The diabetic foot

Foot ulceration is common in diabetes mellitus. Foot problems remain the most common cause of hospital admission among individuals with diabetes mellitus in developed countries. The lifetime risk of a person with diabetes developing an ulcer may be as high as 30%, and ulcers precede about 85% of lower limb amputations in diabetes. Up to 50% of older patients with type 2 diabetes have risk factors for foot problems, and regular screening by careful clinical examination is essential; individuals found to be at risk should attend more regular follow-up, with education in foot self-care. The key to the management of diabetic neuropathic foot ulceration is aggressive debridement with removal of callus and dead tissue, followed by application of some form of cast to offload the ulcer area. Most ulcers heal if pressure is removed from the ulcer site, arterial circulation is sufficient, and infection is appropriately managed. Recent trials provide evidence to support the use of additional local therapies for hard-to-heal ulcers. Patients with a warm swollen foot without ulceration should be presumed to have acute Charcot neuro-arthropathy until proven otherwise. The optimal approach to reducing ulceration requires regular screening, patient education and a team approach to management, both in the community and in hospital.