Trophic ulcers with diabetes on the legs

Why is diabetes often accompanied by the formation of ulcers on the body, and why is it so difficult to get rid of them? With regard to the formation of ulcers in diabetes, there really are many questions to which medicine is fully capable of giving explanations.

Diabetes is a complex disease that manifests itself not only by increasing the sugar level. The function of many organs is disrupted, the innervation and trophism of the skin is deteriorating. Unfortunately, this process is difficult to treat, and can arise again in the same place.

Epidemiology

Ulcers are the most common diabetic complication. They are associated with about a third of hospitalizations of patients with diabetes.

Ulcers in about one in two patients result in limb amputation (or a pair of limbs).

According to statistics, ulcerative tissue damage is registered in 80% of diabetics with a 15-20-year experience of the disease. At the same time, two out of three patients die from a gangrenous complication.

About 40% of patients after surgery lose the ability to move, or are severely restricted in movement. Approximately 60% of cases have purulent necrotic consequences and on the other limbs, so these patients have to amputate the other leg.

Gangrenous complications of an ulcer in diabetes are 40 times more common than in people without diabetes. In 85% of patients, amputation is caused by a foot ulcer.

The cause of development of ulcerative lesions in diabetes in 4 cases out of five is external mechanical damage.

[1], [2], [3], [4], [5],

Causes of the ulcers in diabetes

In people suffering from diabetes, the main disorder is a disturbed mechanism of carbohydrate metabolism - both in blood cells and in the cellular structures of the whole organism. In some cases, such a violation does not manifest itself in any way, until there are either signs of diabetes, or other secondary disease (which many do not associate with diabetes). Such a secondary pathology can be a stroke, acute myocardial infarction, a sharp deterioration of the visual function, the development of renal failure. Ulcers are most often found in patients with type 2 diabetes - most likely because this type of disease can last for long without any symptoms, at a time when metabolic processes in the tissues are already violated.

Physicians point to another important reason for the formation of ulcers in diabetes - this is the patient's inattention and ignoring the advice of doctors on changing diet and lifestyle. Unfortunately, many patients continue to smoke and drink alcohol, despite the doctor's requirement to exclude the bad habits of his life.

Also, a significant role is played by individual provoking risk factors.

[6], [7], [8], [9], [10], [11], [12]

Risk factors

• Mechanical injuries of the skin (scrapes, cracks, burns, etc.).
• Varicose veins, other vascular diseases.
• Wearing poor-quality or uncomfortable shoes.
• Disturbance of lymph drainage in the limbs.
• Atherosclerotic changes in blood vessels, hypertension.
• Bedsores, prolonged wearing of bandages, including gypsum.
• Prolonged state of intoxication, ketoacidosis, liver and kidney disease.
• Non-compliance with the doctor's recommendations on diabetic nutrition, the presence of bad habits.

[13], [14],

Pathogenesis

Pathogenetic characteristics of the occurrence of ulcers in diabetes are diverse. The essence is: diabetes is a complex exchange pathology, which is accompanied by a malfunction of susceptibility and insulin production. Diabetes type 1 occurs with a violation of insulin production. For type 2 diabetes, this symptom is not typical, but insulin susceptibility is impaired, which leads to its improper use by the body.

Insulin is an indispensable protein hormone that takes a direct part in the processes of glucose uptake and transformation. If the tissues perceive insulin incorrectly, then a series of disorders will begin - in particular, the level of glucose in the bloodstream will increase. This, in turn, entails the development of neurovascular changes.

The medical changes are described by different terms. Thus, damage to neurons in diabetes is called the term "diabetic neuropathy", and with changes in the smallest vessels speak of diabetic angiopathy. Both the first and second pathology is a consequence of a systemic failure of metabolic processes.

First of all, the violations concern the vascular walls, which become thin and brittle. Capillaries are clogged, and large vessels are gradually affected by atherosclerosis. However, ulcers in diabetes do not appear in all patients, but, first of all, those who ignore the treatment, do not listen to medical recommendations and do not control the glucose values in the blood. The fact is that ulcers do not occur "on a flat spot": their appearance should be preceded by a high level of sugar and the state of ketoacidosis.

The formation of ulcers in most cases is combined with the appearance of eczema or dermatitis. If you do not carry out treatment, the ulcerative hearth increases in size, and even can develop into gangrene.

[15], [16], [17],

Symptoms of the ulcers in diabetes

Ulcers are one of the frequent complications of diabetes, which develops after a certain period of time after the onset of the disease. For example, with decompensated diabetes, ulcers can be formed already throughout the year.

Medical specialists have defined a conditional classification of the appearance of ulcers - these are a kind of stage of the disease, which are characterized by a separate set of symptoms:

1. The pre-ulcer stage, in which the formation of ulcers is already beginning, but for the patient this remains barely noticeable. The first signs of the initial stage can be:

• decrease in receptor sensitivity (pain, temperature susceptibility worsens);
• the appearance of subtle pain in the ankle, as well as a feeling of mild burning and / or itching;
• the appearance of minor seizures in the ankle;
• swelling of the extremities (in varying degrees);
• changes in skin color, increased pigmentation, redness or blueness, the appearance of a vascular pattern.

2. The stage of the initial clinic - at this stage the patient already pays attention to the first signs, but far from all cases it considers it necessary to consult a doctor. Although it is at this stage that treatment can lead to a maximally positive prognosis. The first signs of the second stage are as follows:

• the appearance of minor skin imperfections, erosion;
• the formation of sores that are difficult to heal.

3. Stage of apparent clinical symptoms:

• destruction of the upper layers of the skin, the formation of crusts on ulcers;
• the appearance of bloody discharge, then - purulent;
• an increase in the size of ulcerative foci;
• appearance of other foci, different in size and depth of lesion.

4. Progressing stage:

• transformation of small trophic ulcers into a purulent infected focus;
• the appearance of intoxication (fever, fever, headache, weakness);
• aggravation of pain in the legs;
• damage to deep tissues (up to the bone).

5. Gangrenous stage - accompanied by the development of moist gangrene part of the limb.

Like any damage, an ulcer with diabetes is accompanied by pain, but at an early stage this pain can be mild, even almost invisible. With the aggravation of the process, the symptoms are especially evident at night: there are sensations of itching, seizures, limbs, as it were, "poured."

What do ulcers look like in diabetes?

At first, small wounds, scratches, scrapes may appear on the skin in the event that the formation of an ulcer in diabetes is preceded by mechanical damage. Further, the wounds begin to bleed and eventually increase in size. When infection of the wound develops an external infectious and inflammatory process: the secretions become purulent, and the tissues around the focus swell and blush.

The peptic ulcer expands, but at first the patient does not feel pain - this is the result of impaired innervation in the tissues.

The ulcer with diabetes practically does not give in to usual treatment, which is also a typical sign of the disease.

Forms

Different types of ulcers in diabetes require different approaches to treatment. Certainly, any trophic ulcer in diabetes occurs as a result of the defeat of the fine capillary network and nerve fibers, but each individual species has its own characteristics and characteristics that are taken into account by the doctor in determining the treatment regimen. So, ulcers of the lower extremities are subdivided into such varieties:

1. Capillary foot ulcer in diabetes mellitus develops as a result of damage to the capillary network. This type of pathology is diagnosed most often.
2. Venous ulcers of the lower leg in diabetes mellitus are caused by a disorder of the venous system. As a rule, venous ulcers are found in patients who have not sought medical help for a long time and did not treat diabetes, or conducted it incorrectly. In a similar situation, the ulcer does not initially appear on the foot or finger, but affects the shin area, or becomes a consequence of the growth of the necrotic process.
3. Arterial ulcers on the legs with diabetes are formed when the arterial lumen is clogged, which is often the case with a violation of blood clotting and atherosclerosis. Such a disturbance causes a rapid necrosis of tissues localized from below the affected segment of the artery.
4. Pyogenic ulcer with diabetes is the result of microbial damage to small wounds and scratches on the skin.

Some types of ulcers with diabetes are found more often, and others - less often. For example, the most commonly diagnosed foot and shin ulcers.

An ulcer on the heel with diabetes also occurs quite often, and in most cases is formed with long-existing heel cracks, hives, or after puncturing the heel with a hard and sharp object. Sometimes a diabetic can develop ulcers even after getting a normal splinter.

An ulcer with diabetes on the finger occurs when wearing uncomfortable shoes, with the appearance of abrasions, blisters, etc. Such lesions are difficult enough to be treated, and often result in an operation to remove one or more fingers.

Gastric ulcer in diabetes mellitus does not belong to the category of trophic lesions typical for the disease. It is rather a concomitant pathology. Typical for diabetes, trophic ulcers are formed in the zone with impaired innervation - usually on the lower limbs. Nevertheless, the presence of a stomach ulcer on the background of diabetes requires particularly complex treatment and compliance with the appropriate diet.

Ulcers in the arms with diabetes, as well as on the trunk or head, are extremely rare. Only in isolated cases can the ulcer form after a significant traumatic injury - for example, after a burn, a lacerated wound, an open fracture, etc. Due to its physiological characteristics, the vascular network of the lower extremities is more prone to pathological changes than the vessels of the hands. Therefore, the legs are affected in the first place. But - there are exceptions, and this must be taken into account when carrying out the diagnosis of ulcers.

[18], [19], [20], [21], [22]

Complications and consequences

Ulcers in themselves are complications of diabetes, however, the wounds on the skin can also be complicated - especially often this happens when a secondary infection occurs.

The consequences of an ulcer in diabetes include such complications:

• erysipelas - erysipelas - microbial skin infection, which is accompanied by severe intoxication (streptococcal tissue damage);
• secondary inflammatory process in the lymph nodes, lymphatic vessels - indicates the spread of infection;
• sepsis (general intoxication against the background of development of gangrene).

The degree of severity of complications depends on the course of the main pathology, the prescription and depth of the trophic disorder, and the type of trophic disorder. Many patients have to amputate part of the limb, or the entire limb - this happens when a painful process is started.

As a result of self-treatment, or improper treatment of ulcers in diabetes, other problems often arise:

• skin diseases like eczema or dermatitis;
• damage to the vessel with further bleeding;
• the development of anaerobic infection, tetanus;
• defeat of joints;
• miase is a parasitic disease.

Ulcers in diabetes require a serious attitude. Any patient should be aware that ignoring the doctor's recommendations can lead to disastrous consequences, to disability and even to death.

[23], [24], [25], [26], [27], [28], [29],

Diagnostics of the ulcers in diabetes

First of all, the doctor pays attention to the patient's complaints. If, on a background of diabetes, a person periodically experiences numbness of the legs, increased fatigue, swelling, hyperpigmentation, then it is already possible to draw certain conclusions regarding the diagnosis.

An external examination of the patient is also mandatory. In addition to the characteristic features of the ulcer itself, it is possible to detect deformation of the foot, ankle, and neuro-osteoarthropathy. With the help of tests, the quality of temperature, tactile, proprioceptive, pain, and vibration sensitivity is determined. Tendon reflexes are checked.

During the examination, attention is also paid to skin color, puffiness, the presence of the pathology of the joints. Particular attention is paid to the size and location of the ulcer, the nature of the discharge, the clarity of the edges, the state of healthy skin.

The following tests are mandatory:

• general analysis and biochemistry of blood (indicate the presence of inflammation, assess the quality of blood coagulation function);
• general urine analysis (indicates a change in renal function);
• study of blood glucose level.

Instrumental diagnostics includes radiopaque arteriography, Doppler study of arterial blood circulation, computer capillaroscopy.

Often the diagnostic program includes rheolymphovasography, thermal imaging, impedance measurement.

[30], [31], [32], [33], [34]

Differential diagnosis

Differential diagnosis is carried out with collagenoses, blood diseases, occupational intoxications. Separate differentiation is subject to such diseases:

• obliterating atherosclerosis;
• phagadenic ulcer;
• stagnant ulcers (a consequence of decompensation of the cardiovascular system);
• tuberculosis ulcers, syphilitic ulcers, leprosy ulcers, radiation ulcers.

Rarely in patients, so-called official ulcers, or artificial ones, are found. Their patient applies independently, for the purpose of simulation - as a rule, such ulcers indicate the mental instability of the patient.

[35], [36], [37], [38]

Treatment of the ulcers in diabetes

Local treatment of trophic ulcers with diabetes includes a systematic cleansing of the ulcer, treatment of the skin around the wound, regular dressings. The possibility of applying ointments is agreed with the doctor in charge. Details about the methods of treatment of ulcers in diabetes read in this article.

Prevention

The main condition for the prevention of ulcers is the implementation of the recommendations of the doctor in charge. Such recommendations are necessarily voiced to all patients suffering from diabetes.

Ulcers can occur in any diabetic, if he does not pay proper attention to the constant monitoring of blood sugar. Therefore, prevention, in the first place, is to normalize the level of sugar and to support maintenance therapy for diabetes.

Other equally important tips for preventing ulcers:

• It is necessary to observe the careful hygiene of the feet, timely and correctly cut the nails, prevent the development of fungal infection.
• As often as possible, it is necessary to clean, dry and air the shoes - this is an important condition for leg health.
• When choosing shoes and socks, you should pay special attention to their quality and fit to the size to avoid the appearance of scuffs, blisters, trampled feet.
• If possible, avoid overheating and excessive cooling of the legs, and do not overstrain them.
• Regularly - for example, every evening, it is advisable to inspect the feet, fingers, ankle. Particular attention should be paid to the presence of external damage, punctures, splinters. In diabetics, even such minor injuries can cause the formation of sores.

[39], [40], [41], [42], [43],

Forecast

The further outcome of the disease depends on the extent to which the main pathology will be aggravated - diabetes mellitus, and also on how seriously the patient will treat medical recommendations. If the patient is diagnosed with an isolated neuropathic type of ulcer, provided the timely and adequate therapy is provided, the prognosis can be considered relatively favorable.

If diabetes is severe, with increasing vascular disorders, then in such a situation it is not necessary to talk about an optimistic prognosis.

Ulcers in diabetes are difficult to treat. But: the sooner you pay attention to the problem, the earlier the therapy is prescribed - the greater the probability that the patient's condition will return to normal.

[44], [45],