Diabetic Foot Ulcers: Prevention and Early Warning Signs

Why the diabetic foot is vulnerable

Three problems combine:

1. Neuropathy (nerve damage): loss of feeling, so injuries are not felt; changes in foot shape and pressure points; dry, cracked skin from loss of sweating. 2. Poor circulation (peripheral arterial disease): less blood flow means slow healing and higher infection risk; signs include cold feet, shiny hairless skin, leg pain on walking that eases with rest. 3. High blood sugar and weakened defences: infections take hold and spread quickly.

Added to these are foot deformities (bunions, claw toes, Charcot foot), thick calluses, poor eyesight that prevents inspection, obesity, kidney disease, smoking and previous ulcers. See diabetes at home after 60, neuropathy foot care and diabetic foot care at home.

Who is at highest risk

• Loss of feeling in the feet (test with a monofilament by a doctor or nurse).
• Poor pulses or circulation.
• A previous foot ulcer or amputation.
• Foot deformity, bony prominences, thick calluses.
• Kidney disease, dialysis; see chronic kidney disease home care.
• Poor vision.
• Smoking.
• Long-standing diabetes with poor control.
• Living alone or frailty, with no one to check.

A yearly foot examination by a doctor, nurse or podiatrist classifies risk; high-risk feet need checks every one to three months. Ask for it.

Daily foot check

Make this a habit, with a family member helping if needed.

1. Look at the whole foot, top, sole, heel, between toes and nails, in good light. Use a mirror on the floor or a phone camera to see the sole; see magnifier lamp guide. 2. Look for: cuts, blisters, red or dark spots, swelling, cracks (especially heels), peeling or soggy skin between the toes, corns, calluses, ingrown or thick nails, changes in colour or shape, discharge, or a sore that does not heal. 3. Feel: warmth, swelling, hard areas, dryness. 4. Smell: a foul smell may indicate infection. 5. Check shoes and socks by hand for stones, folds and rough seams before putting them on. 6. Record changes and photograph; compare day to day. 7. Act: see "Warning signs" below.

Protecting the skin

• Wash daily in lukewarm water (test with an elbow or thermometer, not the foot) and mild soap; do not soak for long.
• Dry carefully, especially between toes.
• Moisturise the tops and soles, not between the toes.
• Trim nails straight across after washing; do not cut corners or too short; ask a podiatrist if sight is poor or nails are thick; see nail, hair and foot care for the dependent elderly.
• Never cut corns or calluses, use blades, corn plasters or chemical removers; see a podiatrist.
• Avoid hot water bottles, heating pads, hot sand and floors; keep feet away from heaters and fires; see hot pack safety for older skin.
• Never walk barefoot, indoors or outdoors, including to the bathroom and the temple.
• Treat athlete's foot early; see skin conditions in older adults.
• Protect from insect bites and sun.
• Do not use home remedies such as hot oil, turmeric pastes or herbal poultices on a sore; see a doctor.

Footwear and socks

• Shoes that fit: wide, deep toe box, soft upper, no internal seams, cushioned, supportive sole, adjustable fastening. Shop in the afternoon, measure both feet and wear the usual socks. See choosing shoes for older feet.
• Therapeutic shoes and insoles may be prescribed for deformity or past ulcers; see insoles and orthotics for foot and heel pain.
• Socks: seamless, soft, moisture-wicking, with loose tops; change daily; no darns.
• Avoid: pointed shoes, high heels, flip-flops, sandals with straps between toes, tight shoes, plastic shoes, and hand-me-downs.
• Break in new shoes gradually, checking feet afterwards.
• Indoor footwear: soft, closed, non-slip slippers.
• Do not use tight bandages or garters.
• Compression stockings need a doctor's check of circulation first; see compression stockings guide.

Blood sugar and general health

• Keep sugar within the doctor's target; high sugar slows healing.
• Stop smoking.
• Control blood pressure and cholesterol.
• Stay active safely, with suitable footwear; see exercise with diabetes.
• Eat well: protein and nutrients help skin and healing; see nutrition for diabetes after 60.
• Attend regular check-ups for feet, eyes and kidneys.

Warning signs of an ulcer or infection

Go to a doctor or hospital the same day for:

• any break in the skin on the foot, blister, cut, sore or crack that is not healing in a day or two;
• redness, warmth, swelling or pain in a foot or toe;
• pus, discharge or a bad smell;
• red streaks up the leg;
• fever or chills, or feeling unwell with a foot problem;
• a black, blue or very pale area of skin or toes;
• a sudden change in foot shape (Charcot foot), with a warm, swollen foot;
• a foot that is cold, pale and painful;
• new numbness or severe pain.

Call 112 if there is spreading redness with fever, confusion, rapid breathing, severe drowsiness or signs of sepsis (very unwell, fast heartbeat, low blood pressure), or a black foot with severe pain. A foot infection in diabetes can become life-threatening within a day or two.

What to do if you find a wound

1. Stop walking on it and rest the foot, raised. 2. Cover with a clean dry dressing, without tight tape; do not apply creams, antiseptic pastes or home remedies unless a doctor says so. 3. Do not pop blisters or cut dead skin. 4. Call the doctor or go to a diabetic foot clinic, or the emergency department, today. Do not wait to "see if it heals". 5. Check blood sugar, and note the wound size, colour, date found and photograph. 6. Bring the person's medicine list and footwear to the visit. 7. Follow the treatment plan closely: regular dressing changes by a nurse, offloading (keeping pressure off) with special shoes or a boot or cast, antibiotics only if prescribed, sugar control, circulation tests, X-ray if needed. Healing takes weeks, and offloading is key; see wound care at home for older adults. 8. Do not stop prescribed medicines or change them without the doctor.

Family and carers

• Do the daily check if your parent cannot see or reach their feet, kindly and with respect.
• Make appointments for the foot examination and keep them.
• Check footwear often and replace worn shoes.
• Learn the warning signs and make sure the household knows.
• Act the same day, not tomorrow.
• Provide transport to a foot clinic.
• Support mood and independence: foot problems can be frightening.
• Watch the carer's wellbeing; see caregiver burnout signs and prevention.

Indian climate and lifestyle notes

Monsoon dampness encourages fungal infections between the toes; dry feet carefully. Hot summer floors can burn numb feet; wear footwear on terraces and in temple courtyards, and carry thin shoes or non-slip socks where shoes are removed. Chappals are common but give poor protection; closed shoes are safer. Avoid barefoot walking on pooja floors where possible, and consider covering feet with socks where acceptable. Take extra care on festival days with long standing and crowds. See mobility aids for temples and weddings.

When to ask a professional

A doctor or diabetologist should check feet yearly and manage sugar and circulation. A podiatrist can care for nails, calluses and footwear. A wound care nurse or surgeon treats ulcers. An orthotist supplies therapeutic footwear. For senior services, call Elderline 14567. In an emergency, call 112.