areas. Nail fungus can also be treated with antifungals and prevented with good foot care.
- Blister. Fluid-filled lesion caused by repeated abrasion, such as a sandal strap rubbing against the ankle.
- Bunion. Painful swelling of the bursa (a sac containing friction-reducing fluid) at the big toe’s first joint, with the toe turning in toward the other toes.
- Calluses and corns. Thickening of the skin due to friction or pressure, such as from improperly fitting shoes. To prevent damage to the skin, diabetic patients are advised to avoid harsh over-the-counter remedies.
- Cracked skin. Minor lesions caused by dry skin, especially in the heels. Even the smallest openings allow infection to enter. Use of lotions or petroleum jelly can help prevent cracking.
- Hammertoes. Painful, claw-like curling of the toes caused by a weakened foot muscle that shortens the tendons. Sores can develop on the tops of the toes and bottom of the feet. Hammertoes can change the foot’s shape and make it hard to walk and to find shoes that fit. Causes include heredity and wearing shoes that are pointy or too short. Hammertoes can be treated with surgery, under local anesthesia, that lengthens the Achilles’ tendon.
- Ingrown toenails. An edge of the nail growing into the skin. Tight shoes and improperly cut nails can cause ingrown toenails.
- Plantar warts. Noncancerous growths on the bottom of the foot, caused by a common virus. Plantar warts can go away on their own, but a physician might recommend surgical removal if they are painful, spread or cause other problems. To allow healing, people should not walk on plantar ulcers. Patients with diabetes should avoid harsh over-the-counter remedies. Prevention includes wearing shower shoes in locker rooms and common bathing areas.
- Ulcer. Open wound caused by any of the above factors as well as other sources of trauma. Treatment includes antibiotics and wound care. If not tended to early, ulcer can destroy tissues, leading to gangrene and the risk of foot or leg amputation.
Diabetic patients with one or more of the following risk factors have an increased risk of developing severe foot problems:
- Severe foot deformity, such as Charcot foot
- No pulse in the foot
- Previous foot ulcer
- Previous amputation
People with diabetes can prevent or delay diabetic foot problems by controlling glucose (blood sugar), blood pressure and cholesterol. People with diabetes have control over many factors that influence the condition of the feet and the risk of infections and other complications. These factors include skin care, toenail care, footwear and routine medical care.
All people with diabetes are advised to:
- Stop smoking to improve circulation.
- Follow their physician-recommended diet to help control glucose and cholesterol.
- Have a glycohemoglobin test every three months to monitor glucose control.
- Stay active. Patients should consult their physician before starting an exercise program. Some may need to avoid high-impact activities such as running and jumping, and instead try low-impact exercise such as walking, swimming, water aerobics, bicycling or chair exercises.
Skin care for the feet includes hygiene, daily inspections and related concerns. The National Institutes of Health (NIH), National Diabetes Education Program and other authorities advise people with diabetes to:
- Wash the feet daily with mild soap in warm (90 to 95 degrees Fahrenheit, about 32 to 35 degrees Celsius) but not hot water.
- Use a thermometer or elbow before bathing to ensure the water is not too hot.
- Avoid soaking the feet to keep them from drying them out.
- Dry the feet well, especially between toes, by patting with a towel, not rubbing.
- Use talcum powder or cornstarch to help keep the feet dry.
- Apply a moisturizer as recommended by a physician.
- Avoid use of lotion between the toes, where moisture forms.
- Inspect the feet daily for blisters, scrapes, cuts, sores and other wounds.
- If vision is impaired, examine the feet by touch from toe to heel.
- Use a hand mirror or floor mirror to help with inspections.
- Ask a relative or caregiver to help if self-examination is not possible.
- Avoid harsh chemicals such as Epsom salts, iodine and mercurochrome.
- Check with a physician before treating calluses, corns and bunions.
Toenail care can prevent ingrown nails, nicks, fungus and other problems when done properly:
- Clip the nails about once a week along the contour of the toe.
- Smooth the edges with an emery board if needed.
- Avoid cutting the corners to prevent ingrown nails.
- Trim the nails after bathing for easier cutting.
- Avoid nail fungus by using footwear in damp public areas such as showers and pools.
- Consult a podiatrist or other foot specialist for nail care if thick nails, poor eyesight, inability to reach or other problems interfere.
Proper footwear is essential. Self-injury caused by ill-fitting shoes is one of the most common and most preventable causes of minor foot trauma leading to amputation. Blisters, sores and other potentially dangerous problems can be avoided by ensuring a correct fit and addressing other areas of concern:
- Buy shoes in the evening. Feet tend to be smaller and less swollen in the morning.
- Consider regular use of athletic shoes made of breathable materials.
- Ask a physician about special diabetic shoes or orthotic inserts, often covered by Medicare or other insurance.
- Avoid footwear made of plastic, vinyl and other nonbreathable materials.
- Use shoes with laces or Velcro straps that allow adjustment for swelling or deformity.
- Alternate two or more pairs to let shoes dry between use.
- Avoid high heels, pointy toes and sandals, which cause pressure points.
- Consult as needed with a pedorthist, a medical specialist who fits shoes.
- Check inside shoes for gravel and other objects before putting them on.
- Wear padded, seamless socks with shoes to reduce risk of blisters and sores.
- Avoid socks with an elastic band that can impede circulation.
- Change socks daily.
- Never go barefoot. Use slippers, shower shoes or beach shoes as appropriate.
A wide range of foot care products are marketed to people with diabetes. Recent studies suggest that daily use of infrared skin thermometers may reduce recurrence of foot ulcers, that vibrating insoles may improve balance and that special double-layer socks might help prevent sores. Individuals interested in such products are advised to ask their physician which products can help and which may be ineffective or even harmful.
Medical care should routinely take the feet into account. Diabetic patients have the responsibility of immediately informing their physician of any foot problem. Patients also should ask the physician to:
- Visually inspect the feet at every visit.
- Do a complete annual foot exam, including assessment of sensation and circulation.
- Offer specific instructions on foot care.
- Prescribe special diabetic shoes or inserts if necessary.
- Provide a referral to a podiatrist or other foot specialist as needed.
Patients with diabetic foot problems are recommended to keep the blood flowing to the feet. Exercises that will increase circulation in the feet include:
- Leg lifts and knee bends while lying on the side or seated
- Moving the ankles up and down
- Wiggling the toes several times a day for several minutes at a time
Miscellaneous areas of foot care:
- Do not use heating pads or hot water bottles on the feet.
- Keep the feet away from radiators, campfires and other sources of heat.
- Prop up the feet when sitting.
- Avoid crossing the legs for long.
- Guard against frostbite in cold weather.
A physician can provide more information about diabetic foot care, including details about exercise, diet, hygiene, skin care, footwear and orthotic inserts. The U.S. government urges people with diabetes to avoid infections, ulcers, amputations and other complications by taking part in a regular program of foot care.
Questions for your doctor regarding foot care
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 foot care and diabetes:
- What should I do to care for my feet?
- Should I perform my foot care program every day?
- Should my feet be inspected every time I see a doctor?
- How often should I have a comprehensive foot exam, and by whom?
- What should my comprehensive foot exam include?
- Do I have any foot conditions that need to be treated or monitored?
- Should I do exercises to help my feet?
- Are there any exercises or activities I need to avoid?
- What kind of shoes and socks should I wear?
- Should I see a podiatrist, pedorthist or other foot specialist?
- Should I use a foot thermometer or other medical devices in caring for my feet?
- Can I improve the health of my feet by quitting smoking or better controlling my glucose, blood pressure or cholesterol?