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Foot Care Q&A: Part 1
People with diabetes often have questions about how best to care for their feet and what to do when problems occur. To help answer these questions, Diabetes Self-Management interviewed several foot-care experts — including four podiatrists and one pedorthist — who regularly work with people with diabetes. A podiatrist is a doctor of podiatric medicine (DPM), who is qualified by his education and training to diagnose and treat conditions affecting the foot, ankle, and related structures of the leg. Podiatrists are also known as podiatric physicians or surgeons. A pedorthist is a professional trained to prevent or alleviate foot problems through the use of footwear, including shoes, orthotics, and other foot devices. The experts interviewed for this article were the following:
• Dr. Keith A. Beauchamp, DPM, a podiatrist who has a private practice in Macon, Missouri.
• Dennis Janisse, CPed, a certified pedorthist who is President and CEO of National Pedorthic Services, Inc., and is a Clinical Assistant Professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin. He teaches pedorthic courses at Northwestern Medical School and the Medical College of Wisconsin. He is a past president of the Pedorthic Footwear Association.
• Dr. Neil Scheffler, DPM, a podiatrist and coauthor of the book 101 Tips on Foot Care for People with Diabetes, published by the American Diabetes Association. He has a private practice in Baltimore, Maryland.
• Dr. Pedro Smukler, DPM, a podiatrist with private practices in Brooklyn and Manhattan, New York. Not only does he see patients in his office, but he also visits patients in their homes.
• Dr. Stephanie Wu, DPM, MSc, a podiatrist and Associate Dean of Research, Associate Professor of Surgery, Associate Professor of Stem Cell and Regenerative Medicine, and Director of the Center for Lower Extremity Ambulatory Research (CLEAR), at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, in Chicago.
1. When a person who has diabetes comes to you for the first time, what do you teach?
Dr. Wu: I teach them the importance of keeping their blood glucose under control through diet, checking their blood glucose, and exercise, as well as the importance of regular doctor visits and getting into the habit of checking their feet before they go to bed every night.
I also show my patients gross pictures or point out the people who are in the waiting area in wheelchairs who have had amputations or other problems. It helps them understand what could happen, and it gives them a reason to take care of themselves. I don’t mean to scare them, but no one thinks anything is going to happen to him. Foot problems are like high blood pressure: There are no symptoms and no pain involved. People with high blood pressure don’t realize it’s causing a problem until they have a heart attack or stroke. Similarly, a patient of mine who works in a pizzeria stepped on a nail [but wasn't in pain]. He thought he was too busy to take care of himself until it was too late. So I tell my patients, “This can happen to you, but it doesn’t have to.”
Dr. Scheffler: I really emphasize the need for daily self-examination. People with diabetes need to look at the tops and bottoms of their feet and between their toes. Once they know what normal is for them, they will be able to pick up on changes and take care of them right away. How to address these changes depends on how severe the change is. If it’s a wound with pus, I tell them to call me or go to the ER right away; waiting even 24 hours can be too much. On the other hand, if it’s a scratch and the person has no other problems, it’s not an emergency.
Some people who have poor vision or are obese can’t see their feet. In these cases I recommend that their caregiver (if they have one) perform the daily inspection, or I recommend they use a large mirror with handles. I also discuss the big three risk factors for amputations, which are neuropathy [nerve damage], peripheral arterial disease (PAD), and deformity [foot conditions such as bunions and hammertoes].
Dr. Beauchamp: Early on, most doctors test to see whether a person has feeling in his feet. They use a monofilament, which is like a piece of fishing line, to do this test. I also test for the ability to sense vibration. This has been shown to detect diabetic peripheral neuropathy earlier than the monofilament test. This helps me detect neuropathy and prevent related problems before it gets dangerous.
Dennis Janisse: For my patients who can walk, I recommend wearing a pedometer and getting 10,000 steps in a day.
2. What do you recommend for dry, cracked skin?
Dr. Scheffler: I first recommend using anything you have in the house. Most people have some kind of lotion or cream. If you are a man and live with a woman, she’s got some. Use hers. Then if what you are using doesn’t work, remember the purpose of these products: They hold moisture in. Put the product on after you have washed your feet, but don’t dry them completely before applying your lotion or cream. Do dry between your toes, and don’t apply your lotion or cream there. I usually prescribe Lactinol-E [a moisturizer containing lactic acid and vitamin E], or other, over-the-counter products with urea. You can gently use a pumice stone. Be careful not to rub hard or too long, and choose a pumice stone, not a metal [rasp or shaver]. Save metal for the Gouda cheese.
Dr. Smukler: It depends on how cracked the skin is. Usually a product with 12% ammonium lactate is where I start. The lotion is weaker than the cream. If that doesn’t work, I recommend a product with 40% to 50% urea.
Dr. Wu: Personally I like lactic acid 10% cream. Lactinol is an example. If a patient can’t afford to buy that, I recommend Eucerin cream. The cheaper lotions and creams smell and feel nice, but the majority of the content is water, which doesn’t do anything, and before long, it’s gone. I believe the key is to wear socks to bed after applying your cream of choice to facilitate better cream absorption. And, yes, you never want to put lotion or cream between your toes.
Dr. Beauchamp: I like to use an ammonium lactate type of lotion such as Lac-Hydrin or AmLactin. A 12% solution works well.
Dennis Janisse: I don’t recommend anything with alcohol in it. Alcohol is drying.
3. What can I do for my dry, discolored toenails?
Dr. Scheffler: First, find out why. Is it a fungus? I would ask your podiatrist to take a clipping and have it tested. Many times, I’m fooled. If it is a fungus, there is a topical product called Formula 3, and there’s laser treatment. Oral antifungal medicines can affect your liver. Some people try Vicks VapoRub. That will make the nails softer and easier to cut, but it doesn’t get to the nail bed to cure the problem. People with diabetes should not be self-treating.
Dr. Wu: Go see a foot doctor. Toenails can become thick and discolored from fungal infections, yeast infections, inadequate nutrition, poor health, genetics, other conditions such as psoriasis, or even poorly fitted shoes. While there are numerous home remedies and nail formulations available on the market that can help hide and mask the discolored nail, it’s best to determine and treat the underlying cause of the condition.
Dr. Smukler: It depends on the cause. If it’s due to a fungal infection, there are some over-the-counter lotions that sometimes work. As for prescription oral medicines, I normally prescribe Lamisil (generic name, terbinafine). I haven’t had problems with side effects from it. I test patients’ blood before they start it and within 30 days to make sure it isn’t affecting their liver.
Dr. Beauchamp: For dry, discolored toenails you need to determine the cause of the dryness and the discoloration. These are two separate symptoms that can be caused by nutritional problems, chemotherapy, systemic diseases including rheumatological disorders of various types, physical trauma, and infections of either a bacterial or fungal nature, to name several.
Dennis Janisse: The oral drugs don’t have a very good reputation and are not usually suggested. If the nail is too troublesome, you can have it removed. There is a 50% recurrence rate with the topical treatments.
4. What can I do for athlete’s foot?
Athlete’s foot is a very common fungal infection of the feet. The scientific name for it is tinea pedis. It can occur on one or both feet. It is contagious, but some people are more susceptible to getting it than others. People with diabetes are up to three times more likely to develop athlete’s foot than people who don’t have diabetes.
Dr. Smukler: Once you have determined that it is in fact athlete’s foot, two things need to be done: treat the foot, and treat the shoe. Athlete’s foot is caused by a fungus infection. Fungus needs three things to be happy: moisture, heat, and darkness. Many times a doctor will give you a medicine to put on your feet twice a day. That will only work for a couple of days. I recommend over-the-counter Lamisil lotion or cream for your feet and over-the-counter Tinactin (tolnaftate) antifungal powder for your shoes. After applying it to your shoes, let them air out for 24 hours before wearing them again. This means you will need to wear a different pair of shoes while treating the first pair, then treat the second pair while wearing the first. It takes a certain amount of fungus before you feel the itch. Therefore, just because the itch has gone away doesn’t mean the infection is gone. I suggest continuing the treatment for two weeks after the symptoms are gone.
Dr. Wu: You can try over-the-counter antifungal preparations first. These preparations should contain one of the following antifungal medicines: terbinafine, miconazole, clotrimazole, or tolnaftate. What most people don’t realize is that the fungus spores can live on their shoes, socks, bathroom floors, and carpets. They may end up infecting the rest of their family. So in addition to using the over-the-counter antifungal medicines, a person should also change his socks often, clean the bathroom floor with bleach after he has showered, and alternate between different pairs of shoes every day, wearing one pair while letting the other pair(s) air out in the sun for at least 24 hours. If the athlete’s foot persists after doing the above, consider paying a visit to the doctor for prescription antifungals. Most people don’t need more than an over-the-counter product.
Dr. Beauchamp: Athlete’s foot is what I refer to as a “garbage can” diagnosis that really describes a fungal infection of the foot. There are several species of fungi that can affect the human foot, and each one of them may cause slightly different skin changes and symptoms. I generally treat these with a broad-spectrum over-the-counter antifungal like Lamisil cream in conjunction with an over-the-counter hydrocortisone applied twice daily. I tell my patients that they really need to be treating their shoes with the antifungal sprays and allowing them to dry between wearings (or utilizing a boot dryer) to reduce reinfection. I also suggest spraying out their showers with a mild bleach solution throughout the treatment period. Usually in about two weeks things are a lot better. For really deep-seated fungal infections that do not respond to this, I will sometimes use an oral medicine such as Diflucan (generic name, fluconazole).
Dennis Janisse: To prevent athlete’s foot, keep your feet clean and dry. Wear socks that wick moisture away rather than absorb it. There are socks made with copper, which has antifungal properties. For example, check out Aetrex Copper Sole Socks.
Dr. Scheffler: First determine if that is what you have. Many times it looks like dry skin. Over-the-counter athlete’s foot preparations won’t do any harm. If one of them works, great. If you have it, know that it will most likely come back. If it is in your nails, shoes, or elsewhere, it all needs to be treated. The over-the-counter products won’t penetrate your nails. You most likely have to treat your nails as described earlier. You must also treat your shoes and your home environment.
5. I have hammertoes. What is the treatment for that?
Hammertoes are the permanent bending — or downward curling — of one or both joints in the second, third, fourth, or fifth toes. It can also happen in the first toe (the big toe), but it is not as common there. Most problems arise in the second toe due to the longer length of the toe.
Dr. Wu: Hammertoe treatment is dependent on how rigid or stiff it is. This simple test helps determine the rigidity of the toe: Use your finger to try to straighten out the toe. If the toe can be straightened, it’s what we call a “reducible” deformity. If the toe cannot be straightened, it’s what we call a “nonreducible” deformity. For the toe that can be straightened, there are hammertoe straps and splints that can help realign the toes. It is important to have your podiatrist recommend one for you, however. Not all of the hammertoe devices you may see advertised in magazines will be the right one for you.
For a toe that cannot be straightened, surgery is usually necessary to correct the hammertoe. In general, we advise people to switch to more comfortable footwear. Pointed and high-heeled shoes are not recommended, because both force the toes to rub against the front part of the footwear. People who develop corns and calluses from the hammertoe may want to see a foot doctor to have them trimmed and may benefit from toe padding to help prevent further irritation. Corticosteroid injections are used from time to time to alleviate the pain and swelling. Some people have gone so far as having their foot doctor inject dermal fillers to internally pad the area to allow them to wear high-heeled shoes without irritation.
Dr. Smukler: Hammertoes are bone deformations. You cannot really treat them without surgery. There are straps to prevent blisters or protect existing blisters from developing into open wounds. Without proper treatment, sooner or later a callus will develop.
Dr. Scheffler: Hammertoes are a deformity. The best treatment is surgery for straightening the toe. If you have neuropathy or peripheral arterial disease, however, surgery may not be an option for you. You need to remove pressure from the bone on the inside, and from the shoe on the outside. Wear shoes with a wide and deep toe box. There are products that hold the toe in a straightened position, such as so-called Budin splints, and gel pads to cushion the underside of the toes. It’s best to see your podiatrist for a recommendation on what you need.
Dennis Jannise: Shoes can accommodate most hammertoe-type deformities. Unfortunately, many people don’t like the way the shoes look because they are similar to the way their feet look. Surprise! Toe gadgets with straps and elastic really don’t work and can be very dangerous for people who have diabetes.
Dr. Beauchamp: Hammertoes come in various forms. Some of them are rigid, and some are flexible. There can be multiple causes for the deformity such as hereditary orthopedic deformity or biomechanical compensatory changes. Some respond well to padding and splinting devices, and some may require surgical intervention.
6. What is the treatment for bunions?
Bunions occur when the big toe angles in toward the other toes, causing the joint at the base of the big toe to protrude. The resulting bump at the base of the big toe can make it difficult to find shoes that fit. Bunions can also be painful and interfere with walking.
Dr. Wu: In general, we advise patients to switch to more comfortable footwear, specifically with a wider toe box. Pointed and high-heeled shoes are not recommended, because both force the bunion to rub against the front part of the footwear. Arch supports or other forms of orthotics that transfer force off the area of the bunion can also be helpful. People who develop corns and calluses from bunions may want to see a foot doctor to have them trimmed and may benefit from toe padding to help prevent further irritation. There are numerous bunion splints and toe straighteners on the market. If the bunion is stiff and rigid, a splint will have little to no effect, and surgery is usually indicated. If the bunion can be straightened, a bunion splint and toe straighteners will help a little more, but the bunion will return very quickly after the splint is removed, and there is no evidence to support the long-term success of bunion splints.
Dennis Janisse: The solution for bunions is the same as that for hammertoes: wearing proper footwear. There are always surgical solutions for these. I’m not sure why people would opt for that, but they do.
Dr. Beauchamp: Bunions are treated based on a comprehensive evaluation. The degree of the deformity, level of pain, cosmesis [desire for a more normal appearance of the joint], and whether a person is an appropriate candidate for surgery all enter into the decision-making process for bunion treatment. Wide footwear, orthotic therapy, padding and splinting with periodic care, surgery, as well as no treatment at all can be appropriate forms of therapy based on the individual’s symptoms and needs.
Dr. Scheffler: These, like hammertoes, increase the risk of getting a wound. Treatment strategies are surgery, wearing properly fitting shoes, and/or pads.
7. What do you recommend for diabetic peripheral neuropathy?
Diabetic peripheral neuropathy is nerve damage in the feet, legs, hands, and/or arms due to diabetes. Typical symptoms of peripheral neuropathy include numbness, tingling, a pins-and-needles sensation, and pain.
Dr. Beauchamp: Diabetic neuropathy can be a very difficult problem to treat. I start all my patients off with the two mainstays of all diabetic therapy, diet and exercise. Once blood glucose is under control, I will first try something like Metanx [a nutritional supplement sold by prescription]. This has helped some of my patients with mild to moderate symptoms. I like that I’m not introducing anything more than a vitamin complex, which is less likely to interact with other medicines, of which older people tend to be on more and more. If that doesn’t work, I’ll move them to Lyrica [pregabalin, a prescription drug approved to treat diabetic nerve pain] and notify their family practice doctor about what we’re doing. Most have been very helpful working in conjunction with me in trying to solve their peripheral neuropathy.
Dr. Wu: There is really no cure for diabetic peripheral neuropathy, though patients who have it can minimize the problem by keeping their blood glucose level under control. Antidepressants or anticonvulsant medicines are sometimes used to help reduce pain and discomfort. More recent medicines that are FDA-approved for diabetic peripheral neuropathy include pregabalin (an anticonvulsant), and duloxetine (brand name Cymbalta, an antidepressant). However none of these treatments improves sensation in the feet.
Dr. Smukler: When it comes to pain, I used to use capsaicin [sold as an over-the-counter ointment or cream], but there are better [prescription] medicines and creams now, such as Voltaren Gel (diclofenac, a nonsteroidal anti-inflammatory drug), Lidoderm (lidocaine patches), and Flector Patches (another form of diclofenac). Physical therapy can be helpful. Heat can be helpful, but it’s not something patients should do on their own. They need specific recommendations and supervision from their health-care provider, because if you have peripheral neuropathy, you are at risk for not feeling the heat and getting burned.
Dr. Scheffler: It depends on the type of neuropathy. Is it painful, or is it numb? Is it in early or late stages? There are some vitamins that may be helpful, and there are oral medicines such as gabapentin (brand name Neurontin), Lyrica, and Cymbalta. Don’t listen to your neighbors’ advice; get advice from your foot doctor!
Dennis Janisse: Proper shoes and inserts can help a lot.
Editor’s note: This concludes Part 1 of “Foot Care Questions and Answers.” Stay tuned for Part 2, which will cover shoes, socks, shoe inserts, and pedicures for people who have diabetes.
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