Caring For Your Feet

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One of the greatest fears amongst diabetics is that they might lose a foot or leg to amputation.  This is indeed a valid concern as diabetics are more prone to developing foot complications. 

Here we look at some of common questions you may have.

1. Foot Care Tips

Why Is It Important For Me To Take Care Of My Feet?

Most people take their feet for granted, but if you want to lead a healthy, active and independent life, having healthy feet is a must.  People who have diabetes will need to pay special attention to their feet because diabetes affects both the nerves and small blood vessels, making them prone to developing foot ulcers that may not heal.

By taking proper care of your feet and having your doctor or diabetic nurse check your feet regularly, you can often prevent diabetic foot complications.  Many of the lower limb amputations in diabetics are preventable!

Are Diabetics More Likely To Develop Foot Infections?

Yes, diabetics are significantly more prone to developing foot infections for the following reasons:

1.  Diabetic Neuropathy: 

High blood sugar levels over time cause peripheral neuropathy (damage to the peripheral nerves).  Diabetics with "sensory neuropathy" may not be able to feel their feet well, so they may not notice injury, sores or high pressure areas on their feet.  They may continue to walk on the injury (which would normally cause pain in someone without nerve damage), causing further damage to the tissues.

Diabetic neuropathy can also affect the motor (affecting movement) nerves.  This could cause the foot not to align properly and create too much pressure in one area of the foot.

2. Peripheral vascular disease:

Diabetes also affects the flow of blood because it damages both large and small blood vessels.  Without good blood flow, it takes longer for a sore or cut to heal. Poor blood flow in the extremities (ie. the arms and legs) is called "peripheral vascular disease."  If you have an infection that will not heal because of poor blood flow, you are at risk of developing ulcers or gangrene.

What Are The Risk Factors For Developing Diabetic Foot Problems?

Peripheral neuropathy is a major risk factor.  If poor circulation is also present, the risk increases.

Other risk factors include foot deformities, thick nails, limited joint mobility, history of having previous foot ulcers/amputations.  Having other diabetic complications such as diabetic kidney disease (diabetic nephropathy) and eye disease (retinopathy) indicates widespread small vessel disease, and this would increase the risk of foot complications as well.

What Can I Do To Prevent Diabetic Foot Problems?

• First and foremost, ensure that your diabetes is well controlled!

• Keep your feet clean and dry.

• Get into the habit of examining your feet every day.  Look and feel both feet, on top, the bottom, the back and sides, as well as between the toes.  Look for areas of redness, ulcers, breaks in the skin etc.  Seek prompt medical attention should you spot any potential problems.

• Cut and file toenails carefully.  Avoid cutting too deep as this would increase the risk of getting ingrown toenails.

• Moisturize dry skin with a good moisturizer.

• Wear well-fitting socks and shoes.  Soft leather or sports shoes are preferable.  Avoid going barefoot, even at home.

• Have your feet checked regularly by your doctor/nurse.

Does My Weight Affect My Feet?

Yes.  The more you weigh, the more stress is transmitted through your knees, ankles and feet.  People who are obese tend to place their feet wider than normal because their thighs hold the legs outwards.  This means that their body weight is transmitted more to the inner part of the foot, thereby changing the normal mechanics of walking.

If you are overweight, speak to your doctor about how you can safely go about losing weight.  Ensure that you wear comfortable shoes which offer good support.

What Are The Common Foot Problems That Occur In Diabetics?

The following are problems that may occur in anyone, however, for those with diabetes, these common foot problems may lead to serious infections if not managed properly.

Athlete's foot (Tinea Pedis): This is a common fungal infection of the foot, resulting in itching, redness and cracking.  Damp and warm conditions encourage the growth of these fungi.  Breaks in the skin's natural barrier allow bacteria to enter, causing secondary infections.  Medication (either topical or oral) are effective in treating fungal infections, but they must be used regularly.

Fungal infection of nails (Onychomycosis): Nails that are infected with a fungus may become discolored (yellowish-brown or opaque), thick and brittle, and may separate from the rest of the nail.  Unlike fungal infections of the skin, infections of the nail are more difficult to treat. Medications applied directly to the nail are available, but may not be very effective.   Oral medication prescribed by your doctor may be required.

Calluses: A Callus is a build-up of skin that becomes hardened. Calluses are common foot conditions for diabetics and, are caused when weight is placed unevenly on a certain area of the foot. Calluses are generally caused by shoes that do not fit properly.   Proper care is necessary if you have a callus. After your bath or shower, use a pumice stone to gently remove the build-up of tissue. Use cushioned pads and insoles in your shoes. Topical medications also may be prescribed to soften calluses. NEVER try to cut the callus or remove it with a sharp object.

Corns: A corn is a small growth that is similar to a callus in that corns are characterized by a build-up of hard skin. However, a corn generally develops around the bony area of the toes.  Proper care is necessary if you have a corn. After your bath or shower, use a pumice stone to gently remove the build-up of tissue.  DO NOT try to cut the corn or remove it with a sharp object.

Blisters: Blisters usually occur when shoes rub against moist skin, creating enough friction to weaken the bond between layers of skin.  Wearing shoes that do not fit properly or wearing shoes without socks can cause blisters, which can become infected.  When treating blisters, it's important not to burst them, as the skin covering the blister helps protect it from becoming infected.  Use an antibacterial cream and clean, soft bandages to help protect the skin and prevent infection.

Dry skin: Dry skin occurs when there is not enough moisture in the skin. Dry skin, while common, can also be dangerous when it cracks and leads to infection.  Use moisturizing soaps and lotions to help keep your skin moist and soft.  Ensure that you drink sufficient fluids to remain well hydrated.

Bunions: Bunions may form on one or both feet.  A bunion forms when your big toe angles in toward the second toe.  Often, the spot where your big toe joins the rest of the foot becomes red and callused. This area may also begin to stick out and become hard.  Bunions may run in families, but are most often caused by wearing of high-heeled shoes which taper toward the toes.  The use of padding on the foot may help protect the bunion from irritation.  Special devices used to separate the big and second toes are sometimes used.  If the bunion causes severe pain or deformity, surgery to realign the toes may be necessary.

Hammertoes: A hammertoe is a toe that is bent downwards because of a weakened muscle.  They can also be caused by shoes that are too small.  Hammertoes can cause difficulty with walking and can lead to other foot problems, such as blisters, calluses, and sores.  Splinting and corrective footwear can help in treating them. In severe cases, surgery to straighten the toe may be necessary.

Plantar warts: Plantar warts are commonly confused with corns/calluses.  Plantar warts are caused by a virus that infects the outer layer of skin.  They are typically painful, but this sensation of pain may be absent in diabetes with neuropathy.  Warts may be treated by topical medication or histofreezing.

Ingrown toenails: Ingrown toenails occur when the edges of the nail grow into the skin, leading to pain, redness and infection. They are most commonly caused by tight-fitting shoes.  Keeping your toenails properly trimmed is the best way to prevent ingrown toenails.  If you have a persistent problem or if you have a nail infection, you may need to see your doctor.

Foot ulcers: A foot ulcer is a break in the skin or a deep sore.  When the skin breaks, the area can quickly develop an infection and should be treated carefully. See your doctor immediately.


2. Nail Care Tips

Can I Cut My Own Toenails?

It depends on whether or not you can do so safely.  Many people may find it difficult to do so because of poor vision, and may have difficulty reaching their toes.  If you can see and reach your feet comfortably, ensure that you have good lighting and a good pair of nail clippers or nail file.  You have to be extremely careful when you trim your toenails.  It is important to make sure you don’t cut the skin with the nail clippers, because microorganisms can enter the body through the opening in the skin.  For that reason, filing tends to be less risky than cutting.

If you have poor circulation, or your feet are numb from neuropathy, you should not attempt to cut your toenails yourself.  Get a family member or friend to assist.  If your nails are difficult to trim, you may need assistance from a professional.

How Do I Safely Trim My Toenails?

It is important to trim the toenails straight across according to the shape of the toes.  Don’t cut them too short, and do not try to trim them into the corners, because this can lead to ingrown toenails.  A good time to trim your toenails is immediately after a bath, because your toenails will be softer and easier to trim. Be sure to file your toenails when you have finished clipping them.

If you notice ingrown toenails, do not try to cut them out yourself. Contact your health care professional and let him/her deal with any nails that are ingrown.  Do not wait until you develop an infection before you seek help.

What Should I Use To Trim My Toenails?

You may try looking for a nail clipper which looks like a pair of wire cutters or pliers.  This type of nail clipper may be found at some pharmacies/drugstores, and it offers better control compared to the conventional nail clippers, thus reducing the chance of accidental injury.

Nail clippers should be kept clean, dry and sharp.  Never use blunt clippers, because a blunt cutting edge will require you to exert more pressure, and this can lead to injury if they slip.

Sharp corners may be filed down with a large nail file or emery board.  Some people find nail files meant for artificial fingernails good for toenail filing because they tend to be coarser.

What Should I Do If I Accidentally Cut Or Injure Myself?

Thoroughly clean the wound with soap and water.  You may apply a bandage or dressing to keep the wound clean, but ensure that you do not wrap the bandage too tightly as this may further compromise blood supply to your toe.

Do not be reassured if the wound doesn't hurt.  Sensory neuropathy may reduce sensation in your toes and you may not experience any pain even if there is a serous injury or infection.

What Should I Do If My Toenails Are Very Thick?

A very thick toenail can exert significant pressure on the skin and potentially cause ulcers/abrasions.  Hence, it is a good idea to have it trimmed down or removed.  Whether or not you can do it yourself really depends on how thick it is.  Most people will need some help from a podiatrist or health care practitioner.

Fungal infection of the nails is the typical cause of thick toenails.  Topical treatments may help to some extent, but most will require oral antifungal medication to eradicate the infection.  Treatment is typically over several months and is given as treatment "pulses".  This would involve taking medication for one week, followed by a medication-free period of three weeks.  The next "pulse" of one week treatment is given, followed by another three weeks break.  Nail infections generally require three to four "pulse" treatments.

3. Skin Care Tips

How Should I Wash My Feet?

Wash your feet daily with a mild soap and warm water.  If your feet have reduced sensation due to neuropathy, check the temperature of the water with your hands/elbows first to ensure that you don't end up scalding your feet.  If you have dry skin, use a moisturizing soap.

Wash the top, soles, sides and between the toes well.  Do not soak your feet as this can dry out the skin excessively and possibly lead to infections.  Rinse well and pat dry thoroughly.  Do not rub.

After washing, use moisturizing lotion on your feet to prevent cracking. Do not put lotion between your toes.

My Skin Is Very Dry. Do I Need to Use Skin Lotions? What Kind Should I Use?

It is important to moisturize dry skin to prevent itching and cracking.  Maintaining a healthy skin barrier will keep germs out and reduce the chance of infections.  Moisturizers are available in many forms - creams, lotions, ointments and oils.  For most people, any good moisturizer will do, so long as you remember to use it regularly.  Choose a kind that you like and are comfortable with.

Avoid lotions with alcohol because they evaporate and remove moisture from the skin.  Also avoid perfumed lotions as some people may be sensitive to them.  Ask your doctor or pharmacist to recommend a moisturizer if you are not sure which one to use.  You may need a prescription moisturizer if you have severely dry skin.

The best time to moisturize your feet is after a bath, to help seal in the moisture your body has absorbed.  Remember NOT to moisturize between the toes.  Moisturize regularly and often, to maintain healthy skin.

What Should I Do If I Have Athlete's Foot?

The first thing you should do if you suspect that you have a fungal infection of your foot/feet, is to get it properly diagnosed by your doctor.  Your doctor will prescribe anti-fungal creams and occasionally even oral medication to treat the infection.  A few things to remember with regard to treating athlete's foot:

• Remember to always dry well between your toes.  Also try to air your feet whenever possible.  Fungi grow well in moist and warm environments.

• Change and wash your socks daily.

• Fungal injections are typically itchy.  Avoid scratching.  Scratching may cause abrasions which increase your risk of secondary bacterial infections.

• Remember to continue applying anti-fungal creams for at least two weeks after your skin appears to have healed completely.  This is to kill off any residual fungi which may be present.  Stopping treatment too early often results in recurrent infections.

What Should I Do About Foot Odour?

The main cause of foot odour is sweat.  Sweat itself is odorless, but it creates the ideal environment for certain bacteria to grow and produce bad-smelling substances. Therefore, more smell is created with factors that cause more sweating, such as wearing shoes and/or socks with inadequate air ventilation for many hours.  Some people have naturally sweaty feet, which can make the problem worse. 

Always wear socks when you wear shoes.  Polyester and nylon are common materials used to make socks, but these materials provide less ventilation than cotton or wool. Also wear shoes that allow air to circulate.  Dry out your shoes between wearings.

If the problem persists, you may try anti-perspirant for feet, or a foot powder designed to control foot odour.  Some insoles are specially designed to help with odour problems.

Do remember that foot odour is sometimes caused by fungal infections, or more seriously, a foot ulcer which has become infected.  Thoroughly check your feet and consult your doctor if you detect a wound or any skin changes.


4. Tips About Footwear

How Do I Protect My Feet?

• Never go barefoot. Always protect your feet by wearing shoes or hard-soled slippers or footwear.

• Avoid high heeled shoes and shoes which taper out too much in front.  Avoid shoes that expose your toes or heels.

• Try on new footwear with the type of socks you usually wear, before buying them.  Make sure your shoes fit properly.

• Give yourself time to "break into" a new pair of shoes.  Do not wear new shoes for more than an hour at a time.

• Look and feel inside your shoes before putting them on to make sure there are no foreign objects inside your shoes which may cause injury to your feet.

• Wear natural-fiber socks (cotton, wool, or a cotton-wool blend).

• Wear special shoes if your health care provider recommends them.

How Do I Go About Choosing The Right Type Of Shoes?

The following types of shoes are best for people with diabetes:

• Laced-up shoe with a high, rounded toe box.  If you have trouble tying laces, try shoes with Velcro fasteners.

• The upper part of the shoe should be a soft, breathable material such as leather or fabric, instead of plastic or synthetic material.

• Shoes with an outer sole made of stiff material.

• Good-quality athletic shoes or walking shoes are often excellent choices.

• Avoid sandals, clogs and slippers because they do not provide the kind of protection you need.  Avoid high-heels and tight, pointed shoes. 

• Inside of shoe should be soft with no rough areas.

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Further Reading

The article above is meant to provide general information and does not replace a doctor's consultation.
Please see your doctor for professional advice.