Skin ulcerations. They can be painful for patients and terrifying for families. They bring to mind the image of bed sores, possibly caused by neglect and abuse. But, anyone who has a loved one in a healthcare facility should understand that not all ulcers are the same—and, perhaps somewhat reassuringly, most are not the result of negligence. Ulcers can and do happen, even in the presence of excellent clinical care.

There are a variety of skin ulcers. Most people know a bit about decubitus ulcers or pressure sores, also known as bed sores. Kennedy Terminal Ulcers (KTUs), another type of pressure sore, occur at the end of life. But, there are several other types of ulcers that are non-pressure-related, including venous stasis ulcers, arterial ulcers, and neurotrophic (diabetic) ulcers. In this post, we will cover neurotrophic, or diabetic, ulcers.

Patients with diabetes mellitus are at an increased risk for numerous long-term complications, so it certainly is not surprising that diabetes can negatively affect the body’s largest organ—the skin. Diabetics often suffer damage to the nerves, known as neuropathy, resulting in a loss of sensation in the lower extremities. Additionally, elevated blood glucose levels can damage blood vessels, resulting in decreased blood flow to the lower extremities. Together, this damage sets the perfect stage for lower extremity injuries and subsequent ulceration.

As with all types of ulcers, diabetic ulcers have some defining characteristics:

• LOCATION: Diabetic ulcers are usually located on pressure points on the bottom of the feet, although ulcers associated with trauma can occur anywhere on the lower extremities.
• APPEARANCE OF WOUND: The borders of a diabetic ulcer are punched out and the surrounding skin is usually calloused. Diabetic ulcers are often small wounds of varying depths. These ulcers frequently have a pale wound bed, little or no granulation, and necrotic tissue. The ulcers generally have minimal to no drainage, unless the wound is infected, in which foul-smelling and/or purulent drainage may be present.
• APPEARANCE OF EXTREMITY: The affected extremity may be warm to the touch, red, and swollen. Pulses will be present unless arterial disease is present.
• TESTING: A variety of simple, non-invasive tests can be performed to detect the presence of neuropathy and assess the quality of blood flow to the lower extremities.

Once a diabetic ulcer develops, treatment should focus on pressure relief, debridement (removal of dead tissue), management of any infection, and surgical intervention as indicated. Off-loading can be accomplished using cast boots, therapeutic shoes, and custom insoles. Debridement can be achieved by surgical means, or non-surgically with topical agents. Diabetic ulcers can become limb- and life-threatening in the event of an infection. If an infection is suspected, wound cultures are necessary to determine the appropriate course of antibiotic treatment. Bone cultures and/or radiographic examinations are used to confirm osteomyelitis (an infection of the bone). Unfortunately, once osteomyelitis is present, the infected bone usually must be removed.

Although diabetic ulcers are just one type of ulcer encountered in healthcare settings, they often pose the greatest risk for adverse outcomes. Prevention and management of diabetic ulcers is key. Many have heard the old adage that an ounce of prevention is worth a pound of cure; that adage is particularly true when it comes to preventing diabetic ulcers. Patients should be educated on ways to reduce their risk for developing diabetic ulcers, including daily examinations of the lower extremity skin, daily washing and drying of the feet, adequate control of blood glucose and lipid levels, routine podiatry care, neuropathy screening, appropriate footwear, and avoidance of cigarette smoking.

Diabetic ulcers can be alarming, just like bed sores and other types of wounds. But with an understanding of their physiological cause and possible interventions, providers and families can work together to find the best treatment and achieve the best outcome for patients. When it comes to skin ulcers, knowing the facts can help alleviate emotional upset and prevent unnecessary claims and allegations—a win for everyone involved.