An ulceration (ulcer) is a break in the skin or tissue lining of the body. When they hear this term, many people think of stomach ulcers. Any person with numbness or loss of sensation to their feet is at risk for developing an ulceration on their foot. Ulcers can develop as a result of an injury, a blister, rubbing from shoes or folds in the sock, pressure from a prominent bone, dry cracking skin at the heel, foot fungus between the toes or simply stepping on a piece of glass or a splinter. Without normal sensation, a small area or rub or irritation can go unnoticed and this soon develops into an open sore. In many cases, the first sign of the ulcer is drainage on the socks. If the ulcer continues to go unnoticed and becomes infected, the first sign may be redness creeping on to the top of the foot.
Ulcers can be difficult to see if they are on the bottom of the foot or between the toes. In this picture here, a small ulcer has developed on the inside of the great toe. This is a common area of ulceration because of the pressure of the great toe against the second toe. There is callus tissue and some redness and peeling tissue surround the ulcer which has a deeper center. This ulcer could have developed from a blister or a corn.
If this ulcer is not treated properly, the increased pressure from the second toe will cause it to become larger. Keeping the pressure off the ulcer is important, as is proper wound care by a podiatrist.
Many diabetics don't take simple cuts and scrapes on their feet seriously. But, 1 in 4 diabetics with an ulceration will go onto amputation. Ulcerations, no matter how small, should be taken seriously. Diabetics should check their feet everyday and follow the tips listed below.
There are a few classification systems for ulcers, but the following is one of the most commonly used, called the Wagner Classification specifically for diabetic (or neuropathic) ulcers).
Grade 0: Skin is intact and there is a bone deformity, increasing the risk of ulceration.
Grade 1: Superficial ulceration which is localized to one area.
Grade 2: Deep ulceration which extends to the tendon, joint or to the bone.
Grade 3: Deep abscess with bone infection
Grade 4: Gangrene of the toes and/or forefoot
Grade 5: Gangrene of the foot which extends to the midfoot region.
Take these steps to help prevent diabetic foot complications:
1. Check your feet everyday! This is an absolute necessity. If you can’t reach your feet, have a friend or family member check your feet. If needed, put a mirror on the floor and put your foot over it to look for cuts, scraps, bruises, openings or areas of irritation. Make sure you check between your toes. Look for moist areas, white areas or red areas. Look for anything unusual. If you see something unusual, make an appointment with your podiatrist.
2. Don’t walk around barefoot. Needles, tacks, broken glass, splinters of wood can be hidden in the carpet, even if you vacuum regularly. You can puncture a foot without sensation. Punctures can go unnoticed and develop into ulceration or infections.
3. Watch out for folds in your socks. Rough seams and small folds in the socks can cause areas of irritation that may lead to skin breakdown and ulceration.
4. Don’t be a victim of fashion. High fashion shoes usually lead to a high number of problems in the feet. Make sure the shoes are wide enough. Don’t buy shoes that are too wide or too long which can cause a lot of slipping. Pick shoes that are soft and flexible and allow for cushioning on the top and sides, but are rigid on the sole. Make sure they don’t fold in half. You may be eligible for your insurance to pay for diabetic extra-depth shoes with custom insoles. These shoes will take the pressure off your feet and help prevent ulcerations. Ask your doctor. General information for picking out shoes.
5. Check your bath water with your hand before you put your foot in it. The temperature your foot feels is much different from the temperature your hand feels when you have neuropathy. Make sure to check the temperature with your wrist. This will be much more accurate than testing the water with your foot.
6. Avoid medicated corn pads. Medicated corn pads contain acid and can be dangerous to diabetics. Yes, it will remove the corn, but there is a good chance it will also remove all the surrounding skin. What you will be left with is an ulceration. Check foot products you buy to make sure they are safe for diabetics.
7. Dry between your toes. Increased moisture between your toes can lead to the skin breaking down or foot fungus. This can eventually lead to an ulcer between the toes. Ulcers between the toes go unnoticed for longer periods of time and they can be difficult to treat.
8. Avoid cotton socks. Those white cotton socks you were told to wear for so many years are not the right socks for a diabetic. Cotton socks don't wick moisture properly, they lose their elasticity quickly and have a greater chance for thick seams and bunching at the toes. Try synthetic socks, acrylic or small fiber wool socks. More information on socks.
9. Know your risk. Some diabetics do not have any loss of sensation or circulation in their feet. They are not at risk of developing an ulceration and have a low risk of an infection becoming a problem. Others, have severe neuropathy or circulation problems and don’t know it. It’s important to know your risk. Make sure your primary care doctor evaluates your feet and uses a monofilament wire (thin wire to assess sensation) or refers you to a podiatrist.
10. Do not trim your own toenails, calluses or corns. If you have a loss of sensation or blood supply then have your podiatrist trim your corns, calluses or toenails for you every two months.
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last updated 7/10/10
Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.