Diabetes, Smoking, and Poor Circulation: A Terrible Combination

Diabetics have enough to worry about with their feet, including poor sensation, possible wounds, and infections that can cost them a toe, part of the foot, or the leg.  When you add smoking tobacco products and bad circulation in the arteries going into the foot, the results can be devastating.

Smoking has many health problems associated with it.  The effect that smoking has on blood flow control, tissue healing, and overall tissue health in the foot cannot be understated.  Smoking has a very negative effect on the size of the blood vessels entering the foot and within the foot.  This effect means that vital oxygen and nutrients cannot get to the tissue as easily in the foot, and this can lead to poor skin and tissue health, foot wounds, and even pain.

When combined with poor circulation already present because of other factors, such as obesity, high cholesterol, and genetic risk, the immediate risk to the health of the foot is severe.  Diabetes and smoking are even risk factors themselves for poor circulation in the legs.  When you combine all three of these, you have foot and leg tissue that is more likely to get injured, stay injured due to poor healing, and become gangrenous.  Diabetics who smoke and have poor circulation are far more likely to lose their foot or leg due to infection, gangrene, or other serious skin and tissue disease from simple causes like a scratch, scrape, or thick broken callus.  Leg pain from the combination of these conditions can be unbearable at times, with little relief available from medication.  The risk of death within 5 years after an amputation due to these conditions is higher than many forms of cancer.

All of this can be prevented, however, by doing a few things:

• Keep blood sugar under control.
• Stop smoking.
• Get a simple noninvasive circulation test to see if there is a problem with blood flow in the legs.

If you are diabetic, smoke, and are at risk for poor circulation, you owe it to yourself to protect your legs and your life.  Make the decision to be healthier today.

Until next time,
Scott R. Kilberg DPM
Podiatrist in Fishers, Indianapolis, and Noblesville Indiana

Dangers In the Garden For Diabetic Feet

As the spring is continuing and slowly progressing toward the summer, the annual ritual of tending to the garden takes place.  For diabetics, this can actually be a dangerous time for their feet if one is not careful.  I would like to discuss some of these dangers, and ways to prevent them.

Puncture wounds into the skin are a constant danger to diabetic feet, and in the garden where there are many sharp dangers this can especially be a problem.  These dangers can include sharp pieces of mulch, sticks and twigs, broken pottery, glass and construction debris like nails, as well as the garden tools themselves.  It is absolutely important that diabetics wear the proper footwear for work outside.  This does not include old ragged shoes that one does not mind getting dirty.  Stable, supportive, and thick soled shoes are vital to protecting the foot from puncture wounds, which often result in deep foot infections and possibly gangrene from soil-based bacteria.

Sharp plants likewise pose a danger to exposed skin.  Thorns, barbs, and sharp shrub branches can scratch exposed skin, especially on the arms, legs, and ankles.  Long sleeve shirts, pants, socks can help protect skin from getting scratched.  Even a simple scratch can be an entryway for bacteria into the skin, eventually leading to cellulitis.

In the garden, objects tend to find their way into shoes.  These can include landscape pebbles, mulch particles, or other debris.  Once in, a diabetic foot may not feel the object due to sensation loss.  This can lead to an indention in the skin at the very least, and an eventual skin wound at the worst.  Periodically checking one's shoes and physically emptying them out can remove these objects, and keep the skin protected.

Finally, the very water that makes the garden grow can pose a potential problem for the foot of a diabetic.  Shoes inevitably get wet when watering plants or walking in a garden with wet soil from a recent rain.  When that moisture stays against the skin in the form of a wet sock, the spaces in between the toes and the skin over bottom of the foot can get moist.  This moisture leads to foot fungus infection, and as the moist skin breaks down bacteria can take advantage of the skin defect and start an infection.  When socks become wet, they should be changed once the gardening is over, or if one is tending the garden all day the socks should be changed periodically as they become wet.

To all those out there making our landscape beautiful, happy gardening this spring, and keep your feet safe!

Until next time,
Scott R. Kilberg DPM
Indianapolis podiatrist treating diabetic foot problems

Why Care For the Spaces In Between Your Toes

One of the most overlooked parts of the foot is the area in between the toes.  These dark spaces often get little attention as they are not directly visible.  Unfortunately for diabetics, ignoring the spaces in between the toes can spell disaster.

The spaces in between the toes are a perpetually dark, moist area that can harbor lint, skin debris, as well as fungus, bacteria, and the moisture they love.  For most people these things are simply a matter of hygiene or are a nuisance.  Diabetics have a slightly greater challenge in that these organisms, as well as the peeled skin debris or clothing fuzz they inhabit around, can pose a higher risk for skin infections to occur.  The most basic infection in between the toes is a fungus infection, also known as Athlete' Foot.  Unless severe, this is a nuisance infection that is easily treated with over-the-counter antifungal creams.  However, diabetic feet are far more sensitive to bacteria, and bacteria love to follow a fungal infection as the fungus creates microscopic defects in the skin for bacteria to cling to and enter.  This is known as a secondary infection.  If enough bacteria burdens an area, a skin infection called cellulitis can develop.  This infection can spread up the foot, and possibly can move up the leg and threaten the health of the leg itself.  Untreated infections can even get into the blood stream and cause serious disease and organ failure due to the toxins the bacteria produce.  In contrast, skin fungal infections do not spread beyond the toes and bottom of the foot.

Even in the absence of fungus, unhealthy skin in between the toes can crack and split, leading to small fissures in the skin that can allow bacteria to enter and cause an infection, leading to all the complications mentioned above.

To prevent all this, the spaces in between the toes need to be well cared for.  For diabetics, this includes daily gentle cleansing of all debris in between the toes with soap and water, as well as careful drying to prevent unnecessary moisture from being retained in the space.  Additionally, the skin between the toes should be inspected for any sores, cracks, redness, peeling, or abnormal drainage.  If these are found, a visit to one's podiatrist may be in order.  Unfortunately, not everyone can reach between the toes to provide this care on their own feet.  For those that can't, it is important to have a friend or family member help.  This care is necessary, and there should be no shame in asking for assistance in cleaning the foot.  It may make the difference between healthy feet and an amputation.

Until next time,
Scott R. Kilberg DPM
Podiatrist in Indianapolis, Noblesville, and Fishers treating diabetic foot infections

Options For Diabetic Neuropathy Pain If You Can't Take the Oral Meds

Peripheral neuropathy causes problems for a significant number of diabetics, including burning pain, tingling pain, clamping pain, and shooting, electrical-like pain.  There are a number of ways to treat this pain if simple blood sugar control does not work.  Some of the more common medications used include gabapentin, Lyrica, and Cymbalta.  Unfortunately, not everyone can take these medications as they can potentially cause side effects that may not be tolerable.  These include sedation, lethargy, dizziness, and leg swelling, amongst many others.  For those who cannot tolerate the use of these meds, there are alternate options available to control the pain of diabetic neuropathy.  For those reading this post, this is not a recommendation for any product or treatment, simply a discussion as to what physicians commonly use as alternates to the FDA approved neuropathy medication.  For your own specific neuropathy, you need to coordinate care with your primary care doctor, endocrinologist, neurologist, pain management specialist, or podiatrist if they treat neuropathy.

Some of the oldest remedies are also some of the most gentle and helpful.  Topical salves have been used for centuries to treat ailments.  One of these, capsaicin cream, is a product derived from hot pepper extract.  It can disrupt the pain process that the brain perceives.  In some people with diabetic neuropathy, this may be helpful.  Care must be taken not to expose other areas of the skin to the cream, and gloves should be worn during application.  Rubbing one's eyes after application is also a bad idea!  A similar product is called Biofreeze.  This cooling gel is similar to a Ben-Gay like product, and is used as a topical pain reliever.  Some cases of peripheral neuropathy can be treated with this product.  There are countless other products in stores that claim to reduce pain via topical application.  Some may work, most will not.  Remember, neuropathy is not typical pain, and typical pain relievers may not help.  A number of pharmacies around the country can also create prescription-level topical pain reducers with compounds that act against nerve pain in concentrations less that what can cause side effects if ingested orally. These compounded agents are helpful in some cases, but require a prescription.

Alternative oral medications that target one potential aspect of peripheral neuropathy, namely deficiency in some components of vitamin B, can be useful in some people to reduce their pain.  Prescription medical food supplements like Metanx or non-prescription Neuremedy work for some people, but not everyone.  Additionally, some compounding pharmacies have been creating their own supplements for prescription use. There is scientific data to back up some of these medication's formulation and ability to deliver the nutrient better into the body (particularly Metanx), so they are more than just simple health food store supplements.  However, one must be aware that their effectiveness is very dependent on the person using them, with some people seemingly randomly improving and others not.  The good news is that they are generally safe and have little issues with drug interactions or side effects, so they can be worth a try.

Other neuropathy treatments can come from specialists in nerve based pain, namely pain management specialists or neurologists.  These specialists may have surgical approaches to treatment, including selective nerve treatments or spinal cord stimulators.  These treatments can disrupt the abnormal nerve sensation, and provide pain relief.  They are often consulted once more traditional medicine-based neuropathy treatment fails.

For those of my readers with diabetic neuropathy pain, please be aware that it is not something you have to live with, but your treatment does need to be managed by a physician.  Taking some Tylenol or a left-over narcotic pain pill is a poor long-term substitute for true neuropathy treatment, and most likely will not work.  Talk to your family doctor, endocrinologist, or podiatrist about your own options for relief.

Scott R. Kilberg DPM
Podiatrist in Indianapolis, Noblesville, and Fishers IN treating foot pain and nerve pain

Bruise On The Foot: Should A Diabetic Worry?

Foot bruising is common for diabetics and non-diabetics alike.  The problem with diabetics is that the event that caused the bruising is often not noticed, because of poor sensation.  That is to say, a diabetic can stub their toe , kick a door frame, or have something drop on the foot, and they may not feel much, if anything, of this injury.  Bruising is simply blood leaking under the skin, and occurs when blood vessels break (particularly small capillaries in the skin, varicose veins, or deep tissue blood vessels from tearing ligaments and tendon injuries).  The blood sits there, and is eventually absorbed by the body.  In the foot, a bruise can be seen anywhere- common areas include the toes, the ball of the foot, on top of the foot, and around the ankle.  The unfortunate part is that bruising is not a reliable sign of the seriousness of the injury.  Some injuries are minimal and still bruise, while sometimes bruising is simply the outward sign of a torn ligament or even bone fracture.

So, how should a diabetic handle a new foot bruise at home?

The first thing that should be done is to try and remember how the bruise may have occured if it was not felt before seeing it for the first time.  If it was part of a more significant injury, like something heavy dropping on the foot or a twisting injury/fall, an evaluation by one's podiatrist is in order.  If one cannot remember an injury, or if it was something minor like stubbing the foot gently in a doorway, then one should examine their own foot. If there is swelling with the bruising, pain, warmth, redness, parts out of place (like a toe pointed up or off to the side), if the bruise is more than a couple inches wide, or if there is looseness or cracking to the part of the foot with the bruise, then one should visit their podiatrist.  This is also the case if there is an opening in the skin.  If the bruise is the only thing noted, then that part of the foot needs to be monitored for any worsening over the course of the next several days, and activity should be reduced as a precaution.  If one is in doubt, a visit to a podiatrist is still always a good idea to rule out a worse injury or fracture, and this should be done if there is any worsening symptoms.

If the bruise is under an entire toenail or a callus, then a visit to a podiatrist is recommended.  Toenail bruises that take up most of the room under the nail can indicate a fracture of a bone at the end of the toe that has penetrated through the skin under the nail, causing the bruising.  Prompt treatment is needed to prevent bone infection in the toe.  Bruises under calluses often indicate that an ulcer (foot wound) has formed under the callus.  This needs wound care, as many infected wounds in diabetic feet begin simply as bruised areas under a callus.

Until next time,
Scott R Kilberg DPM
Podiatrist in Indianapolis, Noblesville, and Fishers Indiana treating foot injuries

Why You Should Not Walk On Your Wound Dressing On the Bare Floor

Many diabetics inevitably develop skin wounds on their feet at some point, with many of these wounds located on the bottom of the foot.  These diabetic foot wounds require experienced wound care by a well trained physician or wound care specialist.  As part of most wound care, a dressing is used to protect the wound, keep it moist, and also pad the surface around the wound.  Many of these dressings wrap around the foot and ankle to keep them secure.

Many people are still able to bear weight and walk on these dressings, although protective devices like walking boots are often used to reduce pressure, especially to wounds on the bottom of the foot.  The reality though is that people will inevitably bear weight without this protection at home, whether this is advised by the treating doctor or not.  This may be for a quick trip to the bathroom, or more extensive like an entire weekend day of pacing the house.  This unprotected weight can have an adverse effect on the healing of the wound, something I have discussed on numerous other posts.  What is of more practical concern for this week's post is that dressings, when walked on at home no matter whether on carpet, tile, or wood, will get really soiled.  Gauze dressings and their outer covering can get filthy from the dust, dirt, and hair found on the floor.  This soiling contains bacteria that can make their way into the gauze, and possibly into the wound.  Although I can't exactly cite it, I do recall reading a study at one point that demonstrates bacteria can infiltrate through something like 16 layers of gauze.  No matter how clean your home or personal sense of hygiene is, the simple fact that a dirty dressing can put your wound at risk for infection should prompt you to keep it off the ground.

Keeping the recommended walking boot or medical shoe on when walking at home is a must, for both pressure reduction and dressing cleanliness.  If these devices are not necessary (such as for wounds on the top of the foot that do not need pressure reduction), the use of a deep shoe or house slipper when walking at home is still necessary to keep the dressing clean.  If your shoes do not allow a dressing to fit, then your podiatrist or wound care specialist should be able to get you a medical shoe (also called a post-op shoe as it is often used after foot surgery) to use at home.

Until next time,
Scott R. Kilberg DPM
Indianapolis podiatrist treating diabetic foot wounds

Are Discolored Toes Ever Not Something Serious?

Diabetics are keen to changes in the color of their feet as part of a good self-exam program at home to catch any complications from diabetes early enough.  These include infections and injuries, things I have blogged about for some time now.  While redness to the toes is usually a danger sign for a diabetic, there are cases in which the color change can be somewhat normal, and not necessarily the sign of a significant problem.

Some people develop red or reddish-purple discoloration to their toes (and fingers) due to a common condition called Raynaud's disease.  This condition can develop from childhood, or it can develop later on in life, and can be noticed suddenly one winter.  In Raynaud's, the arteries that supply blood to the toes constrict due to stimulation from colder weather.  While this is a natural reaction of the body to keep warmth closer to the body core, in some people the constriction is excessive, leading to lower blood supply to the toes, and subsequent skin discoloration.  In severe cases, the toes can hurt and even develop skin wounds, although these are uncommon.  A good discussion of Raynaud's' disease in the feet can be found through the highlighted link to my website.

The problem with Raynaud's in diabetics is that it is difficult to tell if the discoloration is simply Raynaud's disease, or if it is a more serious circulation disorder that diabetics are at risk of getting (along with those with heart disease, high blood pressure, high cholesterol, or those who smoke).  Poor circulation in the large arteries in the leg can sometimes first present as discolored toes.  Additionally, clots in the central and  leg arteries can sometimes break off and travel in pieces down to the foot, where they can become lodged in smaller blood vessels.  This can result in discolored toes, and tissue disease.  These conditions do not reverse with warmer temperatures like Raynaud's disease, and need closer monitoring and intervention.  Of course, some infections can appear as redness to more than one toe, but it is uncommon for all the toes to be discolored without an obvious source of the infection like a skin wound, or redness also well into the foot.

The take-home message of this post is essentially this:  not all redness in toes is a sign of a more serious foot problem for diabetics, and may be relatively normal for some.  However, this is very hard for someone to try and determine on their own, and a visit to their foot doctor (or primary care doctor if a foot specialist is not available) is advised.

Until next time,
Scott R. Kilberg DPM
Indianapolis Podiatrist serving Indy, Fishers, Carmel, Noblesville, Westfield, and McCordsville Indiana