Skin and Toenail Problems The care of the skin and toenails of diabetic foot patients is often considered a tedious task, but is an important part of the total diabetic foot care. As a result of autonomic neuropathy, the loss of the skin thermoregulatory system causes the skin of the foot to become abnormally dry and prone to skin breakdown. These wounds can lead to infection when the cracks involve the dermis. Patients need to routinely check the skin once or twice a day and apply skin cream to the dry skin. The skin between the toes should be cared for frequently to avoid moisture, these areas are most susceptible to phosphoric changes and excessive moisture can cause the skin to be blistered and softened. Applying a topical lotion or a thin layer of petroleum jelly ointment after a bath can stop the skin from hydrating afterwards. Shoes and insoles Wearing foot-appropriate shoes or using insoles is a key part of caring for foot problems in people with diabetes. Even patients with a partial foot grade of 0, which means there is no actual injury or infection but a risk of it occurring, need proper and professional advice. Very ill-fitting shoes and concentration of plantar pressure within the shoe are the most common problems, and these problems are the beginning of lower limb ulcers, infections and amputations in diabetics. Patients need to change their fashionable behaviors and attitudes so that they can use well-fitting shoes. Patients also need to change their unhealthy lifestyle habits, such as changing their diet and smoking habits. The stress of wearing ill-fitting shoes on a patient’s sensory-deficient foot is a greater threat to the patient’s health than diet and smoking problems. Proper foot care usually includes choosing shoes that fit well, and this is a priority for people with diabetic feet. Common sense Understand that a lack of normal protective sensation is the cause of diabetic foot problems. When you can’t feel you can get hurt. Remembering to always protect yourself when moving around is the best care. What people with diabetic foot should know for themselves: Check your feet Check your feet twice a day. If you can’t see every part of your feet because you have poor vision or can’t bend over, you can use a mirror or ask your partner to check them for you. Inspect your feet thoroughly looking for cracks, blisters, red spots, cuts and ulcers or excessively moist skin between your toes. Wash your feet daily with warm water and mild soap. Usually use an area not affected by neuropathy such as the elbow or another person to help you test the temperature of the water. Remember that you can burn your feet and not feel it. Gently and carefully vacuum the water between your toes, not wipe them dry. Never use an electric blanket, hot water bottle or any other heat source to warm your feet. This can lead to serious injury in less than a minute. If you feel your feet are cold at night, you can sleep with socks on. Corpus callosum Do not use chemically sourced or medicated insoles. They can cause burns. Do not trim the corpus callosum yourself with a razor blade. Use a pumice stone or a foot file to gently rub away calluses during bathing. Keep the skin moist regularly with a gentle skin wash; this will prevent cracks and infections from occurring. Applying a thin layer of petroleum jelly after bathing will prevent moisture loss. Do not apply creams, topical drops or ointments between the toes, as this can make these areas excessively moist. When skin problems are persistent or difficult to deal with you will need to see a doctor. Some calluses can only be removed by a professional, especially if you have severely impaired peripheral circulation. Toenail problems Keep your nails straight and do not try to cut nails that are embedded in soft tissue. File your toenails daily to reduce the frequency of nail trimming. Avoid rubbing the skin. If your toenails are too thick or too hard to trim, consult your doctor. Shoe choice Remember that fashion is the enemy of people with diabetes with neuropathy. Many, many foot problems are caused by improperly pressurized shoes. Make sure the shoe is long enough and wide enough and that there is enough room for the toes, especially for patients who have claw-toe deformities. Avoid shoes made of non-breathable synthetic materials; leather is still the best material due to its ability to shape and stretch. Do not wear shoes made of hard materials such as plastic or similar synthetic leather. Check your feet frequently when putting on new shoes. Do not wear new shoes for more than 1 hour on the first day. If you have neuropathy or have had very serious foot problems in the past, consult a footwear manufacturing specialist or other professional to make shoes that fit your feet. Choose shoes that fit when you buy shoes, rather than going for shoes in the size you remember. When shoes change, the foot changes in width and shape. People with diabetes with neuropathy may develop severe ulcers after only 1-2 hours of wearing very ill-fitting shoes. The hallmarks of a shoe that is appropriate for a diabetic are several characteristics: The toe must be wide and deep enough to prevent pressure especially on the dorsal aspect of the interproximal phalangeal joint in patients with mallet toes. The leather should be soft enough to fit the patient’s foot. Non-elastic materials such as plastic, canvas or synthetic leather should be avoided because they do not change shape with the foot and can lead to high pressure areas. Shoes usually need to have a variety of adjustable closures, such as lace-up or hook-and-loop closures, as these allow for more adjustment of the shoe. Heel air cushions or heel supports especially pillow block like ones have groups to reduce pressure on the Achilles tendon area. One of the most important features of shoes for diabetics is the need for extra depth in the vertical direction. This is important to provide room for the presence of deformed toes or to place specially designed protective insoles. This is especially critical for those patients who have prior plantar ulcers, MTP joint hyperextension deformities and mallet toes. The ultimate shoe for a diabetic patient should be one that has no bang and is deep enough in the shoe. The insole of a suitable commercially available shoe can be removed and replaced with a custom-made insole. Wearing shoes Check your shoes for foreign objects before you wear them each time. Constantly changing the shoes you wear during the day can reduce the risk of pressure problems. Do not use hard devices or rigid orthotics in your shoes, as these can put additional pressure on the foot. Stockings and socks Avoid wearing stockings and socks with rubber bands or garters at the top. Do not wear stockings and socks that use a lot of stitches. Change your stockings and socks daily. Stockings and socks made of absorbent or natural materials such as cotton and wool are best. Notify those who care about your feet Have your feet checked regularly by your internist. Insoles The use of insoles is the primary method of conservative treatment and prophylaxis for patients with deformities and neuropathies and dull sensation in the feet, especially those with a history of previous foot ulcers. Softer materials can be placed close to the upper layer of the patient’s foot so that they can be compressed more easily than the skin of the foot. This requires the support of a firm material that maintains the shape and structural integrity of the device within the shoe. Insoles can be placed in different shoes, depending on how many pairs of shoes the patient has. Insoles need to be replaced regularly. Having two pairs of insoles and using them alternately can extend the life of the insoles. The interval between changing insoles for diabetics is very imprecise and depends on the number of insoles used and the patient’s activity level, but is usually 6-12 months. Additional results can be obtained by digging a hole in the metatarsal head area of the insole and filling it with a cushioning material. The most important role of the insole is to relieve the area of localized pressure concentration that may lead to soft tissue injury. Insoles cannot completely relieve the pressure dispersed in the patient’s foot because it is a combination of muscle activity, the patient’s own condition, and the earth’s gravitational field. Insoles and orthopedic footwear can delay the frequency of impact and distribute the applied pressure, thus relieving areas of particularly high pressure. For diabetic patients with neuropathy or a history of ulcers, the use of hard orthopedic supports, especially those made of plastic and popular athletic shoes, is an absolute contraindication. The use of hard orthopedic braces in patients with dysesthesia can have disastrous consequences. It is important to emphasize that patients who are using insoles for the first time may need to adapt to a larger size, properly shaped shoe with room for the insole. Education of the patient Education of the diabetic patient is necessary. As mentioned in the pathophysiology section, neuropathy robs the patient of many impaired sensory inputs, especially in the diabetic foot. Patient education and informing the family of preventive measures are needed in reducing the occurrence of serious consequences.