Foot ulcers may appear long before they come in patient's notice. Elderly people may wrongly perceive signs and symptoms in lower limb as harbingers of senility and ignore a potentially correctable condition. Symptoms of peripheral neuropathy and arterial insufficiency precede ulcer formation. Ulcers most commonly occur on following sites:

• Heel
• Medial aspect of navicular bone 
• Inferior aspect of cuboid bone
• Medial or lateral malleoli
• Tips of toes (hammer toes)
• Any pressure points, e.g. area rubbing against shoe surface.

Any diabetic patient having following signs and symptoms is susceptible to develop ulcers. Peripheral neuropathy, when present, will present with symptoms of altered sensations in limb. These include paresthesia, hypreresthesia, hypoesthesia and dysesthesia. Loss of sweating and cold extremities is signs of autonomic neuropathy. Muscles may be atrophied and limb posture (in supine position) or shape may be abnormal due to earlier complications. Moreover, diabetic patients very frequently present with symptoms of arterial insufficiency that may be:

• Pain in limb (at rest or on ambulation) especially in calf muscles.
• Weakness in limbs
• Change in color of skin or gangrenous limb
• Hair loss
• Intermittent claudication (pain in limbs on walking a short distance) or ischemia of foot.

Increased demand of muscle during exercise or activity, when not adequately met, will cause accumulation of lactic acid, hence causing pain of intermittent claudication. Patients with atherosclerotic disease can be without symptoms while some people can have frank ischemia. History should be aimed at these signs and symptoms, which may also be helpful in early diagnosis and prevention of later complications and/or recurrent ulcers.

Examination is done to assess vascular perfusion, peripheral neuropathy, signs of osteoarthopathy and infectious ulcers. Examination of ulcer is also done taking into consideration its site, shape, margins, edges and tissue present in ulcer bed. General examination of limb may reveal hammer toes, calluses, fissures, previous scars or brittle nails. Special attention should be paid to interphalangial space that may sometimes show ulceration or microbial infection.

• Inflammation

  Remote temperature monitoring (RTM) is an evidence-based and recommended component of standard preventative foot care for high-risk populations that can detect the inflammation preceding and accompanying DFUs. [ncbi.nlm.nih.gov]

  Trophic wound of shin with inflammation chronic wound at coccyx chronic wound at leg. Trophic wound of shin with inflammation child boy with bandage on leg and lying down hospital bed. Below knee amputation stump. [shutterstock.com]

  Wound macrophage isolation to determine miR-21 [ Time Frame: 14 weeks ] To determine if ex vivo supplementation of miR-21 mimic and recombinant MFG-E8 resolve inflammation in wound macrophages isolated from Negative Pressure Wound Therapy sponges from [clinicaltrials.gov]

  They are known to be involved in fibroblast and keratinocyte migration, tissue re-organization, inflammation and remodeling of the wounded tissue. [en.wikipedia.org]

  BMC Cardiovasc Disord 6 : 35, 2006 ↵ Dogra G, Irish A, Chan D, Watts G: Insulin resistance, inflammation and blood pressure determine vascular dysfunction in CKD. [doi.org]

• Falling

  Of persons needing medical attention post-fall, 17% had experienced at least 1 fall and >30% reported falling more than 1 time. [o-wm.com]

  Reduced body sway equals stability, balance and proper gait – and a significant reduction in diabetic falls. [barefoot-science.com]

  Your income falls within our guidelines. HealthWell assists individuals with incomes up to 400-500% of the Federal Poverty Level. The Foundation also considers the number in a household and cost of living in a particular city or state. [healthwellfoundation.org]

  […] hypotension by using a number of self care techniques, such as: standing or sitting up slowly and gradually drinking plenty of fluids to increase the volume of your blood and raise your blood pressure wearing compression stockings to help prevent blood falling [nhs.uk]

  Despite this rise in numbers, it is important to note that major amputation rates among diabetics are falling, as shown in a 2006 study in Helsinki [3]. [clinicalcorrelations.org]

• Congestive Heart Failure

  He said the admission rate for people with diabetes was comparable to that of congestive heart failure, kidney disease, depression and most types of cancer. [express.co.uk]

  Compression should generally not be used in the setting of peripheral arterial disease or uncompensated congestive heart failure. [clevelandclinicmeded.com]

  The hemorrheologic agent cilostazol is contraindicated in patients with congestive heart failure. See Medication regarding the product's black box warning. For more information, see Diabetes Mellitus, Type 1 and Diabetes Mellitus, Type 2. [emedicine.medscape.com]

• Noncompliance

  Inappropriate application of TCCs may result in new ulcers, and TCCs are contraindicated in deep or draining wounds or for use with noncompliant, blind, morbidly obese, or severely vascularly compromised patients. [clinical.diabetesjournals.org]

  An alternative cast for the noncompliant patient would be a nonremovable Scotchcast boot. [doi.org]

  The cast cannot be removed, reducing the risk of patient noncompliance with pressure relief. The cast application is technically demanding and should only be applied with care and expertise. [clevelandclinicmeded.com]

• Nausea

  Adverse events observed in the clinical trial included infections, increased pain, swelling, nausea, and new or worsening ulcers. [fda.gov]

  Adverse reactions in the study included infections, nausea and swelling. An estimated 29 million people in the United States have been diagnosed with diabetes, according to the Centers for Disease Control and Prevention. [nationalpainreport.com]

  And though research findings are mixed, ginger may also help reduce motion sickness and nausea related to chemotherapy and surgery. Standard dosage to treat nausea is 1 gram of ginger per day and no more than 4 total daily grams. [livestrong.com]

  Often, a person with diabetes will notice unexplained blood sugar spikes, fever, aches, hot and cold flashes, nausea, and fatigue. If you experience any of these symptoms, consult a physician immediately. [healingyourwound.com]

• Vomiting

  You begin vomiting. When should I contact my healthcare provider? You see new drainage on your sock. Your foot becomes red, warm, and swollen. Your foot ulcer has a bad smell or is draining pus. [drugs.com]

  A report published in the Journal of the Australian College of Medicine showed that ginger syrup, ginger tea, grated ginger and ginger ale (made with real ginger) can safely and effectively reduce pregnancy-related nausea and vomiting. [livestrong.com]

  Systemic infection may sometimes manifest with other clinical findings, such as hypotension, confusion, vomiting, or evidence of metabolic disturbances, such as acidosis, severe hyperglycaemia, and new‐onset azotaemia. Figures and Tables - Table 1. [cochranelibrary.com]

• Heart Failure

  He said the admission rate for people with diabetes was comparable to that of congestive heart failure, kidney disease, depression and most types of cancer. [express.co.uk]

  Compression should generally not be used in the setting of peripheral arterial disease or uncompensated congestive heart failure. [clevelandclinicmeded.com]

  The hemorrheologic agent cilostazol is contraindicated in patients with congestive heart failure. See Medication regarding the product's black box warning. For more information, see Diabetes Mellitus, Type 1 and Diabetes Mellitus, Type 2. [emedicine.medscape.com]

  Factors Affecting Healing Picwell et al. [ 117 ] studied factors affecting healing of diabetic foot ulcers that included the location of ulcer, duration of diabetes, ulcer duration, the presence of heart failure and peripheral arterial disease. [omicsonline.org]

• Foot Disease

  Diabetic foot disease is a result of three main pathologies, which can occur singly or in combination: diabetic peripheral neuropathy, peripheral arterial disease and infection. [ncbi.nlm.nih.gov]

  G, Apelqvist J ( 2005 ) The global burden of diabetic foot disease. [doi.org]

• Foot Pain

  All people with diabetes can develop foot ulcers and foot pain, but good foot care can help prevent them. Treatment for diabetic foot ulcers and foot pain varies depending on their causes. [healthline.com]

  Better off-loading adherence was, in turn, predicted by larger and more severe baseline DFUs, more severe neuropathy, and NeuroQoL foot pain (P < 0.05). [ncbi.nlm.nih.gov]

  Current concepts review: Charcot arthropathy of the foot and ankle. Foot Ankle Int. 2007; 28(8):952-59. 11. Maskill JD Bohay DR, Anderson JR. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010; 31(1):19-22. 12. [podiatrytoday.com]

• Contusion

  […] amputation, and death. 5 According to the American Diabetes Association, 2 PN affects approximately 60% to 70% of patients with diabetes. 2 Patients with PN may have unsteady gait and/or impaired proprioception that may put them at risk for falls, fractures, contusions [o-wm.com]

  Stratégie de recherche documentaire Nous avons effectué des recherches dans le registre spécialisé du groupe Cochrane sur les plaies et contusions, CENTRAL, Ovid MEDLINE, Ovid MEDLINE (citations en cours & autres citations non indexées), Ovid EMBASE et [cochranelibrary.com]

• Foot Ulcer

  All three of these risk factors are present in 65% of diabetic foot ulcers. Calluses, edema, and peripheral vascular disease have also been identified as etiological factors in the development of diabetic foot ulcers. [clinical.diabetesjournals.org]

  Depending on severity, a diabetic foot ulcer may be rated between 0 and 3. 0: at risk foot with no ulceration 1: superficial ulceration with no infection 2: deep ulceration exposing tendons and joints 3: extensive ulceration or abscesses Tissue around [dermnetnz.org]

• Skin Ulcer

  Keratinocytes and dermal endothelial cells, excluding leukocytes that infiltrate wounds, are the main source of soluble factors regulating healing of skin ulcers. [ncbi.nlm.nih.gov]

  […] title=Category:Diabetic_foot_ulcer&oldid=311113383 " Categorie : Skin ulcers Diabetic foot Categoria nascosta: Uses of Wikidata Infobox [commons.wikimedia.org]

  Trophic canker on skin wound healing on leg of child and lying down hospital bed. Trophic canker on skin Illustration of skin ulceration diabetic ulcer, cracked heel, fungus infection, stinky foot problems, Ulcers icon. [shutterstock.com]

  Ulcers usually begin with small abrasions which deepen. However, some ulcers begin with undermined skin which breaks down. Ulceration may progress to expose subcutaneous tissues, tendon, bone or joint. [foothyperbook.com]

  This causes dry skin and fissure formation, which predispose the skin to infection. [aafp.org]

• Delayed Wound Healing

  Molecular analyses of biopsies from the epidermis of patients have identified pathogenic markers that correlate with delayed wound healing. These include overexpression of c-myc and nuclear localization of β-catenin ( 13 ). [doi.org]

  […] as the primary cause for vascular impairment. [1] The risk of developing PAD is increased with diabetes and ischemia is considered the biggest culprit delaying wound healing. [1] Diabetic neuropathy and ischemia combined is called neuroischemia. [physio-pedia.com]

  PVD reduces blood flow to the extremity, which frequently leads to delayed wound healing and wound infection, putting the patient at risk for possible limb loss. 6 A prospective study 7 that examined patients with a history of a foot ulcer found that [o-wm.com]

  During this time the clinicians should also evaluate your overall blood glucose control because it is known that people with high blood glucose levels also demonstrate delayed wound healing. [diabetesselfmanagement.com]

• Renal Insufficiency

  In addition, a low ABI has been associated with a higher risk of coronary heart disease, stroke, transient ischemic attack, progressive renal insufficiency, and all-cause mortality [ 19 ]. [link.springer.com]

  Modification of low density lipoprotein by advanced glycation end products contributes to the dyslipidemia of diabetes and renal insufficiency. Proc Natl Acad Sci U S A. 1994 ; 91 : 9441–9445. [doi.org]

• Kidney Failure

  […] disorders of clotting and circulation that may or may not be related to atherosclerosis Diabetes Renal (kidney) failure Hypertension (treated or untreated) Lymphedema (a buildup of fluid that causes swelling in the legs or feet) Inflammatory diseases [my.clevelandclinic.org]

Diabetic foot ulcer workup needs a good history along with complete general and local examination. History must involve questions regarding symptoms of neuropathy, vascular insufficiency and duration of diabetes. A detailed history of pain and redness must be taken. Foot ulcers and other complications are directly related to duration and severity of disease. Cold extremities, loss of sweating, brittle nails, fissures, hypertrophic calluses and history of past ulceration are very often described by patients. More often, physicians discover these signs in general physical examination. Patient may give a history of renal disease, eye problems or other diabetic complications. Medication history may also prove to be beneficial in certain cases. 

After general physical examination, peripheral vascular system and peripheral nerves are examined [9]. While examining peripheral vascular system, look for any change in color of limb, pigmentation, prominent veins, hair distribution, dryness, fissures, nail lesions, deformities of bones and ulcers or sinuses. While palpating, note temperature of skin and compare it with skin of opposite limb. An increased temperature is a sign of active inflammatory process, whereas dry, cold skin is indicative of ischemia and autonomic neuropathy in that area. Check and compare pulses in both limbs, including dorsalis pedis, posterior tibial, popliteal and femoral artery (note that during general physical examination, other pulses like radial, carotid etc are also checked). Tests for capillary refilling time, intermittent claudication and peripheral sensation should also be done. Interphalangial clefts should be looked for any hidden ulcers or lesions.

Ulcer examination is done with a sterile stainless steel probe. Look for site, color, any discharge (blood/pus), margins and edges of ulcer. Check the ulcer base for any granulation tissue, pus or bone showing from it. Sinus tracts progress from ulcer to underlying tissue and sometime into bones. Depth of sinus tracts must be assessed using stainless steel probe [10].

Laboratory investigations include routine investigations of complete blood count, Erythrocyte Sedimentation Rate (ESR), leukocytosis, blood and urine sugar and urine ketone bodies, electrolytes and creatinine levels. Hemoglobin A1C levels are monitored in order to check glycemic control in patients. Other tests, for renal and hepatic function, should also be done to ascertain patient’s metabolic status. Culture examination from samples taken from ulcer is not that much valuable as all ulcers harbor microorganisms. However, in case of secondary infection, that may help in identification and medical treatment.

Special investigations involve:

• Imaging techniques like X-ray, MRI 
• Thermoregulatory sweat testing, quantitative sudomotor axon reflex testing and quantitative direct and indirect axon reflex testing or heart rate variability rate (these tests are to ascertain degree of autonomic/sensory/motor neuropathy).

• Hyperglycemia

  Furthermore hyperglycemia causes generation of free radicals which leads to oxidative stress (OS). [ncbi.nlm.nih.gov]

  DESPITE the fact that in the severest cases of hyperglycemia the crystalline lens is clear enough to allow adequate visualization of the deeper structures, there is a deep-rooted belief that a relationship exists between cataract and diabetes. [jamanetwork.com]

  There may also be present some metabolic conditions that are not optimal for wound-healing, delaying the process even more (hyperglycemia, hyperlipidemia, hyperinsulinemia, pro-coagulative state). [clinicaltrials.gov]

  Because the blood supply required to heal a diabetic foot ulcer is greater than that needed to maintain intact skin, chronic ulceration can develop. 9 Vascular changes that lead to diabetic foot ulcers correlate with hyperglycemia-induced changes in the [journals.lww.com]

  Furthermore, the Diabetes Control and Complications Trial 2 and other prospective studies have confirmed the pivotal role of hyperglycemia in the onset and progression of neuropathy. [clinical.diabetesjournals.org]

• Dyslipidemia

  Pyridoxamine inhibits early renal disease and dyslipidemia in the streptozotocin-diabetic rat. Kidney Int. 2002 ; 61 : 939–950. [doi.org]

An infected wound may contain foreign particles, microorganisms, dead and necrosed tissue that hinder cell migration and inhibit healing. Debridement is removal of dead, damaged or infected tissue in order to promote healing in rest of tissue that is normal. It can be done in DFU using a sharp scalpel, ensuring effective removal of all the damaged tissue and, if necessary, some portion of surrounding tissue, since necrosis can extend beyond ulcer bed. This procedure is called surgical (sharp) debridement. Debridement can also be achieved through mechanical, medical, chemical, enzymatic or autolytic (self debridement) methods. In self debridement (used often), dead tissue is allowed to slough off while ensuring adequate care i.e., keeping it dry and infection free. Debridement is followed by dressing and topical wound coverage. The basic principle for topical wound management is to provide a moist, but not wet wound surface. Choice of dressing should be appropriate. Dressing may be wet or dry, depending upon the material used. Following types of wound dressing can be used:

• Hydrocolloid
• Hydrofibre
• Hydrogel
• Transparent films
• Alginates
• Antiseptic dressings (e.g silver dressings or cadexomer)

Medical treatment aims at:

• Treatment and prevention of infection
• Control of pain
• Symptomatic relief of peripheral neuropathy, intermittent claudication and vascular occlusion
• Anti-diabetic drugs
• Newer therapies

For surgical management, patient should first be evaluated by a vascular/podiatric/orthopedic surgeon. Perioperative management, especially a strict glycemic control in patients before and after operation, is both an imperative as well as a complicated procedure. Objectives of surgery in these patients are debridement, vascular reconstruction, revisional surgery for bony architecture or providing soft tissue coverage with grafts, such as skin grafts. Wound closure is done when maximum antiseptic milieu and sufficient granulation tissue is available in wound. It may require grafting healthy skin flap or artificial graft materials, while in case of small wounds, primary closure is also possible. Osteomyelitis and cellulitis requires debridement, reconstruction and revisional surgery. Purpose of revisional surgery may be to remove pressure points in bones that may prone patient to future ulcerations. Vascular reconstruction, in the form of angiography and by-pass surgery, is done to tackle impending ischemia of tissues. Adequate blood supply and nutrition is also necessary for effectiveness of other treatments such as grafting. Amputation is considered when other medical and surgical procedures are of no value, to avoid long term morbidity, and when long-term wound care is not possible.
Offloading of ulcerated area is done to treat and prevent future injuries to foot. Custom designed shoes, soft heeled shoes, padded socks and shoe inserts, contact casts and removable cast walkers are used. These aids help to redistribute pressure over a comparatively larger surface area and prevent excessive pressure at one point. They also accommodate deformities of Charcot foot and avoid friction.

Uncontrolled diabetes correlates with a proportionate early onset of complications. Concurrent hyperlipidemia and hypertension further increase the risk. A regulated glycemic control can help protect patient from microangiopathy, neuropathy, retinopathy and nephropathy. Treatment of diabetic foot ulcer is along following lines:

• Offloading 
• Wound debridement
• Wound coverage
• Antibiotics and other drugs
• Vascular reconstruction and other surgical options
• Control of blood glucose level

DFU can develop infection or can turn into chronic ulcer if treatment is inappropriate or delayed. Patient must consult a physician on noticing an ulcer or sore area in foot. If pressure points have developed symptoms i.e., areas that repetitively come under pressure show change in color or are painful, they should not be ignored. Fractures, osteomyelitis or sepsis are frequent complications. If treatment is sought early, foot ulcers can be treated effectively and complications can be avoided, which, once developed, cause significant morbidity; sometimes amputation of foot may be the only treatment option. In some cases, a benign looking ulcer may turn out to be a grievous danger to health of patient. Treatment of DFU may be protracted over several weeks due to impairment of healing mechanism. 

Diabetes is the most common cause of non-traumatic lower limb amputation. Risk factors and etiologies for diabetic foot ulcers are peripheral neuropathy [3], vasculopathy [4], excessive pressure at certain points in foot [5] and deformities of foot [6]. Peripheral neuropathy, a common complication of persistent high glucose level in blood, is found to be present in 60% of diabetic patients. It can present with motor, sensory or autonomic neuropathy, involving a single nerve or multiple peripheral nerves. In the face of vascular insufficiency, ischemia of tissues, including nerves, occurs. Charcot foot, also known as Charcot osteopathy/Neuropathic osteoarthropathy/Neuropathic osteopathy is a term given to a collection of bone and soft tissue abnormalities in foot with unique clinical presentations. It is present in about 2% of diabetic patients. Bone and joint deformities that occur in a patient with peripheral vasculopathy and neuropathy gives rise to this condition. Foot assumes a characteristic shape, in which dorsum is dome-like and bottom is more concave than normal, while toes are splayed out (in most cases). Ankle mortise may also be displaced. Charcot foot is often accompanied by ulceration in foot (commonly involving toe and medical or inferior aspect of foot). Foot ulceration is the most common cause of hospitalization in diabetic patients.

In the United States, 16 million people suffer from diabetes mellitus. Diabetes is the major contributor to morbidity in Western world and its incidence is increasing throughout the world due to changes in lifestyle, diet and habits of people. Prevalence of DFU is highest in Native Americans, Latino communities of the Eastern United States, and in African Americans [7]. With increasing incidence and prevalence of obesity, hyperlipidemia and hypertension, non-familial incidence of diabetes is increasing, even in children and young adults. In United States, 10% people have type 1 diabetes, called insulin dependent diabetes mellitus and they are usually diagnosed before 40 years of age. However, genetic predisposition is higher in non-insulin dependent diabetes mellitus. Among patients with diabetes, foot ulceration is seen in 15% of patients.

Peripheral neuropathy open link, a complication of diabetes, occurs in 60% diabetics, as described above, and it usually follows within 10 years of onset. About 80% patients with this complication come up with ulceration. Throughout the world, 12 to 24% of the patients of diabetes undergo amputation (incidence of 1% every year).

Diabetic foot ulcer is characterized by a classical triad of vasculopathy, neuropathy and infection. Wound healing is a normal process that may be hampered by some physiological insult, resulting in persistence of wound. An ulcer is a break in the continuity of epithelial lining. Persistent high glucose levels in blood presumably prolong healing process and delay the formation of granulation tissue. Diabetes mellitus also prolongs inflammatory phase in wounds, retards the formation of granulation tissue and causes a parallel reduction in wound tensile strength [2].

High blood glucose can cause hypertension and atherosclerosis with resultant arteriolar hyalinosis, endothelial proliferation and increased thickness of basement membrane. Tunica media may also be involved, which undergoes thickening and calcification (Monckeberg sclerosis). Decreased nutrition supply disrupts myelin synthesis in nerves and hampers the function of sodium potassium ATP-ase. Increased amounts of sorbitol and fructose are also detrimental and hyperosmolar state also causes edema in nerve trunks, and together these changes lead to neuropathy of diabetes, which can involve one or more sensory, motor or autonomic nerves [8]. Thus, hyperglycemia induced by microangiopathy causes metabolic, ischemic and immunological injury to motor, sensory and autonomic nerves.

Sensory neuropathy is manifested as reduced sensations in foot; patient may not notice an injury or trauma to foot. Sometimes persistent trauma that occurs with the use of ill fitting foot wear produces ulceration in foot that may not be noticed by patient. Motor neuropathy in patient causes weakness of intrinsic muscles of foot, while osteoarthropathy weakens bones. All these effects together cause splaying. Upper part becomes convex, dome shaped and foot has a rocking bottom, this characteristic shape is called Charcot foot. Weakness of bones can cause bending or fractures; pressure points are produced inside foot, which if present in weight bearing regions or undergoing repetitive trauma can give rise to ulceration. Fractures usually go unnoticed until marked foot deformity becomes apparent. Sometimes sinus tracts form that lead to underlying bone.

80% of foot ulcers can be prevented through following measures:

• Meticulous podiatric care
• Early and proper management of minor injuries
• Use of appropriate foot wear
• Patient education
• Tight glycemic control and avoidance of other risk factors e.g., smoking, high (saturated) fat diet.

Podiatric care is essential. By routine inspection, regular follow up and with patient education, physician can help patient develop good foot-care habits. Routine inspection and examination of feet, by a physician in a clinic, is preferable, although patient or a caretaker can also carry out inspection at home. Foot care should include regular, gentle cleansing of feet with water and afterwards application of a mousturizer. Patient's foot should be inspected for any pressure sore, minor ulcers, skin dryness, pigmentation, change in color or any of other deformities described above. Custom shoes can be utilized, particularly by those in whom a risk factor has been identified by physician. Purchase of custom foot wear is covered for patients by Medicine Part B, provided an ulcer risk factor has been identified by a certified physician and appropriate documentation has been submitted. A moist foot environment and use of topical antibiotics can help prevent foot ulcers. Minor injures should not be ignored. Patients should be educated to avoid use of home remedies, which can sometimes exacerbate an injury in immunocompromised patients of diabetes.

Diabetes mellitus (DM) is a complex and serious disease with high rates of morbidity and mortality in patients. This pathological condition involves almost all the vital organ in the human body. DM accounts for around 40-60% of lower extremity amputations and most of these amputations result from deterioration of foot ulcer. Extracellular matrix forms largest part of dermal skin [1] and defects in its repair can result from various physiological insults, a well as pathological and aberrant metabolic processes; Diabetes mellitus being one of them. Diabetes mellitus disturbs normal healing mechanism by causing delay in granulation tissue formation and reduction in wound tensile strength [2].

Diabetic foot ulcer, a complication of diabetes mellitus, affects about 15% of patients of diabetes mellitus. Persistent high level of glucose in blood interferes with normal metabolic and healing processes in our body. It results in an abnormal blood supply to body organs, accumulation of harmful products and delayed healing of wounds. Ill fitting shoes, smoking and other risk factors like cardiovascular diseases, hyperlipidemia, hypercholesteremia, hypertriglyceridemia, hypertension and certain hereditary conditions, if concurrently present, may increase the chance of developing these ulcers by many folds. Diabetic foot ulcers account for 80% of leg amputations in the United States.
DFU develops when blood supply to lower extremities has been compromised to such an extent that it causes damage to nerves, bones and soft tissue. Due to altered nerve function, patient does not notice a blister or sore that, if not detected, can lead to infection and aggravation of condition. A limb that is prone to ulcer development may present with one of following symptoms:

• Change in color
• Change in temperature
• Pain or numbness
• Brittle toenails
• Abnormal pigmentation and hair distribution

Moreover patient can have difficulty in walking. Ulcers and blisters may come into patient's notice late, when signs and symptoms of infection appear. Diagnosis is made by physicians on examination. Further investigations may be required in order to identify the cause/causes of ulcer formation e.g., X-ray, CT, MRI or Doppler's Ultrasound studies. Specimen from a wound will be required for prescription of an antibiotic. Blood glucose and HbA1C are tested for assessing glycemic control in patients.

Treatment is through wound debridement, antibiotics, regular dressing change, offloading of foot and surgery, if other strategies are not sufficient. Skin grafting, hyperbaric oxygen therapy, arterial reconstruction and revisional surgery for bones and joints may also be suggested depending upon the condition of limb and prognosis after treatment. DFU can be prevented by maintaining foot hygiene, meticulous wound management and care, and control of diabetes.

1. Iakovos NN, Constantinos M, Nicholas CV. Protective and Damaging Aspects of Healing: A Review, Wounds 2006; 18 (7) 177-185.
2. McLennan S, Yue DK, Twigg SM. Molecular aspects of wound healing, Primary intention. 2006; 14(1) 8-13.
3. Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med. 2004 Jul 1. 351(1):48-55.
4. Arora S, Pomposelli F, LoGerfo FW, Veves A. Cutaneous microcirculation in the neuropathic diabetic foot improves significantly but not completely after successful lower extremity revascularization. J Vasc Surg. 2002 Mar. 35(3):501-5.
5. Boulton AJ. Pressure and the diabetic foot: clinical science and offloading techniques. Am J Surg. 2004 May. 187(5A):17S-24S.
6. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet. 2003 May 3. 361(9368):1545-51.
7. Marshall MC Jr. Diabetes in African Americans. Postgrad Med J. 2005 Dec. 81(962):734-40.
8. Tomic-Canic M, Brem H. Gene array technology and pathogenesis of chronic wounds. Am J Surg. 2004 Jul. 188(1A Suppl):67-72.
9. Gentile AT, Berman SS, Reinke KR, et al. A regional pedal ischemia scoring system for decision analysis in patients with heel ulceration. Am J Surg. 1998 Aug. 176(2):109-14.
10. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA. 1995; 273: 721-723.