Managing Wounds In Diabetic Patients

Overview

Diabetic wounds are a serious concern for people with diabetes as the wounds are prone to infections and can quickly become life-threatening due to a weakened immune system. In some cases, they can lead to amputations of toes, feet, or even legs, impacting a person's life significantly.

Managing diabetic wounds is not only necessary for maintaining good health, it is also crucial for reducing the burden on healthcare systems. Timely treatment can save both resources and hospitalisation time. Moreover, proper wound care can lower the chances of these wounds coming back, improving the overall quality of life for people with diabetes.

What is a diabetic wound?

A diabetic wound is any raw area on the skin surface of a person suffering from diabetes. Diabetic wounds tend to have delayed healing, which can spread and grow in size in the absence of proper care. In severe cases of diabetic wounds, serious infection can develop. Diabetic wounds primarily affect the feet as a result of various factors such as peripheral neuropathy, peripheral arterial disease and impaired immunity.¹

Peripheral/diabetic neuropathy is a form of nerve damage caused by high blood glucose levels. Damage to the nerves causes impaired sensation to touch, pain, temperature and pressure. This lack of sensation makes individuals less aware of sustaining injuries, as they might not feel pain when they get hurt. What starts as minor scratches or blisters can quickly evolve into deeper, infected wounds or neuropathic ulcers.²

Additionally, diabetes can reduce sweating, causing the skin to become dry and prone to cracking. These cracks can then become sites for wounds to develop.³

Diabetes can also lead to peripheral arterial disease, which results in reduced blood supply to the extremities, particularly the legs and feet. This happens because the blood vessels in these areas tend to narrow over time. Consequently, these regions receive insufficient nutrients and oxygen, impairing the healing process after injuries, which can lead to the development ischemic ulcers.⁴

Furthermore, the likelihood of developing a neuro-ischemic ulcer is also high because high blood sugar impairs both nerve and blood vessel function, limiting the body's ability to repair itself.⁵

Types of diabetic wounds

Wounds with an external origin and wounds with an interior origin are the two most prevalent forms.

Wounds of external origin include wounds caused by cuts, burns, bumps and bruises. The diabetic patient may frequently miss these external wounds due to neuropathy and loss of sensation. These wounds can rapidly deteriorate and lead to serious complications without medical attention and would require extensive care.⁶

Wounds of internal origin include foot ulcers, ingrown toenails or calluses. These can lead to the breakdown of skin and surrounding tissues, increasing the risk of bacterial infections and further tissue damage.⁶

Of these types, the diabetic foot ulcer is the most common manifestation of a diabetic wound. It presents as an open sore on the underside of the foot. It can spread into deeper tissues rapidly and lead to significant morbidity.

Consequences of untreated diabetic wounds

Infections 

This is due to the reduced ability of the body to heal wounds and the immune system to fight infections. These infections can rapidly spread to bones (Osteomyelitis) and muscles. Once the infection reaches the bloodstream(sepsis), the patient is at risk of going into septic shock, which can be life-threatening if they do not receive immediate medical intervention.⁸

Amputation

Diabetic wounds can cause the tissues surrounding the wound to become gangrenous or severely infected, causing the tissues to die (necrosis). Amputation may be the only resort when the tissue cannot be repaired,  as it can be life-threatening and carries significant risk to the person's health and quality of life.⁹

Ulceration and chronic pain

Ulceration can lead to pain that lasts for a long time, often requiring a lot of medical input to manage the pain because it does not respond to generic painkillers. This can result from a diabetic wound that is not effectively managed and has subsequently sustained nerve damage.¹⁰

Due to these grave consequences of untreated diabetic wounds, it is critical to detect these wounds early and to intervene to prevent these serious complications.

Recognizing diabetic wounds

Since diabetic wounds tend to progress quickly, it is crucial to identify them at an early stage to receive medical intervention early and lower the risk of associated complications. One should look for the following:

• Visible open sore, especially in extremities¹⁰
• Pain and irritation¹⁰
• Swelling around the sore¹⁰
• Discharge or leaking from the sore – can be fluid or pus. Continuous blood discharge in the pus is indicative of a serious infection¹¹
• Darkened skin around the sore¹²
• A foul smell coming from the area of the sore. This is attributable to bacterial or fungal infections¹¹
• Numbness
• Thickened skin near the sore¹²
• A sore on the foot that is not healing or worsening

Other signs to look out for include:

1. Redness
2. Diminished ability to sense temperature changes, such as when touching hot or cold surfaces¹³
3. Loss of hair in the area¹³
4. Fever
5. Tingling

Wound cleaning and dressing

The following is recommended for wound cleaning and dressing:

1. Wash both your hands with soap and water before wound cleaning and dressing
2. Rinse the wound with warm or lukewarm water. Do not use hot water as this may further irritate the skin or cause burns that would make things worse
3. Apply pressure with a clean gauze to stop any bleeding
4. Apply antibiotic cream and cover with a bandage. Antibiotic dressings may be provided by your primary healthcare provider, especially for infected wounds
5. Keep the wound area clean and dry. Regularly check for any active bleeding or soaking of the dressing as these may require a change of dressing or a review by your healthcare provider

Treatment of diabetic wounds

Diabetic wounds have been reported to be infected in 25-60 per cent of the cases.¹⁴ The main treatment of infected diabetic wounds is antibiotics. Infections that are mild and limited to the upper layers of the skin can be treated with oral antibiotics and topical antibiotics, including antibiotic-coated dressings.

For more serious and deep-seated infections, systemic antibiotics would often be administered through the veins together with local management either through debridement and/or wound dressings.¹⁵

Samples of bacterial cultures can be taken to guide antibiotic treatment, ideally before starting a course of antibiotics. However, this test should never delay the start of  antibiotic treatment as it may hold a considerable amount of risk of developing a severe infection.¹⁵

Offloading pressure

It is important to avoid putting pressure on diabetic wounds. This is because applied stress and friction on the wound reduces blood supply to the wound, greatly hindering wound healing. Various techniques can be used to keep pressure off the wound.¹⁶

The most effective method is using a total contact cast (TCC). This is usually a hard material moulded to the foot to take the weight off the wound. The cast is placed by a cast technician or a trained healthcare provider. It is periodically removed to check for wound healing. Duration of use depends on the wound and the patient's tolerance to it. Once placed, it should be kept clean and dry.¹⁷

Other modalities of offloading pressure include specialized shoes, foot padding, removable cast walkers, using wheelchairs, crutches and other walking aids and bed rest.

Surgical intervention

When infection persists despite receiving the best medical care, surgery is typically necessary. Other indications include the need to make an incision to drain abscess, removal of dead tissue (debridement), removal of foreign objects, attempt to restore blood supply to the area and amputation when necessary as a last resort.¹⁸

Rehabilitation and follow-up

Following initial diabetic wound management, a period of rehabilitation is often instituted. This is to help reduce complications such as stiffness of joints, wasting of muscles and reduced mobility. Rehabilitation programs also target increasing blood supply to the affected area and thus improve wound healing. This is achieved through various exercise and physical therapy modalities.

It is also critical to follow up on diabetic wound patients. This is to assess their diabetes control, wound healing progress and to check for any wound reoccurrence. Follow-ups should be scheduled by a multi-disciplinary team such as podiatrists, diabetic foot nurses, physicians or general practitioner.

Preventative measures

1.) Managing diabetes and blood glucose levels. This includes adhering to one’s treatment recommendations and making lifestyle changes, such as quitting smoking, adopting a nutritious diet, and exercising frequently. By managing diabetes, the risk of developing diabetic wounds is significantly reduced and this also promotes healing of any wounds sustained.

2.) Checking and cleaning the extremities every day because they are more vulnerable to injuries and ulcers. One should use a mirror or ask for assistance with areas that are difficult to see or reach. Carefully trimming the nails with a safe nail trimmer is also recommended to reduce injuries to the foot. Wash the feet with mild soap and lukewarm water. Ensure the space between the toes is dried.

3.) Never walk barefoot but instead wear supportive and fitting footwear. Always don dry, clean socks to help protect the feet. Additionally, avoid wearing tight socks that could hinder the flow of blood to the foot.

Patient education

A key component of diabetes management is educating patients on how to care for diabetic wounds on their own. It involves teaching patients about preventative measures, early identification of a diabetic wound, promoting health-seeking behaviour, teaching them how to take care of the wounds and subsequent follow-up. This gives patients the power to take charge of their health, giving them a sense of independence. 

By avoiding practices that may lead to complications,  patients can enhance their general well-being. Healthcare professionals are responsible for providing this education and making sure that patients have the information and tools they require to effectively manage diabetes and prevent diabetic wounds.

FAQs

What helps diabetic wounds heal faster?

Proper wound care is vital for wound healing. This includes cleaning the wound properly, applying antibiotic ointments, and regularly changing dressing wounds, offloading pressure on the diabetic wound and managing blood sugar levels are crucial for recovery. A balanced diet and adequate hydration can support tissue repair. Quitting smoking, attending follow-up appointments, and adhering to prescribed medication are essential. Additionally, diabetic patients can benefit greatly from patient education and collaborating with a healthcare team for personalized treatment.

How do diabetics treat open wounds?

Begin by cleaning the wound gently with mild soap and lukewarm water, avoiding hot water and harsh scrubbing. After patting the area dry, apply an antibiotic ointment if prescribed by a healthcare provider. Cover the wound with a sterile dressing and adhere to dressing change recommendations. Seek immediate medical attention at any signs of infection, worsening of the wound, or if the wound fails to heal within a reasonable time frame.

What is the best dressing for a diabetic wound?

It is essential to consult a healthcare provider or wound care specialist to determine the most suitable dressing for specific diabetic wounds. The choice of dressing will depend on various factors, including the wound's characteristics, stage of healing, and any underlying complications like infection or poor circulation. 

Do wounds heal faster, covered or uncovered?

Wounds heal faster when kept moist and covered, aiding natural healing, reducing infection risk, and providing comfort. The choice of dressing depends on the wound's specific needs, which are assessed by healthcare providers.

What delays wound healing in diabetics?

Wound healing in diabetic patients can be delayed due to factors like high blood sugar levels impairing immune function, reduced blood circulation which limits nutrient delivery, neuropathy that reduces touch, pain, pressure and sensory temperature and underlying medical conditions like vascular diseases and kidney issues affecting overall health and immunity.

Summary

Diabetic wounds are a significant concern for individuals with diabetes, posing risks of infections and complications that can lead to amputation. Diabetic wounds often affect the feet and are caused by a combination of factors such as nerve damage, reduced sensation, and dry skin. Diabetes also hampers blood supply to extremities, impairing the body's ability to heal wound injuries, leading to wounds that don't respond to over-the-counter painkillers.

Recognizing these wounds early is crucial, as they can deteriorate rapidly. Signs include visible sores, pain, swelling, discharge, darkened skin, and numbness. Proper wound cleaning, dressing and offloading pressure are essential for wound healing. 

Antibiotics may be needed to treat infections and in severe cases, amputation might be considered as a last resort with heavy consideration on the patient's quality of life. Rehabilitation, follow-up, and preventative measures, such as managing diabetes and patient education, play vital roles in diabetic wound management to improve overall health and quality of life.