Transcript Advances in diabetic foot care Focus on prevention

Advances in diabetic foot care:
Focus on prevention
Julie Van Onselen
Independent dermatology nurse specialist
Dermatology Education Partnership Ltd
Learning Outcomes
By the end of this session, you will have:
 Increased understanding of the unmet need
of managing dry skin in feet of people with
diabetes
 Expanded your awareness of appropriate
emollient therapy to treat dry skin on feet
and prevent complications in people with
diabetes
 Improved clinical confidence in advising
patients and providing informed choice on
emollients and formulations, specifically for
diabetic patients
Background – skin problems in
diabetes

80% suffer with some form of diabetic skin problem due
to high blood sugar levels1

44% of people with diabetes have dry skin, which is
susceptible to breakdown1

Dry skin on the diabetic foot (with peripheral
neuropathy and vascular insufficiency) are risk factors
for foot ulcers2

Typical symptoms:
Extreme dryness, calluses, pressure ulcers, cracks,
fissures, foot fungus & bacterial infection
Reference: 1 Goyal A, Rania S, Kaushal S et al (2010) Pattern of cutaneous manifestations in diabetes mellitus. Indian
Journal of Dermatology; 55(1):39-41. 2. Edmunds M (2006) Diabetic foot ulcers: practical treatment recommendations.
Drugs; 66(7): 913-929.
Diabetes skin and feet
Dry skin and fissures
Diabetes skin and feet
Dry skin between toes
Diabetes skin and feet
Callus
Complications
Fungal and bacterial skin
infections
Reference: 1. Daniels R (2011) Foam creams:
effective skin care in patients in diabetes mellitus.
Theme Prax Rep; 11 (5): 179-82
Clinical images reproduced with permission from
the NewZealand Dermatological Society
Incorporated website site
http://www.dermnet.org.nz
Date accessed 1 June 2015
Cream that is not fully
absorbed between toes
in diabetic patients can
cause moisture to build
up and increase the
risk of skin infections1
Complications
Necrobiosis lipoidica, infection and diabetic foot
ulcers
Clinical images reproduced with permission from
the New Zealand Dermatological Society
Incorporated website site
http://www.dermnet.org.nz
Date accessed 1 June 2015
Prevention is key

Treating dry skin is the key to preventing
foot ulceration in diabetes
◦ 44% of people with diabetes suffer from dry
skin which is vulnerable to breakdown1
◦ 2.5% of people with diabetes have foot ulcers
= 80,000 foot ulcers in the UK2
◦ 28% of foot ulcers result in amputation = 100
amputations per week among people with
diabetes2
Reference: 1 Goyal A, Rania S, Kaushal S et al (2010) Pattern of cutaneous manifestations in diabetes mellitus. Indian Journal
of Dermatology; 55(1):39-41. 2 Diabetes UK. Diabetes: Facts and Sats. March 2014. Available at:
http://www.diabetes.org.uk/Documents/About_us/Statsitics/Diabetes-key-stats-guidelinesApril2014pdf Accessed April 2015.
NICE Guidance
People with diabetes at high risk of
foot ulcers i.e. with neuropathy and
absent pulses, or other risk factors,
should be reviewed every 1-3
months.1
Care of people at increased
risk of foot ulcers1
Low risk – Foot care education
Increased risk - Enhance foot
care education
High risk – Skin and nail care
NICE
recommendations1
‘To improve knowledge,
encourage beneficial self
care, minimize inadvertent
self-harm, HCPs should
discuss and agree with
patients a management
plan that includes
appropriate foot care.’
Reference: NICE Clinical guidance for type 2 diabetes CG10. Available htps://www.nice.org.uk/guidance/cg10.
Accessed May 2015.
Skin care advice and support
Use moisturising
cream every day and
wear well-fitting shoes
that protect and
support your feet.1
xxxx Cream BP is
very good and not
expensive.
What is the best sort of
cream for a Diabetic (T1)
to use on their feet to
keep them soft and
moisturised?
Patient forums on line
can give conflicting advice,
which is not evidence based
- but may be convincing!
My GP lets me use xxx
emollient cream , I too
was told not to use this
between my toes .
Diabetes UK> Taking care of your feet. Available at: https://www.diabetes.org.uk/Guide-todiabetes/Monitoring/Feet/etes.org.uk
Accessed May 15
Over to you – which emollient/s
would you advise?
Complete emollient therapy
The most important treatment for all dry skin
diseases1
 Emollient creams and ointments
 Emollient wash products
 Emollient bath and shower products
‘Everything that goes on the skin should be
emollient based and all soaps replaced with
emollient wash products’
However diabetes need specific treatment
tailored especially for their feet
Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18:872-77
OCCLUSIVE EMOLLIENTS PROVIDE A LAYER
OVER THE SURFACE OF THE SKIN
Occlusive emollient cream
 Occlusive emollient creams leave a fine
occlusive layer of non-physiologic lipid or oil
over the skin surface e.g. petrolatum or
mineral oil
 The occlusive layer reduces water loss from
the stratum corneum
Occlusive emollient ointment
 Occlusive emollient ointments contain
a lot more oil and provide more
occlusion over the surface
 Occlusive emollient ointments are
extremely greasy and are cosmetically
unacceptable to many people
Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18:872-77
7.
Emollients containing urea help compensate
for the reduced levels of NMF in dry skin
 Emollients containing NMFs such
as urea, produce similar
rehydration effects to heavy
emollients1
NMF emollient1
 Urea attracts and holds water in
the stratum corneum and helps
compensate for reduced levels of
NMF associated with dry skin2
 NMF-containing emollients have
greater cosmetic acceptability
than heavy emollients due to
their low oil content, and require
less frequent application than
occlusive emollients1
Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18:872-77
Foam humectant creams– a new
innovative formulation
 Normal skin functions are maintained
 Formulation benefits with a twodimensional protective mesh
 Skin is protected & stays intact
 Absorbs quickly & no occluding layer is
formed
 Contains 5% or 10% urea for
hydration and reducing TEWL
 No increase in bacterial growth, in
between the toes
 Can be used on whole foot, around
wound edges and in between the toes
FOAM CREAMS ARE UNIQUE
IN PROTECTING AGAINST
THE REAL RISK OF INFECTION
BETWEEN THE TOES
Evidence: Rapid onset of action - Skin continues
to be moisturised throughout the day
Improvement in Skin Moisture Content
* Source: Prophylaxis using foam creams in various dermatological indications – R. Rudolph, Norden
Conclusions

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Treating dry skin promptly is a key element in
preventing dry cracked skin, which can result in
complications in the diabetic foot
NICE recommends foot care education for all
patients with diabetes
Informed patient choice of emollient formulation is
crucial, to address all areas of dry skin on the foot
and promote self-management
Foam humectant creams are the only formulations
clinically and medically approved for use on the entire
foot, including between the toes for people with
diabetes
Foam creams are innovative formulations which
increase patient acceptance and compliance
Thank you for listening
Any Questions?