Treatment of a diabetic foot is one of the most laborious processes in the treatment of type diabetes mellitus. Moreover, trophic ulcers are most often manifested in the area of the legs and are a kind of damage to rather deep layers of tissue. They are manifested by non-healing wounds for a long period. The reasons for this symptom are hidden in the impaired blood supply to the legs – the most vulnerable part of the body of any diabetic. The most common localization of wound surfaces in this state is fingers, heels, and legs. Diabetic foot therapy is a lengthy process. In this case, a number of techniques must be combined. Only a combined approach helps to avoid complications of the condition leading to limb amputation.
Impact principles
Therapy of trophic ulcers will give the most positive results and be considered successful if it is built in stages. To cope with the presented complication, you should:
- Thorough treatment of the wound area;
- Reducing the load to a minimum;
- Elimination of pathogens from the wound;
- Diabetes therapy;
- Diagnosis and treatment of diseases that inhibit regenerative processes.
It should be recognized that each of the steps presented is extremely important in the treatment of such a condition. When such a list is followed, wound healing occurs in 90% of cases. But if the wounds are complicated by pathogenic microflora and purulent manifestations, respectively, surgical treatment is carried out with parallel detoxification of the diabetic’s body.
If ischemic ulcers appear with a diabetic foot, then revascularization can also be prescribed , that is, restoration at the site of manifestation of a symptom of blood circulation. It is produced by expanding the lumens in the vessels of the limbs.
Local treatment
Local therapy of trophic ulcers involves the management of local as well as general procedures. They are based on removing areas with signs of tissue necrosis, rinsing wounds with medicines and applying funds and dressings.
Necrectomy
The term ” necrectomy ” means the cleansing of the affected areas from dead tissue. That is, suppuration, hard dry calluses and other manifestations that interfere with the healing of the ulcer are eliminated. It is believed that the dead areas are an ideal environment for the life of infectious microorganisms. In addition, they do not allow the required extent to recreate the outflow of fluid from the area of ulceration, interfering with the formation of new tissues. Therefore, the area of necrosis is eliminated in the maximum allowable volume. Excision is performed using:
- Mechanical methods;
- Scalpel;
- Chemical compositions;
- Scissors;
- Special devices.
Not as radical, but also effective in a number of situations, a method in which wet dressings are applied to the hardened areas. Thus, the dead tissue is soaked and quickly rejected by the body. But the most common method remains the removal of necrotic areas with a scalpel or scissors. The exceptions are situations when the necrotic bottom coincides with the articular surface or is based on ischemic manifestation. In the surgical method, the so-called Volkmann spoon is used , which manages to remove necrotic tissue without harming the vessels.
A trophic ulcer must be examined using a bulbous probe, since even a small island of ulceration may have a deep wound channel.
Usually, with a trophic ulcer, corns are formed along the edge. They also need to be removed in order to reduce the degree of pressure on the defect. Also, this manipulation will improve the flow of its content. In some situations, it may be necessary to remove the nail if the wound is located partly on the nail bed, the tip of the finger.
Wound treatment
This process is carried out after each necrectomy and until healing itself. It helps eliminate microorganisms from the area. Sometimes special devices are used whenever possible, but practice has shown that a regular syringe is no less effective. Do not use as a flushing material for ulcers in diabetic foot:
- Iodine;
- Rivanol;
- Potassium permanganate solution;
- Ethanol-based preparations;
- Zelenka.
It is possible to apply the most effective “old-fashioned” means for the procedure, as well as more modern analogues:
- Hydrogen peroxide;
- Dioxidine;
- Chlorhexidine;
- Miramistin ;
- Acerbin ;
- Saline solution.
Acerbin is considered convenient for home use. It comes in the form of a spray and allows you to effectively treat the wound surface.
Bandage
A bandage must be applied even on a small trophic defect. The material must differ in certain properties, including:
- Atraumatic ;
- The property of maintaining a moist environment;
- High absorbency of ulcer contents;
- Barrier characteristics;
- High breathability.
Alginate dressing meets these indicators . It is a modern material and perfectly helps the healing of manifestations that have developed in diabetic feet. Gauze is used less frequently when applying a bandage. Its particles are able to dry out to the wound, which disrupts granulation when changing material. It is possible to use such material if there are dry necrosis, fistulas, wounds with high humidity.
Modern medicine uses mesh dressings, alginates, hydrophilic fibers, hydrogels and other options for trophic type ulcers.
Aids
In addition to dressings, certain substances are necessarily used that have certain properties:
- Antimicrobial medicines – Betadine , Dermazin , Argosulfan ;
- Stimulants regenerative processes – Kuriozin , Ebermin , becaplermin ;
- Proteolytic enzyme compounds – Chymotrypsin, Iruksol .
Ointments can also be applied to ulcers. These include Actovegin, Dioxizol , Solcoseryl , Levomekol .
Limb unloading
This step is just as important as the cleansing treatment for diabetic foot wounds. Whatever medications are used for ulcerative lesions, the defects will not be able to heal normally until the person steps on the affected limb. Accordingly, the first thing to take care of in the presented case is unloading the limb. Complete elimination of the load makes it possible to obtain the most favorable forecasts for such a condition.
The specialist should be aware that most of the patients are not able to comply with the instructions for unloading the leg, since the defects are often painless, and therefore do not interfere with the person’s work and movement.
When localizing wounds of this type on the back of the foot or lower leg, additional methods for unloading are not required: the wound simply should not come into contact with the shoes. But when a defect is found on the heel or foot, a certain device is already required. Nowadays, the most commonly used dressing in this situation is made from polymers. It is a boot, both removable and non-removable. This method is good in that it allows you to carry out normal activities without stressing the part of the leg affected by the pathology. One of the varieties of such an accessory is the unloading half-shoe . Its design is designed to speed up the regeneration processes with the following features:
- A third of the load is transferred to the lower leg from the foot;
- The pressure on the surface of the foot is evenly distributed;
- The wound surface is protected from friction;
- The swelling of the wound part is reduced.
With a diabetic foot, it is not always possible to use a polymer boot – there are certain limitations. They are divided into absolute and relative. The first includes the presence of purulent wounds and necrotic lesions in the wearing area with sepsis and / or gangrene. The latter appear in the form:
- Severe circulatory disorders;
- High humidity in the area of application of the product;
- Deep wounds with a small diameter;
- Fear of putting on the product.
Depending on the type of lesion, unloading devices can accelerate tissue healing. From the onset of manifestation to the full tightening of the ulcer, an average of 40-60 days pass.
The formation of “windows” for a wound in insoles, crutches, orthopedic shoes, restriction of walking are not methods of unloading and are not methods of influencing the diabetic foot.
Fighting infection
Pathogenic microflora is a frequent accompanying trophic ulcers. Accordingly, antiseptics and antibiotics must be used to destroy the infection. Moreover, they are used both in the presence of a focus of infection, and simply with an increased risk of developing a lesion of this type, for example, with large ulcers, ischemic tissue necrosis, and so on. Antibiotics in this case are the most optimal options, since the following pathogens can provoke an infection:
- Enterobacteriaceae ;
- Staphylococci;
- Pseudomonas ;
- Proteus;
- Colibacillus;
- Streptococci;
- Klebsiella.
But the prescription of such drugs is possible only after the bacterial culture . This is explained by the presence of sensitivity of each antibiotic to its own spectrum of pathogens with which it can fight. The most commonly used are penicillins, carbapenems, and others. Reception is carried out orally in milder forms. The course is at least a month.
In severe manifestations, intravenous administration of formulations of this type is required in a hospital. At the same time, wound drainage, detoxification and diabetes treatment should be carried out in parallel . The course takes about 2 weeks.
Diabetes compensation
Diabetes compensation is inextricably linked to performance measurement. This is done using a glucometer . With the first type, it is necessary to fix the indicators up to 8 times a day, and with the second – only 2 times. Compensation involves a decrease in blood sugar levels, preventing it from rising above 6 mmol / L. For correction, sugar-reducing medicines and insulin are used. In such a situation, insulins that are short in characteristics are considered the most effective, which already give the required effect in just a quarter of an hour, but do not have a prolonged effect. That is, with the help of treatment, one type of drug quickly reduces the volume of sugar, and the second does not allow it to rise above the specified mark.
Restoration of blood flow
This stage can be carried out both surgically and medically. Medicines for such purposes are divided into prostanoids and non- prostanoids . The first group is considered more effective and is represented by Vazaprostan , Alprostan . But the second includes:
- Ginkgo Biloba extract ;
- Heparin;
- Medicines based on nicotinic acid;
- Reopolyglyukin;
- Pentoxifylline.
As a surgical procedure, balloon angioplasty is used. That is, with the help of a special device, the vascular lumen is “inflated” at the site of narrowing and this position is fixed with a stent . The second method is bypass surgery, which creates bypass ducts from native tissues or artificial synthetic material. The second method is more time-consuming in terms of performance and gives a correspondingly greater effect. If tissue necrosis spreads, then after surgical restoration of blood circulation there is a possibility of an operation on the diabetic foot in the form of:
- Partial small amputation;
- Wound plastics and suturing;
- Necrectomy .
The type of manipulation is determined based on the patient’s condition and the goals of its implementation. But after that, an appropriate bandage is applied and the necessary procedures indicated above are carried out.
Reducing pain
Often, trophic ulcers are not accompanied by any discomfort. But there are times when the pain is so intolerable that it does not allow the diabetic to live normally. In such cases, doctors usually prescribe drugs from the NSAID group. They relieve inflammation, reduce pain, swelling, and are also antipyretic drugs. these include:
- Movalis ;
- Ibuprofen;
- Diclofenac;
- Nurofen ;
- Solpadein ;
- Phenazepam.
But some of the most effective are ketorolac – based drugs – Ketanov , Ketorolac , Ketorol . To eliminate pain, they are often compared with narcotic drugs. But unlike the latter, they have a feature – they are safer.
Despite the relative safety of use, long-term use of non-steroidal anti-inflammatory drugs is prohibited due to the risks associated with the development of gastric bleeding.
conclusions
In this article, it is already clear that the treatment of a diabetic article and trophic ulcers is a rather multifaceted process. Therapy requires supervision by a physician. At the same time, it is important to combine medical, surgical and other methods of influencing trophic ulcers. Without this, it will not be possible to avoid negative manifestations of the conditio