Foot Conditions in Adults: Diabetic Foot Ulcers

Of the 550 million people worldwide and 37 million people in the United States with diabetes, more than 30% will develop a diabetic foot ulcer. Patients with diabetes are at increased risk of foot ulceration due to neuropathic loss of protective sensation, muscle atrophy and repetitive stress leading to foot deformities, and vascular disease. Periodic diabetic foot examinations performed by the primary care physician can identify preulcerative conditions. If present, these should prompt interventions, such as offloading for the area of concern, patient education, prescriptions for diabetic or custom footwear, or a referral to podiatry. When an ulcer is identified, classification using the SINBAD (site, ischemia, neuropathy, bacterial infection, area [ie, size], depth) system is beneficial for triage in primary care. Initial diabetic foot wound care should begin with assessment in primary care; offloading of the ulcer; treatment of infection if present; and prompt referral to specialists in wound care, infectious disease, or vascular surgery. If signs of ischemia (eg, decreased pedal pulses or blood flow) are identified, patients should be quickly referred for arterial duplex ultrasonography; if the signs of ischemia are more marked, immediate referral for vascular surgery is indicated.