Education Material for Health Care Professionals: Newsletter Version
THE FEET AND DIABETES
Calculations for Becaplermin Gel Dosage
Each square inch of ulcer surface requires approximately 2/3-in. length of gel.
Measure the greatest length and width of ulcer in inches.
Calculate the length of gel (in inches) required from a 15 gram tube by multiplying the length x width x 0.6.
Measure the greatest length and width of the ulcer in centimeters.
Calculate length of gel that should be squeezed from a 15 gram tube by multiplying the length x width divided by 4.
Each square centimeter of ulcer surface requires approximately 0.25-centimeter length of gel.
But coming to the point which was made initially, an ounce of prevention is still better than tons of treatment no matter how advanced these may be!
It is absolutely essential that all of us teach our patients the “Do’s and Don’ts” of foot care!
Inspect feet daily
This is of the utmost importance in order to catch a problem in the earliest stage. But just telling patients that they should inspect their feet is useless. Patients must know what they have to “inspect”! They must search for any breaks in the skin, scalds and burn marks and any redness that may be a sign of infection, any puncture or injury marks, any darkening of the skin, the presence of corns and callus formation. Two areas where he should look very carefully are between toes and at pressure points at the bottom of the feet.
Some patients, especially those that are obese or have joint pains may find it difficult to lift up the feet for a close inspection. They can very easily use a mirror to examine the bottom of the feet. Failing this, a relative would have to be instructed in the means of foot care. Patients who have vision difficulties or are old and infirm would also need the help of a relative. In fact, these are patients who would come into the high risk category so that foot care is all the more important for them.
Wash feet daily
This may not seem a common problem in our country with the habit of having a daily bath, but some patients are under the mistaken notion that diabetic feet should be kept scrupulously dry at all times so that even when they have a bath, they cover their feet with a plastic bag. This is really absurd unless they have a specific problem for which they have been instructed specifically to keep the feet dry.
In addition to maintaining cleanliness (so important to avoid infection), washing the feet daily helps in the skin regaining some moisture that may be lacking because of the neuropathy. The water that is used to wash the feet should be tepid, neither very hot nor very cold. This means that the patient should always check the temperature of the water before pouring it on the feet Some authorities advise that the temperature of the water should be checked by the hands (if the patient withdraws the hand very rapidly, it is very hot) but I would like to caution about this. The neuropathy may also affect the nerves going to the hands and these too may be relatively insensitive to the heat. I feel that it would be best to check the temperature of the water using the elbows.
There is also a tendency in some patients to soak their feet for a while. This is especially true in those who use bathtubs and many patients who have aching feet use tubs or basins to soak their feet in order to get some relief. Worse still, some put a disinfectant solution in the basin, in the misconception that this will clean the feet better. I feel that one should never soak the feet as this often allows the patients' skin to come into contact with the warm water for far too long. More importantly, this causes the skin to become macerated and such a skin is very prone to act as an entry point for infection. The use of disinfectants should be discouraged because the wrong disinfectant or even a mild one in a strong solution can damage the skin considerably. Similarly, the soap that is used for the bath or the washing of the feet should be a very mild one. I usually recommend that a baby soap of any reputable company should be used. After all, the skin of a diabetic should be treated with as much care and attention as that of a newborn baby.
The practice of using rough stones to scrub the feet, especially the soles should be avoided. It leads to too many small cracks and fissures in the skin.
Dry the feet correctly
The towel should be of the soft baby variety. Coarse towels can cause as much damage as the use of stones for scrubbing the feet. The feet should preferably be patted dry rather than be rubbed. Often, many patients give their feet a brisk rub down in the hope that this would improve the circulation. This really does not help and can cause minute breaks in the skin from where infection can enter. Careful attention is to be paid to patting dry the area between the toes as these often tend to remain wet and may macerate.
After the bath
This is the time that most of the patients should examine their feet. If the feet are very dry, then one may need to apply some mild lubricant like "baby" oil. Conversely, if the skin is moist, then it would be better to apply some mild powder especially between the toes. The point to remember is that the skin should be neither too dry nor too moist and therefore there should be a fine balance between the use of lubricants and powder.
The best time to manage the nails is after a bath as the nails are relatively softer at this time. I feel that nails should never be cut by the patient but that he should only file them so that no sharp edge is left. There is no need for cutting the nails very close to the edge or trying to shape them by cutting the side edges inwards. The sharp edge of the scissors tends to cause minute injuries and infection often starts here. Some patients, especially those that have U shaped nails may have a problem with in growing toenails. This should always be managed by a competent doctor and patients should avoid trying to treat such in growing toenails themselves.