Any damage to the skin is a wound—whether caused by traumatic injury, exposure to harmful substances, or even surgery. Management of wound healing has become a medical specialty and there are over 6,000 products on the market that are devoted to wound healing, including advanced dressings, devices and therapeutic modalities. The skin is the largest organ in our bodies, and weighs, on average about six to eight pounds. Skin shields against bacteria or injury, and helps prevent the loss of water, electrolytes (minerals), proteins and other vital substances. Your skin also controls temperature and helps you sense heat, cold, pressure and pain.
As mentioned before, any break in your skin constitutes a wound. If your diabetes is under control, you can have near normal wound healing. However, elevated blood glucose levels can cause healing complications and infection. There are different types of wounds, and some are more common for people with diabetes.
Wounds are classified in several ways:
• Acute vs. chronic. An acute wound heals in a predictable and timely manner, while a chronic wound has delayed or complicated healing.
• Depth. Partial thickness is where tissue damage extends through the top layer of skin and into, but not through, the deeper layer. Blisters and scrapes are partial thickness. Full thickness wounds invade the deepest layer of skin and may involve the subcutaneous tissue, tendon, muscle and bone.
• Cause or origin. Wounds are divided into pressure ulcers (previously known as “bed sores”), arterial, venous, and diabetic/neuropathic ulcers and surgical and traumatic wounds.
Certain wounds are more common in people with diabetes. First, diabetic/neuropathic ulcers are usually found in the feet or lower extremities, and arise from a lack of protective sensation. They are linked with calluses, foot and toe deformities, and repetitive stress. If you have numbness of the nerves in the feet, you are less aware of tissue damage. Keeping blood glucose levels as close to normal as possible can minimize the chances that you will get this type of ulcer. If you have hammertoe or foot deformities which are causing calluses and corns, a foot specialist can remove them and prescribe orthotic inserts or special shoes to help take the pressure off the bony areas of the foot.
Another type of wound common to people with diabetes is the arterial ulcer. These are caused by poor circulation to the tissues through diseased arteries (much like what occurs in the heart or with high blood pressure). These wounds are usually in the lower extremities, are generally round (have a “punched out” appearance), have little or no drainage, and are difficult to heal. If you have shiny, flushed, pale, and hairless skin you may be prone to these wounds. They are often treated with a combination of medications to increase circulation, advanced wound dressings that promote healing, and sometimes a hyperbaric chamber. This is a specialized therapy that helps to deliver oxygen under pressure to the oxygen-starved tissues. If you do not treat such a wound, or if it does not respond to treatment, it may progress to gangrene and become black and leathery. This is a very serious, and possibly life-threatening, condition. You may have a blocked artery, and you may be able to have surgery to improve circulation, but this is not always an option.
People with diabetes are also prone to disease of the veins as well as the arteries, and therefore can be prone to venous ulcers. These usually appear in the inner leg, above the ankle bone. They tend to be irregular in shape, and may have a large amount of drainage. You may have swelling of the legs and ankles, and, over time, the lower leg may become very thick at the calf and much thinner at the ankle. You may also notice gray discoloration, called hemosiderin staining, or develop a thick, leathery, orange peel-like texture to your skin. These wounds are sometimes treated with special dressings and compression to decrease the swelling, which allows healing oxygen and nutrients to get to the wound. Compression may be done by a number of methods including special stockings, ACE-type wraps or even a machine that intermittently compresses the leg with air pumps.
Pressure ulcers are a risk to anyone who may have impaired mobility, so if you have trouble getting around, keep this risk in mind. If you sit for long periods of time, wear tight or ill-fitting shoes, or are in any situation which puts pressure over a bony prominence steadily and over time (even a matter of minutes), this could cut or damage tissues. Pressure is also the enemy of healing because it prevents necessary oxygen and nutrients from getting to the wound site. These ulcers are often treated with a variety of dressings and therapies, but the most important treatment is to relieve pressure in the area.
Neuropathy, or diabetic nerve disease, is the leading cause of lower extremity wounds and amputations. The American Diabetes Association recommends some steps that will help you prevent this complication. First, perform a daily foot inspection. Check all over the feet, including in between toes, for dry or rough areas, cracks, calluses, hot spots, or anything abnormal. If you find something, notify your healthcare professional. Wash your feet daily with gentle soap and warm (but not hot) water. Dry carefully, especially between the toes. Do not soak your feet because that can dry out the skin and increase risk for infection through cracks. Apply a gentle, non-perfumed lotion to the feet, but not between the toes—moisture there may lead to athlete’s foot or other fungus. Wear protective and well-fitting footwear to prevent injury, and change shoes at least twice a day to avoid pressure areas. Cut or file your nails straight across, or along the contour of the toe, leaving a thin white edge. Never cut nails to the quick, and never cut into the corners of the nail. In-grown toenails and thickened nails should only be treated by a professional. Do not attempt to perform “nail surgery” on your own.
With the looming threat of new strains of resistant bacteria such as MRSA and VRE, it’s important to focus on preventing wounds, infections and other complications caused by high blood sugar. You should also know what to do to when something happens. If you happen to receive a minor injury, such as a paper cut, hangnail, or small puncture on your upper body, do not underestimate your risk. Bacteria can enter through even the smallest of wounds, and if blood glucose levels are elevated, the bacteria will feast on that and grow. So be sure to cleanse the wound with cool running water, and protect it from further injury. Dab a little antiseptic on the area, cover it with a bandage, and keep it away from contamination and dirt. Check it daily to be sure it is not getting infected. If you see redness, swelling, or leaking, contact your healthcare professional as soon as possible for further evaluation. If the wound is on your feet or legs, have it evaluated by a professional to identify the possibility of diabetic nerve disease. Remember, high blood glucose feeds infection, and infection makes glucose levels even higher. It can become a vicious cycle if you don’t have it treated properly.
If you get a blister, see whether it is filled with clear fluid or blood. If it is fluid-filled, it is considered superficial; if it is blood-filled, then it is deeper. Never remove the roof of the blister. The fluid inside contains many essential substances, such as growth factors, to speed the healing process. It also serves to pad and protect the injured tissues below, as well as maintaining a closed skin surface to shield against bacteria. It will absorb on its own when the time is right. As with other wounds, protect from further injury. You may also want to replace tight-fitting shoes, if the blister was caused by them.
You can minimize your risk of wounds and infection by keeping blood glucose levels as close to normal as possible. Test often, and take steps to keep your blood sugar in control. Wounds stop healing when blood glucose levels are 200 mg/dl and greater; healing is improved if 180mg/dl or less. Check glucose levels frequently, and notify your health care professional if you sustain an injury. You cannot avoid all wounds, but if you are careful and seek treatment when necessary, they will probably heal.
Beauty is only skin deep, but learn to love the skin you’re in, and take care of your wounds.
About the Author
Bonnie Williams has been a Certified Diabetes Educator (CDE) for 14 years, and a Certified Wound Specialist (CWS) for two years. She is a member of the American Association of Diabetes Educators (AADE), the Foot Care Specialty Practice Group, and is a Past-President and current Board Member of the AADE Northeast Ohio Chapter. She has been a member of the Education Committees of the American Diabetes Association Northeast Ohio Chapter, and the Diabetes Association of Greater Cleveland.
At the Visiting Nurse Service in Akron, OH, she developed the Diabetic Foot Care Program and the Diabetes Resource Nurse Program to cross-train nurses in diabetes care and assessment. Her program achieved Ohio Community Diabetes Control Program recognition as a “Center for Excellence” through the Ohio Department of Health and was the first freestanding homecare agency to receive such an honor.