Advances in diabetic foot care:Focus on prevention

Julie Van OnselenIndependent dermatology nurse specialistDermatology Education Partnership Ltd

Learning OutcomesBy 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 infectionReference: 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

ComplicationsFungal and bacterial skininfections

Reference: 1. Daniels R (2011) Foam creams: effective skin care in patients in diabetes mellitus. Theme Prax Rep; 11 (5): 179-82Clinical 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

ComplicationsNecrobiosis lipoidica, infection and diabetic footulcers

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 keyTreating 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 1-3months.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

Diabetes UK> Taking care of your feet. Available at: https://www.diabetes.org.uk/Guide-to-diabetes/Monitoring/Feet/etes.org.ukAccessed May 15

Use moisturising cream every day and wear well-fitting shoes that protect and support your feet.1

What is the best sort of cream for a

Diabetic (T1) to use on their feet to keep

them soft and moisturised?

xxxx Cream BP is very

good and not expensive.

My GP lets me use xxx emollient

cream , I too was told not to use this between my toes .

Patient forums on linecan give conflicting advice, which is not evidence based - but may be convincing!

Over to you – which emollient/s would you advise?

Complete emollient therapy The most important treatment for all dry

skin diseases1

Emollient creams and ointmentsEmollient wash productsEmollient 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 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

Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18:872-77

7.

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

Occlusive emollient cream Occlusive emollient ointment

Emollients containing urea help compensate for the reduced levels of NMF in dry skin

Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18:872-77s..

Emollients containing NMFs such as urea, produce similar rehydration effects to heavy emollients1

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

NMF emollient1

Foam humectant creams– a new innovative formulation Normal skin functions are

maintained Formulation benefits with a two-

dimensional 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

ConclusionsTreating 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 listeningAny Questions?