What is an ulcer?
Ulcers are wounds that develop on the skin. These wounds are seen most frequently in those with diabetes or who have a low potential to heal from injury. Ulcers can have many causes, however, many are caused by:

• Loss of integrity of the skin
• A decondary infection of the site by bacteria, fungus or virus
• Generalized weakness of the patient
• Delayed healing

Diabetic Ulcers
Diabetic foot ulcers occur as a result of various factors, such as poor blood flow, changes in the shape of your feet or toes, nerve damage, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the diabetic population.

Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt, every ulcer should be seen by your health care provider right away. Neglecting ulcers can result in infections, which in turn can lead to loss of a limb.

The risk of foot ulceration and limb amputation in people with diabetes is lessened by patient education stressing the importance of routine preventive podiatric care, appropriate shoes, avoidance of cigarette smoking, control of hyperlipidemia, and adequate glycemic control.

Preventing diabetic ulcers:

• Manage your diabetes properly. Follow your health care provider's advice regarding nutrition, exercise, and medication. Keep your blood sugar level within the range recommended by your doctor.
• Wash your feet in warm water every day, using a mild soap. Do not soak your feet. Dry your feet well, especially between the toes.
• Check your feet every day for sores, blisters, redness, calluses, etc.
• If the skin on your feet is dry, keep it moist by applying lotion after you wash and dry your feet. Do not put lotion between your toes. Your doctor can tell you which type of lotion is best to use.
• Gently smooth corns and calluses with an emery board or pumice stone. Do this after your bath or shower, when your skin is soft. Move the emery board in only one direction.
• Check your toenails once a week. Trim your toenails with a nail clipper straight across. Do not round off the corners of toenails or cut down on the sides of the nails. After clipping, smooth the toenails with a nail file.
• Always wear closed-toed shoes or slippers. Do not wear sandals and do not walk barefoot, even around the house.
• Always wear socks or stockings. Wear socks or stockings that fit your feet well and have soft elastic.
• Wear shoes that fit well. Buy shoes made of canvas or leather and break them in slowly. Extra wide shoes are also available in specialty stores that will allow for more room for the foot for people with foot deformities.
• Protect your feet from heat and cold. Wear shoes at the beach or on hot pavement. Wear socks at night if your feet get cold.
  11.Keep the blood flowing to your feet. Put your feet up when sitting, wiggle your toes and move your ankles several times a day, and don't cross your legs for long periods of time.
• If you smoke, stop. Smoking can make blood flow problems worse.
• Make sure your diabetes doctor examines your feet during each check-up. An annual foot exam should be performed which should include an inspection of the skin -- he or she may check for redness or warm of the skin. The exam will also be to check for pulses and temperature of your feet and an assessment of sensation to the foot with something called a monofilament.
• See your podiatrist (foot doctor) every two to three months for check-ups, even if you don't have any foot problems.

Pressure Ulcers
Pressure ulcers are also known as pressure sores, bedsores, and decubitus ulcers. These wounds are caused by the breaking down of the skin when constant pressure is placed against the skin. Pressure against the skin reduces blood supply to that area, and the affected tissue dies. This may occur when remaining in one position for too long without shifting your weight.

The following factors increase the risk for pressure ulcers:

• Being bedridden or in a wheelchair
• Being older
• Being unable to move certain parts of your body without help, such as after a spine or brain injury or if you have a disease like multiple sclerosis
• Having a chronic condition, such as diabetes or vascular disease, that prevents areas of the body from receiving proper blood flow
• Having a mental disability from conditions such as Alzheimer's disease
• Having fragile skin
• Having urinary incontinence or bowel incontinence
• Not getting enough nourishment (malnourishment)

Pressure sores are categorized by how severe they are, from Stage I (earliest signs) to Stage IV (worst):

• Stage I: A reddened area on the skin that, when pressed, does not turn white. This indicates that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin breakdown now looks like a crater. There is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

Prevention of pressure ulcers includes:

• Checking those who are bedridden or cannot move for pressure sores every day (head to toe).
• Paying special attention to the areas where pressure ulcers often form. Look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters.
• Change position at least every 2 hours to relieve pressure.
• Use items that can help reduce pressure -- pillows, sheepskin, foam padding, and powders from medical supply stores.
• Eat well-balanced meals that contain enough calories to keep you healthy.
• Drink plenty of water (8 to 10 cups) every day.
• Exercise daily, including range-of-motion exercises.
• Keep the skin clean and dry.
• After urinating or having a bowel movement, clean the area and dry it well. A doctor can recommend creams to help protect the skin.

Healing & Treatment
The following measures may help avoid ulcers in those who may be susceptible:

• Debridement: removal of dead tissue
• Infection Control: use of antiseptics and antimicrobobials, along with frequent changing of dressings
• Nutritional Support: administering vitamins and minerals in appropriate doses (ie. protein, vitamin C, vitamin A, Zinc)

For anyone who has developed an ulcer, medical attention should be sought immediately so that a course of care and treatment may be initiated.

Patient Advocacy Groups

• American Diabetes Association
• American Heart Association
• American Cancer Society
• National Breast Cancer Foundation
• Multiple Sclerosis Society
• Muscular Dystrophy Association
• National Spinal Cord Injury Association

Online Education

• The Wound Institute
• Global Wound Academy
• Wounds A compendium of Clinical Research
• Wound Care Information Network

Wound Care Organizations

• American Diabetes Association
• American Physical Therapy Association
• American Professional Wound Care Association
• Advancing the Practice
• European Pressure Ulcer Advisory Panel
• European Tissue Repair Society
• National Alliance of Wound Care®
• National Pressure Ulcer Advisory Panel
• Wound Healing Society

Last Updated: 12/27/2011